Fillable Form Mo-656 - Offer In Compromise

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STEP 4 — OFFER TO PAY

I/We offer to pay $____________________ (must be more than zero).

Complete Step 6 to explain where you will obtain the funds to make this offer.

Check one of the following:

Cash Offer (offered amount will be paid in 90 days or less.)

Balance to be paid in:

10;

30;

60;

90 days from written notice of acceptance to the offer.

Short-Term Deferred Payment Offer (offered amount will be paid in MORE than 90 days but within 12 months from written notice of acceptance of the offer).

$_____________________________ within _____________________________ days (not more than 90), from written notice of acceptance of the offer; and beginning in the

_______________________ month after written notice of acceptance of the offer, $_____________________________ on the _________________________ day of each

month for a total of ____________________________ months. (Cannot extend more than 12 months from written notice of acceptance of the offer.)

STEP 5 — EXPLANATION OF CIRCUMSTANCES

I/we request an Offer in Compromise for the reason(s) listed below:

NOTE: If you are requesting compromise based on doubt as to liability, explain why you don’t believe you owe the tax. If you believe you have special circumstances

affecting your ability to fully pay the amount due, explain your situation. You may attach additional sheets, if necessary.

______________________________________________________________________________________________________________________________________________

STEP 6 — SOURCE OF FUNDS

I/We shall obtain the funds to make this offer from the following source(s): ____________________________________________________________________________________

______________________________________________________________________________________________________________________________________________

STEP 7 — SIGNATURES

I/We agree to be bound by all the terms and conditions set forth in this offer. Under penalties of perjury, I declare that I have examined this offer, including accompanying schedules and statements, and

to the best of my knowledge and belief, it is true, correct, and complete. I also declare under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am

not eligible for any tax exemption, credit or abatement if I employ such aliens.

SIGNATURE OF TAXPAYER

DATE

SIGNATURE OF TAXPAYER OR SPOUSE

DATE

DOR USE ONLY

On behalf of the Missouri Department of Revenue, I accept the offer to pay in Step 4 for the reasons listed in Step 2.

SIGNATURE OF AUTHORIZED DEPARTMENT OFFICIAL

TITLE

DATE

(01-2010)