Form 656 - Offer In Compromise (Including Form 433-A (Oic), Form 433-B (Oic)) Page 21

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Department of the Treasury — Internal Revenue Service
Offer in Compromise
(Rev. May 2012)
Attach Application Fee and Payment
(check or money order)
IRS Received Date
Section 1
Your Contact Information
Your First Name, Middle Initial, Last Name
If a Joint Offer, Spouse's First Name, Middle Initial, Last Name
Your Physical Home Address
(Street, City, State, ZIP Code)
Mailing Address
(if different from above or Post Office Box number)
Business Name
Your Business Address
(Street, City, State, ZIP Code)
Social Security Number (SSN)
Employer Identification Number
(EIN not included in offer)
Section 2
Tax Periods
To: Commissioner of Internal Revenue Service
In the following agreement, the pronoun "we" may be assumed in place of "I" when there are joint liabilities and both parties
are signing this agreement.
I submit this offer to compromise the tax liabilities plus any interest, penalties, additions to tax, and additional amounts required by law for the tax type
and period(s) marked below:
1040 Income Tax-Year(s)
1120 Income Tax-Year(s)
941 Employer's Quarterly Federal Tax Return - Quarterly period(s)
940 Employer's Annual Federal Unemployment (FUTA) Tax Return - Year(s)
Trust Fund Recovery Penalty as a responsible person of
(enter corporation name)
for failure to pay withholding and Federal Insurance Contributions Act taxes (Social Security taxes), for period(s) ending
Other Federal Tax(es) [specify type(s) and period(s)]
Note: If you need more space, use attachment and title it "Attachment to Form 656 dated
." Make sure to sign and date the
Section 3
Reason for Offer
Doubt as to Collectibility - I have insufficient assets and income to pay the full amount.
Exceptional Circumstances (Effective Tax Administration) - I owe this amount and have sufficient assets to pay the full amount, but due to my
exceptional circumstances, requiring full payment would cause an economic hardship or would be unfair and inequitable. I am submitting a written
narrative explaining my circumstances.
Catalog Number 16728N
(Rev. 5-2012)


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