Settlement Offer Application Form - Oregon Department Of Revenue Page 14
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Terms and conditions
5. I forfeit my right to appeal [ORS 305.280(3)].
By making this offer, I understand and agree to these
terms and conditions:
6. For three years from the date I pay the settlement
1. If I don’t meet all of the terms and conditions of this
offer amount in full, I will file all returns and pay all
offer, the Department of Revenue will cancel the
taxes due. I will pay any tax debt in full within 90
settlement offer and collect the full amount of my
days from the date of the notice I receive from the
debt, including interest and penalties.
department. If I don’t, I violate this settlement offer
agreement and the Department of Revenue will col-
2. I will voluntarily submit all settlement offer pay-
lect the full debt amount.
ments.
7. I authorize the Department of Revenue to contact
3. The Department of Revenue will apply all payments,
third parties (IRS, Department of Employment,
refunds, or credits it receives before my settlement
credit reporting firms, etc) to verify information I
offer is approved to my debt and not to the settle-
provided in the settlement offer application.
ment offer amount.
8. The Department of Revenue will release any tax
4. If I have a current payment plan for this debt, I will
liens on my property after I pay the settlement offer
continue making payments, as agreed, while this
amount in full.
offer is pending.
Taxpayer agreement and authorization to use credit reports
I read and agree to the above terms and conditions. Under penalties of perjury, I declare that I examined this
offer, including all attached documentation, and to the best of my knowledge and belief, it is true, correct, and
complete. I (we) authorize the Oregon Department of Revenue to use credit reports and other tools to verify
any information in this settlement offer application and for collection purposes.
➨
Date
Your signature
SIGN
HERE
➨
Spouse/RDP signature
Date
(if applying jointly, BOTH must sign even if only one had income)
Return your completed application, documentation,
Oregon Department of Revenue
5-percent payment, and payment coupon to:
PO Box 14725
Salem OR 97309-5018
Did you include everything?
Before mailing, please review your application to make sure it’s complete and includes all supporting
documentation. We’ll return your application if you don’t sign it or include payment; are appealing your
tax debt; or haven’t filed all required tax returns (see page 2).
Did you . . .
1. Include a 5-percent payment and a completed payment coupon with this application?
2. Sign the taxpayer agreement and authorization to use credit reports (above)? If applying jointly, did your
spouse/RDP sign it?
3. Complete the Tax Information Authorization and Power of Attorney for Representation form, if needed?
4. Make a copy of this application for your records?
If you answered yes to each question, included all supporting documentation, meet all the conditions for
qualifying (page 2), you’re ready to submit your application. We’ll contact you within 10 business days to let
you know we received it.
If you need to contact us, see page 5.
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