Fillable Form 656-L - Offer In Compromise (Page 5 of 8) in pdf

Form 656-L - Offer In Compromise Page 5

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Page 5

656-L

Department of the Treasury - Internal Revenue Service

OMB Number

Form

Offer in Compromise

(Doubt as to Liability)

1545-1686

(January 2016)

►

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:

Section 1

Individual Information (Form 1040 filers)

Your First Name, Middle Initial, Last Name

Social Security Number (SSN)

IRS Received Date

If a Joint Offer, Spouse's First Name, Middle Initial, Last Name

Social Security Number (SSN)

Your Physical Home Address

(Street, City, State, ZIP Code)

Mailing Address

(if different from above or Post Office Box number)

Employer Identification Number

(For self-employed individuals only)

Individual Tax Periods

1040 U.S. Individual Income Tax Return [List all year(s); for example 1040 2009, 1040 2010, etc.]

941 Employer's Quarterly Federal Tax Return [List all quarterly period(s); for example 03/31/2009, 06/30/2010, 09/30/2010, etc.]

940 Employer’s Annual Federal Unemployment (FUTA) Tax Return [List all year(s); for example 2010, 2011, etc.]

Trust Fund Recovery Penalty as a responsible person of (enter business name)

for failure to pay withholding and Federal Insurance Contributions Act taxes (Social Security taxes), for period(s) ending [List all quarterly period(s);

for example 03/31/2009, 06/30/2009, etc.]

Other Federal Tax(es) [specify type(s) and period(s)]

Section 2

Business Information (Form 1120, 1065, etc., filers)

Business Name

Business Address

(Street, City, State, ZIP Code)

Employer Identification Number

Name and Title of Primary Contact

Telephone Number

(EIN)

(