Form R-20212a - Offer In Compromise Application - Louisiana Department Of Revenue - 2015

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R-20212A (7/15)
Louisiana Department of Revenue
Offer in Compromise Program
Offer in Compromise Application
P.O. Box 201
Baton Rouge, Louisiana 70821-0201
Please read instructions before completing this form and include the $186 non-refundable Application Fee.
Tax Type to be included in this offer
Individual
Business
1. Applicant’s Name (Individual)
Social Security Number
Street Address
City, State, ZIP
Daytime Telephone Number
1. Applicant’s Name (Individual)
Social Security Number
Street Address
City, State, ZIP
Daytime Telephone Number
1. Applicant’s Name (Business)
LA Account Number
Street Address
Parish
City, State, ZIP
Daytime Telephone Number
1. Applicant’s Name (Business)
LA Account Number
Street Address
Parish
City, State, ZIP
Daytime Telephone Number
2. Applicant(s) Mailing Address (If different from above)
3. Applicant(s) Legal Structure
Individual
Proprietorship
Street Address
Partnership
Corporation
Trust/Estate
Corporate Officer(s)
City, State, ZIP
LLC
4. Offer Amount
I/We offer to pay the amount of $__________________ to compromise and settle the tax liabilities listed in Section 6 below and will
pay this amount in the following manner: (Place an “X” in the appropriate box.)
Paid in full with this offer. (Make check payable to the “Louisiana Department of Revenue.”)
A payment of $ ________________ , which is at least 20% of the offer is required; the balance is to be paid within 30
days from acceptance.
Note: An application fee of $186 and a nonrefundable initial payment of at least 20 percent of the amount offered must be submitted
with the Offer in Compromise Application. In the event the Offer in Compromise is rejected, the deposit shall be applied to the tax-
payer’s outstanding tax liability.
5. Method of Payment
Bank Draft
Cash
Credit Card
Money Order
Check
Note: It is understood that this offer will be considered and acted upon in due course and that it does not relieve the taxpayer(s) from
the liability sought to be settled until the offer is accepted in writing by the Secretary of the Louisiana Department of Revenue, two
assistant secretaries, and the Louisiana Board of Tax Appeals, and there has been full compliance with the terms of the offer.
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