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Additional information IRS needs to
Are you the beneficiary of a trust, estate, or life insurance policy?
consider settlement of your tax debt. If you
or your business are currently in a
Are you currently in bankruptcy?
Have you filed bankruptcy in the past 10 years?
bankruptcy proceeding, you are not eligible
to apply for an offer.
Are you or have you been party to a lawsuit?
If applicable, date the lawsuit was resolved:
In the past 10 years, have you transferred any assets for less than their full value?
If applicable, date the asset was transferred:
Have you lived outside the U.S. for 6 months or longer in the past 10 years?
Do you have any funds being held in trust by a third party?
No If yes, how much $
Under penalties of perjury, I declare that I have examined this offer, including accompanying documents, and to the best of my knowledge it
is true, correct, and complete.
Signature of Taxpayer
Signature of Taxpayer
Remember to include all applicable attachments listed below.
Copies of the most recent pay stub, earnings statement, etc., from each employer
Copies of bank statements for the three most recent months
Copies of the most recent statement, etc., from all other sources of income such as pensions, Social Security, rental
income, interest and dividends, court order for child support, alimony, and rent subsidies
Copies of the most recent statement for each investment and retirement account
Copies of the most recent statement from lender(s) on loans such as mortgages, second mortgages, vehicles, etc.,
showing monthly payments, loan payoffs, and balances
List of Notes Receivable, if applicable
Verification of State/Local Tax Liability, if applicable
Documentation to support any special circumstances described in the "Explain special circumstances" section on page 2
of Form 656, if applicable
Attach a Form 2848, Power of Attorney, if you would like your attorney, CPA, or enrolled agent to represent you and you
do not have a current form on file with the IRS.
Privacy Act Statement
The information requested on this Form is covered under Privacy Act and Paperwork Reduction Act Notices which have already been
provided to the taxpayer.
Catalog Number 55896Q