Fillable Form 656 - Offer In Compromise (Page 4 of 7) in pdf

Page 3 of 6

Section 4

Payment Terms

Check one of the payment options below to indicate how long it will take you to pay your offer in full. You must

▼

offer more than $0. The offer amount should be in whole dollars only.

Lump Sum Cash

Check here if you will pay your offer in 5 or fewer payments within 5 or fewer months from the date of acceptance:

Enclose a check for 20% of the offer amount (waived if you are an individual or sole proprietor and met the requirements for Low Income

Certification) and fill in the amount(s) of your future payment(s).

Total Offer Amount

20% Initial Payment

Remaining Balance

- $

= $

You may pay the remaining balance in one payment after acceptance of the offer or up to five payments, but cannot exceed 5

months.

Amount of payment

payable within

Month after acceptance

Amount of payment

payable within

Months after acceptance

Amount of payment

payable within

Months after acceptance

Amount of payment

payable within

Months after acceptance

Amount of payment

payable within

Months after acceptance

Periodic Payment

Check here if you will pay your offer in full in 6 to 24 months.

Enter the amount of your offer $

Note: The total amount must equal all of the proposed payments including the first and last payments.

Enclose a check for the first month's payment.

is included with this offer then $

will be sent in on the

day of each month thereafter

for a total of

months with a final payment of $

to be paid on the

month.

day of the

Note: The total months may not exceed a total of 24 months, including the first payment. Your first payment is considered to be month

1; therefore, the remainder of the payments must be made within 23 months for a total of 24.

You must continue to make these monthly payments while the IRS is considering the offer

(waived if you met the requirements for Low

. Failure to make regular monthly payments will cause your offer to be returned with no appeal rights.

Income Certification)

IRS Use Only

Attached is an addendum dated (insert date)

setting forth the amended offer amount and payment terms.

Section 5

Designation of Payment, Electronic Federal Transfer Payment System (EFTPS), and Deposit

Designation of Payment

If you want your payment to be applied to a specific tax year and a specific tax debt, such as a Trust Fund Recovery Penalty, please tell us the tax

year/quarter

. If you do not designate a preference, we will apply any money you send to the government's best interest. If you

want to designate any payments not included with this offer, you must designate a preference for each payment at the time the payment is made.

However, you cannot designate the $186 application fee or any payment after the IRS accepts the offer.

Note: Payments submitted with your offer cannot be designated as estimated tax payments for a current or past tax year.

Electronic Federal Transfer Payment System (EFTPS)

Did you make your payment through the

Electronic Federal Tax Payment System

(EFTPS)?

Yes

If yes, provide the amount of your payment(s) $

, the date paid

and the 15 digit Electronic Funds Transfer (EFT) Number

Note: Any initial payments paid through the EFTPS system must be made the same date your offer is mailed.

Deposit

If you are paying more than the initial payment with your offer and you want any part of that payment treated as a deposit, check the box below

and insert the amount.

My payment of $

includes the $186 application fee and $

for my first month's payment. I am requesting the

additional amount of $

be held as a deposit.

If your offer is rejected, returned, or withdrawn please check one of the boxes below and let us know what you would like us to do with your deposit.

Return it to you ( Initial here

)

Apply it to your tax debt ( Initial here

)

CAUTION: Do NOT designate the amounts sent in with your offer to cover the initial payment and application fee as “deposits.” Doing

so will result in the return of your offer with no right to appeal.

656

Form

(Rev. 3-2017)

Catalog Number 16728N

Form 656 - Offer In Compromise Page 4

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