Form Dtf-4.1 - Offer In Compromise For Fixed And Final Liability
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3DTF-4.1
New York State Department of Taxation and Finance
(11/08)
Offer in Compromise
For Fixed and Final Liability
Social security number(s)
Name of taxpayer(s)
Employer identification number (EIN)
Home address
Type of tax and entity:
Business address
income
individual
Employer
sales
partnership
withholding
corporation
Address
other
Taxpayer’s representative
Telephone number
Date
(
)
Amount offered
Address
$
(attach Form POA-1, Power of Attorney)
1. Record of liabilities and payments
(to be filled in by taxpayer)
For office use only
(Attach additional pages if needed.)
Notice or assessment
Total payments
Penalty and
number (assessment I.D.)
Tax period
Amount of tax
to date
interest
Amount due
Note: Submit a copy of all notices which are the subject of this offer.
Total $
2a. Is the sum offered in compromise borrowed money?
No
Yes
(If Yes, give name and address of lender and list of collateral, if any, pledged to secure the loan.)
Is the lender a member of your household and/or immediate family?
No
Yes
No payment is required with the submission of an offer.
2b. If this offer in compromise is rejected:
Retain any amount submitted with this offer and credit it to liabilities.
Return any amount submitted with this offer.
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Parent category: Financial