Form R-20212a - Offer In Compromise Application - Louisiana Department Of Revenue - 2015 Page 4

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R-20212A (7/15)
11. Disclosure Agreement (Complete this section if an Offer in Compromise is currently pending or has been completed with the IRS.)
Completed
Date ____________________________________
Accepted (Amount $ ____________ ) or
Declined
IRS Agent Assigned
Pending
Date filed ________________________________
Telephone Number
To be filed
Date ____________________________________
(
)
Tax Period(s) Covered
Amount Owed
Federal Taxpayer Identification Number
___________________________
–
$___________________________
By my/our signature(s) below, I/we authorize the Louisiana Department of Revenue and the Internal Revenue Service to exchange
information from their respective files regarding my/our pending or completed Offer in Compromise.
__________________________________________________________
________________________
Applicant’s Signature
Date
__________________________________________________________
________________________
Applicant’s Signature
Date
Revenue Offices – Hours 8:00 A.M. – 4:30 P.M.
Headquarters
617 North Third Street, Baton Rouge, LA 70802
P.O. Box 201, Baton Rouge, LA 70821-0201
(855) 307-3893
7

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