Fillable Form 656-L - Offer In Compromise (Doubt As To Liability) (Page 5 of 8) in pdf

Form 656-L - Offer In Compromise (Doubt As To Liability) Page 5

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Department of the Treasury — Internal Revenue Service

656-L

Form

OMB No. 1545-1686

Offer in Compromise

(Doubt as to Liability)

(February 2012)

Section 1

Your Contact Information

IRS Received Date

Your First Name, Middle Initial, Last Name

If a Joint Offer, Spouse’s First Name, Middle Initial, Last Name

Your Physical Home Address

(Street, City, State, ZIP Code)

Mailing Address

(if different from above or P.O. Box number)

Business Name

Business Address

(Street, City, State, ZIP Code)

Social Security Number (SSN)

Employer Identification Number

(Your SSN)

(EIN)

(Spouse SSN)

(EIN not included in offer)

Section 2

To: Commissioner of Internal Revenue Service

I/We submit this offer to compromise, based on doubt as to liability plus any interest, penalties, additions to tax, and additional amounts required by

law (tax debt) for the tax type and period(s) marked below:

[Please mark an “X” in the box for the correct description and fill-in the correct tax period(s)].

1040/1120 Income Tax [List all year(s); for example 1040 2009, 1120 2010, etc.]

941 Employer's Quarterly Federal Tax Return [List all quarterly period(s); for example 03/31/2009, 06/30/2010, 09/30/2010, etc.]

940 Employer’s Annual Federal Unemployment (FUTA) Tax Return [List all year(s); for example 2010, 2011, etc.]

Trust Fund Recovery Penalty as a responsible person of

(enter corporation name)

for failure to pay withholding and Federal Insurance Contributions Act taxes (Social Security taxes), for period(s) ending [List all quarterly period(s);

for example 03/31/2009, 06/30/2009, etc.]

Other Federal Tax(es) [specify type(s) and period(s)]

Note: If you need more space, use a separate sheet of paper and title it “Attachment to Form 656-L Dated

.” Sign and date the

attachment following the listing of the tax periods.

Section 3

Amount of the Offer

I/we offer to pay $

Must be more than zero ($0) and payable within 90 days of the notification of acceptance, unless an alternative payment term is approved at the

time the offer is accepted.

Section 4

Terms