Multi Agency Form For Offer In Compromise Page 4
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12SECTION 1. OFFER IN COMPROMISE
To make an offer please check the box next to the corresponding agency. For all offers, you must complete Sections 1
through 8 of this application. You must also complete and sign the appropriate offer agreement in Section 9. For
Corporations, Partnerships, and Limited Liability Companies, use form FTB-4905BCT for FTB offers and BOE-490C for
BOE offers.
I wish to make an Offer in Compromise to BOE for liabilities associated with the following BOE account
BOE
numbers:
. (You must complete Part I of Section 9, pg. 10.)
FTB
I wish to make an Offer in Compromise to FTB for liabilities associated with the following FTB account
numbers:
. (You must complete Part II of Section 9, pg. 11.)
I wish to make an Offer in Compromise to EDD for liabilities associated with the following EDD account
EDD
numbers:
. (You must complete Part III of Section 9, pg. 12.)
SECTION 2. PERSONAL INFORMATION
Note: Complete all blocks, except shaded areas. Write “N/A” (Not Applicable) in those blocks that do not apply. Attach additional pages as needed.
First Name
MI
Last Name
Social Security Number
Date of Birth
Other name(s) or alias(es) used
First Name of Spouse or
Registered Domestic Partner
(RDP)
MI
Last Name of Spouse or RDP
Social Security Number
Date of Birth
Other name(s) or alias(es) used
Taxpayer’s Driver License Number
State
Driver License Number of Spouse or RDP
State
Dependent’s Name
Date of Birth
Social Security Number
Relationship
Current Address
Previous Address (if at current address less than 2 years)
(
)
(
)
Phone Number:
Phone Number:
Name and address of your tax representative (Please attach a Power of Attorney)
(
)
Phone Number:
DE 999CA (6-06) (INTERNET)
Page 4 of 12
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