Offer In Compromise Application - Tennessee Department Of Revenue Page 9
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25Page 9
OIC-1
12. DISCLOSURE AGREEMENT
This section is to be completed only if an Offer In Compromise is currently pending or has been recently acted upon by the
IRS for the applicant. Separate signature(s) are required for this section.
[
] Completed
(Date
)
[
] Accepted (Amount $
) or [
] Declined
(mm/dd/yyyy)
[
] Pending
(Date
)
IRS Agent Assigned
(mm/dd/yyyy)
[
] To be Filed
(Date
)
Phone Number
(mm/dd/yyyy)
Tax Period(s) Covered
Amount Owed
SS # or FEI #
$
By my/our signature(s) below, I/we authorize the Tennessee 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
POWER OF ATTORNEY'S SIGNATURE
DATE
For information or assistance, contact your Revenue Collection Officer directly or reach the Collection
Services Division at (615) 741-7074 or Revenue.Collection@tn.gov.
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