Form 656 - Offer In Compromise Page 2

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Department of the Treasury — Internal Revenue Service
Offer in Compromise
(Rev. March 2017)
To: Commissioner of Internal Revenue Service
IRS Received Date
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 in Section 2 or Section 3 below.
Did you use the Pre-Qualifier tool located on our website at
prior to filling out this form?
Note: The use of the Pre-Qualifier tool is not mandatory before sending in your offer. However, it is recommended.
Include the $186 application fee and initial payment (personal check, cashier's check, or money order) with your Form 656. You must also include the
completed Form 433-A (OIC) and/or 433-B (OIC) and supporting documentation. You should fill out either Section 1 or Section 2, but not both,
depending on the tax debt you are offering to compromise.
Section 1
Individual Information (Form 1040 filers)
If you are a 1040 filer, an individual with personal liability for Excise tax, individual responsible for Trust Fund Recovery Penalty, self-employed
individual, individual personally responsible for partnership liabilities, and/or an individual who operates as a single member LLC or a disregarded entity
taxed as a sole proprietorship you should fill out Section 1. You must also include all required documentation including the Form 433-A (OIC), the $186
application fee, and initial payment.
Your First Name, Middle Initial, Last Name
Social Security Number (SSN)
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)
Your Home Mailing Address
(if different from above or Post Office Box number)
Is this a new address?
If yes, would you like us to update our records to this address?
Employer Identification Number
Individual Tax Periods
If Your Offer is for Individual Tax Debt Only
1040 Income Tax-Year(s)
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
941 Employer's Quarterly Federal Tax Return - Quarterly period(s)
940 Employer's Annual Federal Unemployment (FUTA) Tax Return - Year(s)
Other Federal Tax(es) [specify type(s) and period(s)]
Note: If you need more space, use attachment and title it “Attachment to Form 656 dated
.” Make sure to sign and date the
(Rev. 3-2017)
Catalog Number 16728N


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