Offer In Compromise Application - Tennessee Department Of Revenue Page 6
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25Page 6
OIC-1
Tennessee Department of Revenue
Offer in Compromise Application
SS #
1. Applicant(s) Name and Street Address
SS #
FEI #
Email Address :
Daytime Phone # (
)
2. Applicant(s) Mailing Address (If different from above)
3. Applicant(s) Legal Structure
[
] Individual
[
] Proprietorship
[
] Partnership
[
] Corporation
[
] LLC
[
] Corp. Officer(s)
4. REQUIRED: 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: (Check One Only)
[
] Paid in full with this offer. (Make check payable to the “Tennessee Department of Revenue”)
[
] A deposit of $
is attached, the balance to be paid within 30 days from acceptance.
[
] Offer will be paid in
monthly payments of
.
5. The Tennessee Department of Revenue will immediately deposit any payment made with this offer. The deposit of
this payment constitutes neither a waiver of any of the Department’s rights, nor acceptance of the offer.
6. Description of Tax Liabilities To Be Compromised
Tax Type
Account Number
Period(s)
[
] Individual Income Tax
[
]
Sales & Use Tax
[
] Franchise & Excise Tax
[
]
Business Tax
[
]
Other (Specify)
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