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

Page 6 of 6

Shared Responsibility Payment

s) If your offer includes any shared responsibility payment (SRP) amount that you owe for not having minimum

(SRP)

essential health coverage for you and, if applicable, your dependents per Internal Revenue Code Section 5000A

- Individual shared responsibility payment, it is not subject to penalties, except applicable bad check penalty, or to

lien and levy enforcement actions. However, interest will continue to accrue until you pay the total SRP balance

due. We may apply your federal tax refunds to the SRP amount that you owe until it is paid in full.

IRS Use Only.

I accept the waiver of the statutory period of limitations on assessment for the Internal Revenue Service, as described in Section 7(n).

Signature of Authorized Internal Revenue Service Official

Title

Date

(mm/dd/yyyy)

Section 8

Signatures

Under penalties of perjury, I declare that I have examined this offer, including accompanying schedules and statements, and to the best of my

knowledge and belief, it is true, correct and complete.

►

Signature of Taxpayer/Corporation Name

Phone Number

Today's Date

(mm/dd/yyyy)

By checking this box you are authorizing the IRS to contact you at the telephone number listed above and leave detailed messages concerning

this offer on your voice mail or answering machine.

►

Phone Number

Today's Date

Signature of Spouse/Authorized Corporate Officer

(mm/dd/yyyy)

By checking this box you are authorizing the IRS to contact you at the telephone number listed above and leave detailed messages concerning

this offer on your voice mail or answering machine.

Section 9

Paid Preparer Use Only

Signature of Preparer

Phone Number

Today's Date

(mm/dd/yyyy)

By checking this box you are authorizing the IRS to contact you at the telephone number listed above and leave detailed messages concerning

this offer on your voice mail or answering machine.

Name of Paid Preparer

Preparer's CAF no. or PTIN

Firm's Name (or yours if self-employed), Address, and ZIP Code

If you would like to have someone represent you during the offer investigation, include a valid, signed

Form 2848

8821

with this application

or a copy of a previously filed form. You should also include the current tax year.

Privacy Act Statement

We ask for the information on this form to carry out the internal revenue laws of the United States. Our authority to request this information is section §

7801 of the Internal Revenue Code.

Our purpose for requesting the information is to determine if it is in the best interests of the IRS to accept an offer. You are not required to make an offer;

however, if you choose to do so, you must provide all of the taxpayer information requested. Failure to provide all of the information may prevent us from

processing your request.

If you are a paid preparer and you prepared the Form 656 for the taxpayer submitting an offer, we request that you complete and sign Section 9 on Form

656, and provide identifying information. Providing this information is voluntary. This information will be used to administer and enforce the internal

revenue laws of the United States and may be used to regulate practice before the Internal Revenue Service for those persons subject to Treasury

Department Circular No. 230, Regulations Governing the Practice of Attorneys, Certified Public Accountants, Enrolled Agents, Enrolled Actuaries, and

Appraisers before the Internal Revenue Service. Information on this form may be disclosed to the Department of Justice for civil and criminal litigation.

We may also disclose this information to cities, states and the District of Columbia for use in administering their tax laws and to combat terrorism.

Providing false or fraudulent information on this form may subject you to criminal prosecution and penalties.

656

Form

(Rev. 3-2017)

Catalog Number 16728N