Offer In Compromise Statement Of Offer - Arizona Department Of Revenue

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Arizona Department of Revenue Offer in Compromise Statement of Offer
Statement of Offer
I/We offer to pay $_________________i n lieu of
Taxpayers Name(s) DBA or Corp Name
the above-mentioned liability. I/We acknowledge
the above liability is due and owing to the Arizona
Department of Revenue and request the
Department abate the remaining balance due
Street Address
pursuant to ARS 42-1004.B.By submitting this
Offer in Compromise, I/We understand and agree
to the terms and conditions on the reverse side of
Zip Code
this form.
Mailing address if different from above
Payment Terms
Payment in full enclosed with this Offer.
Payment in full within: ___30, ___60 or ___90
days from date of acceptance of the Offer.
Payment in full to exceed 90 days from date of
acceptance of the Offer.
Tax Type
Amount Owed
Amount of monthly payment $
Monthly payment due date
Individual Income
What is the source of funds for your offer?
SSN number
Reason for Offer
Spouse SSN number
State briefly your reason for making this offer.
Transaction Privilege Tax
Include any information you feel pertinent to this
Offer in Compromise
License number
Withholding Tax
License number
Federal Tax Information
Corporate Income Tax
Amount of Tax liability owed to the Internal
Revenue Service.
License number
Waste Tire Tax
Have you submitted an Offer to IRS?
License number
Are you making Payments?
Amount of monthly payment $
If you are submitting an Offer in Compromise for a
Business Liability please indicate your
organizational type:
I/We agree with the terms and conditions set forth
Sole Propertiertship
in this form. That I/We have fully examined this
offer, and to the best of my knowledge and belief,
it is true, correct and complete.
Limited Partnership
Corporation Is charter still active?
Signature of Taxpayer
Signature of Taxpayer


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