Form Boe-490 - Offer In Compromise Application Page 4
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11BOE-490 (S1B) REV. 1 (1-06)
Please complete all blocks, except shaded areas. Write “N/A” (Not Applicable) in those blocks that do not apply.
Information should be typed or printed.
SECTION 1. BASIS FOR THE OFFER
The following facts and reasons are submitted as grounds for consideration and acceptance of this offer. (Attach
additional pages as needed.)
SECTION 2. SOURCE OF FUNDS
If any or all of the amount being offered is from a loan, please provide the following information:
LENDER’S NAME
PHONE NUMBER
(
)
STREET ADDRESS (city, state, zip code)
TOTAL AMOUNT OF THE LOAN
$
DESCRIBE THE SOURCE(S) OF THE OFFERED FUNDS (If the offered funds are from a loan, please describe how you intend to repay the loan.)
If this Offer in Compromise is denied, the Board is to:
Retain any amount deposited and credit it to the current tax liability.
Return the amount deposited.
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