Form A-212 - Petition For Compromise Of Delinquent Taxes - Wisconsin Department Of Revenue
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4PETITION FOR COMPROMISE OF DELINQUENT TAXES
Prepare and file in duplicate with the Department of Revenue district office nearest you. See section 20 on this petition for
the locations of the district offices. Corporations need not complete sections 5, 6 and 14 on this petition, however two
copies of Schedule A for corporations must be prepared and filed with this petition. NOTE - If your offer is accepted in
compromise of your delinquent tax liability, the amount offered must be paid in full within ten (10) days from the date the
offer is accepted.
Social security number
Seller's permit number
Withholding number
1. Name of petitioner
Business address
Business telephone
(
)
Home address
Home telephone
(
)
2. Record of delinquent taxes
Type of Tax
Taxable Period
Unpaid Liability
3. Failure to pay the taxes listed above is due to the following causes:
4. If the delinquent taxes were incurred in the operation of a business, has the business been discontinued?
Yes
No
If discontinued, when?
What disposition was made of the assets?
5. Family information
Name of spouse
Your Age
Age Spouse
Name(s) of dependent(s) - list
Relationship
Age
Petitioner
Spouse
6. Employment information
Present employer
Gross salary per week
Take home pay per week
If unemployed, give date
last employed and gross salary per week
7. List names of banks and other financial institutions you have done business with any time during the past 3 years.
Name and Address
Name and Address
Do you rent a safety deposit box in your name or in any other name?
Yes
No
If yes, give name and address of bank where the box
is located.
Wisconsin Department of Revenue
A-212 (R. 8-00)
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