Form 14773-A - Offer In Compromise Withdrawal Joint
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1Department of the Treasury - Internal Revenue Service
14773-A
Form
Offer in Compromise Withdrawal - Joint
(December 2017)
Offer number
Taxpayer Identification Number
Taxpayer Identification Number
(last 4 digits)
(last 4 digits)
To whom it may concern:
We hereby withdraw our Offer in Compromise (OIC) dated
. We understand that by withdrawing this OIC,
we waive our appeal rights.
Signature
Name (printed)
Date
Signature
Name (printed)
Date
Please complete this section if you submitted a deposit with the OIC. (This does not include the non-refundable
application fee you paid.) (If you need additional space, attach a separate sheet.)
Amount of Deposit $
Check one
We wish to have our OIC deposit refunded to us.
We consent to the application against our outstanding tax liability, as shown below, of the above amount deposited on
my OIC.
Taxpayer ID Number
Type of Tax
Period
Amount to be Applied
(last 4 digits)
Sign here to acknowledge application of deposit
Signature
Date
Signature
Date
14773-A
Catalog Number 68987G
Form
(Rev. 12-2017)
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