Offer In Compromise Business Request For Settlement Form
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5Commonwealth of Virginia
Department of Taxation
Offer In Compromise
Business Request For Settlement
Name Of Business
FEIN
Address Of Business
Va. Account No.
Telephone No.
T/A Name, If Different
To: Tax Commissioner
I/We submit this offer to settle tax, interest, and penalties for the periods indicated below.
Sales Tax For The Period(s):
Withholding Tax For The Period(s):
Corporate Tax For The Period(s):
Other (Specify) For The Period(s):
I/We Offer To Pay $
Payment Attached
If you are unable to enclose the full amount offered, state when the full payment
will be received. (Ex.: within ten (10) days from the date the offer is accepted.)
I/We submit this offer for the reason checked below:
Doubt As To Collectibility. My financial statement is attached.
Doubt As To Liability. My detailed explanation is attached.
Request For Waiver Of Penalty Due To Reasonable Cause. My detailed explanation is attached.
*See following page for terms and conditions.
I/We, the undersigned, declare that I/we have examined this offer, including accompanying schedules and statements, and to
the best of my/our knowledge, it is true, accurate, and complete. I/We hereby grant the power of attorney to act for me/us to
compromise the above referenced liability(ies) to
. Also, I/we grant
authorization to verify any financial data by use of a credit report.
Signature of Taxpayer(s)
Date:
Daytime Phone:
Signature of Taxpayer's Representative
Date:
Daytime Phone:
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