Michigan Department of Treasury
Reset Form
5186 (Rev. 10-15)
Request for Independent Administrative Review of Rejected Offer in Compromise
Issued under authority of Public Act 122 of 1941 and Public Act 240 of 2014.
INSTRUCTIONS: Complete and submit this form when you believe that your original Michigan Offer in Compromise was rejected
incorrectly. An independent administrative review will set aside a rejection of an offer in compromise only upon clear and convincing
evidence presented by the taxpayer that the rejection was the result of fraud, adoption of a wrong principle, or error of law by
Department of Treasury personnel.
Mail this completed form to: Michigan Department of Treasury, Office of Legal Affairs, PO Box 30716, Lansing MI 48909
This form will not amend a rejected Offer in Compromise. Do not send payments with this form.
PART 1: TAxPAyeR INfORMATION
Filer’s First Name
M.I.
Last Name
Social Security Number
Telephone Number
Spouse’s First Name (if applicable)
M.I.
Last Name
Spouse’s SSN
Telephone Number
Business Name (if business assessments are included in the offer)
FEIN, ME or TR Number
Telephone Number
Address
City
State
ZIP
Mailing Address (If Different from Above)
City
State
ZIP
PART 2: ReASON fOR ReqUeST
Check why you are requesting a review of your Offer in Compromise rejection, and in the space below explain why you believe the rejection was
incorrect. Be specific. The independent administrative review will only consider documentation filed with the original Offer in Compromise submission.
Attach a copy of the rejection letter with this form. Attach additional pages detailing your reasons for disagreement with the rejection if necessary. Do not
submit the forms and attachments included with the original Offer in Compromise submission. Do not send payments with this form.
Rejection was an adoption
Rejection was an error
Rejection was a result of fraud
of a wrong principle
of law by Treasury personnel
PART 3: TAxPAyeR SIgNATURe
(ReqUIReD, eveN If POweR Of ATTORNey fORM IS ON fIle)
Taxpayer’s Signature
Date
Signature of Taxpayer’s Spouse (if applicable)
Date
Business Taxpayer: Authorized Signature
Date
Authorized Signer’s Name (Print or Type)
Title
Telephone Number
PART 4: ThIRD PARTy DeSIgNATeD RePReSeNTATIve
By checking this box, I authorize the Michigan Department of Treasury to discuss with and to provide a copy of any papers or correspondence
relating to this Offer in Compromise to a third party designated representative identified below.
NOTe: The taxpayer is required to complete and file the Authorized Representative Declaration (Power of Attorney) (Form 151) if this was
not included in the original application or if the party designated on this form is different from the designee named in the original application.
Designee’s Name
Telephone Number
1
