Form Otr-10 - Application For Wage Earners, Self-Employed Individuals, And Business Page 2
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2OFFER IN COMPROMISE
Doubt as to liability Doubt as to Collectibility Special Circumstances
Note: If you are requesting compromise based on doubt as to liability, explain why you don’t believe you owe the tax. If you believe special circumstances exist
that is affecting your ability to fully pay the amount of tax due, please explain. You may attach additional sheets if necessary.
8. Under penalties of perjury, I/We declare that I/we have examined this offer, including accompanying scheduled and statements, and to the best of my/our
knowledge and belief, the information provided is true, correct, and complete.
____________________________________________________________________ ________________________________________________
Signature of Taxpayer proponent Date
____________________________________________________________________ ________________________________________________
Signature of Taxpayer proponent Date
____________________________________________________________________ ________________________________________________
Signature of Taxpayer proponent Date
FOR INTERNAL USE ONLY
Proposed Offer in Compromise
Reason for approval/denial:
Accepted Rejected
_______________________________________________________________________________________________
Signature and Title of OTR Official
Date
_____________________________________________________________
____________________________________________
1 1 0 1 4 t h S t r e e t , S . W . S u i t e 2 7 0 W , W a s h i n g t o n , D C 2 0 0 2 4 ‐ ( 2 0 2 ) 7 2 7 ‐ 4 T A X ( 4 8 2 9 )
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