Form 656 - Offer In Compromise Page 3

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Low-Income Certification
(Individuals and Sole Proprietors Only)
Do you qualify for Low-Income Certification? You qualify if your gross monthly household income is less than or equal to the amount shown in the chart
below based on your family size and where you live. If you qualify, you are not required to submit any payments during the consideration of your offer. If
your business is other than a sole proprietor or disregarded single member LLC taxed as a sole proprietor and you owe employment taxes after January 1,
2009, you cannot qualify for the waiver. IRS will determine whether the household income (at the time of the offer submission or at the time the offer is
processed, whichever is lower) and family size support the decision not to pay the application fee.
Check this box if your household's gross monthly income is equal to or less than the monthly income shown in the table below.
Size of family unit
48 contiguous states and D.C.
For each additional person, add
Section 2
Business Information (Form 1120, 1065, etc., filers)
If your business is a Corporation, Partnership, LLC, or LLP and you want to compromise those tax debts, you must complete this section. You must also
include all required documentation including the Form 433-B (OIC), and a separate $186 application fee, and initial payment.
Business Name
Business Physical Address
(Street, City, State, ZIP Code)
Business Mailing Address
(Street, City, State, ZIP Code)
Employer Identification Number
Name and Title of Primary Contact
Telephone Number
Business Tax Periods
If Your Offer is for Business Tax Debt Only
1120 Income Tax-Year(s)
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
Reason for Offer
Section 3
Doubt as to Collectibility - I do not have enough in assets and income to pay the full amount.
Exceptional Circumstances (Effective Tax Administration) - I owe this amount and have enough assets to pay the full amount, but due to my
exceptional circumstances, requiring full payment would cause an economic hardship or would be unfair and inequitable. I am submitting a written
narrative explaining my circumstances.
Explanation of Circumstances
– The IRS understands that there are unplanned events or special circumstances, such
(Add additional pages, if needed)
as serious illness, where paying the full amount or the minimum offer amount might impair your ability to provide for yourself and your family. If this is the
case and you can provide documentation to prove your situation, then your offer may be accepted despite your financial profile. Describe your situation
below and attach appropriate documents to this offer application.
(Rev. 3-2017)
Catalog Number 16728N


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