www.irs.gov

Form 656 (Rev. 5-2001) Catalog Number 1 6728N

Form 656

Offer in

se

This Offer in Compromise package includes:

•	Information you need to know before submitting an offer in compromise

•	Instructions on the type of offers you can submit

•	Form 433-A, Collection Information Statement for Wage Earners and Self-Employed Individuals, and Form 433-B, Collection Information Statement for Businesses

•	A worksheet that wage earners and self-employed individuals can use to calculate their offer amount

•	Instructions on completing an offer in compromise form

•	Two copies of Form 656

Note: You can get forms and publications by calling 1–800–829–1040 or 1–800–829–FORM, or by visiting your local Internal Revenue Service (IRS) office or our website at www.irs.gov.

What You Need to Know Before

Submitting an Offer in Compromise

What is an

An Offer in Compromise (OIC) is an agreement between a taxpayer and the Internal Revenue Service (IRS) that resolves the taxpayer’s tax liability. The IRS has the authority to settle, or compromise, federal tax liabilities by accepting less than full payment under certain circumstances. The IRS may legally compromise for one of the following reasons:

 Doubt as to Collectibility — Doubt

Offer in

exists that you could ever pay the full amount of tax owed.

Compromise?

 Effective Tax Administration —

 Doubt as to Liability — Doubt exists that the assessed tax is correct.

There is no doubt the tax is correct and no doubt the amount owed could be collected, but an exceptional circumstance exists that allows us to consider your offer. To be eligible for compromise on this basis, you must demonstrate that collection of the tax would create an economic hardship or would be unfair and inequitable.

Form 656, Offer

Form 656, Offer in Compromise, is the official compromise agreement. Substitute forms, whether computer-generated or photocopies, must affirm that:

You must initial and date all pages of
the substitute form, in addition to signing and dating the signature page.

in Compromise,

and Substitute

Forms

1.The substitute form is a verbatim duplicate of the official Form 656, and

You can get Form 656 by calling 1–800–829–1040 or1–800–829–FORM, by visiting your local Internal Revenue Service (IRS) office, or by accessing our website at www.irs.gov

2.You agree to be bound by all terms

and conditions set forth in the official Form 656.

Am I Eligible for

You may be eligible for consideration of an Offer in Compromise if:

a. a collection information statement,

Consideration

and

of an Offer in

1. In your judgment, you don’t owe the tax liability (Doubt as to Liability). You must submit a detailed written statement explaining why you believe you don’t owe the tax liability you want to compromise. You won’t be required to submit a collection information statement if you’re submitting an offer on this basis alone.

b.a detailed written narrative.

Compromise?

The narrative must explain your exceptional circumstances and why paying the tax liability in full would either create an economic hardship or would be unfair and inequitable.

We’ll also consider your overall history of filing and paying taxes.

2.In your judgment, you can’t pay the

entire tax liability in full (Doubt as to Collectibility). You must submit a collection information statement showing your current financial situation.

Note: If you request consideration

3.You agree the tax liability is correct

on the basis of effective tax administration, we’re first required to establish that there is no doubt as to liability and no doubt as to collectibility. We can only consider an offer on the basis of effective tax administration after we’ve determined the liability is correct and collectible.

and you’re able to pay the balance due in full, but you have exceptional circumstances you’d like us to consider (Effective Tax Administration). To receive consideration on this basis, you must submit:

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When Am I

You are not eligible for consideration of an Offer in Compromise on the basis of doubt as to collectibility or effective tax administration if:

Note: If you are an in-business

Not Eligible for

taxpayer, you must have filed and deposited all employment taxes on time for the two (2) quarters preceding your offer,
as well as, deposit all employment taxes on time during the quarter you submit your offer.

Consideration

of an Offer in

Compromise?

1. You haven’t filed all required federal tax returns, or

2. You’re involved in an open
bankruptcy proceeding.

What We Need

For us to process your offer, you must provide a complete and correct Form 656 and:

 A taxpayer name is missing

to Process

Your Offer in

 A Social Security Number or Employer

Compromise

Identification Number is missing, incomplete, or incorrect

•	Form 433-A, Collection Information Statement for Wage Earners and Self-Employed Individuals, if you are submitting an offer as an individual or self-employed taxpayer.

 An offer amount or payment term is unstated

•	Form 433-B, Collection Information

•	A signature is missing

Statement for Businesses, if you are submitting an offer as a corporation or other business taxpayer.
We may also require Forms 433-A from corporate officers or individual partners.

 A collection information statement (Form 433-A or Form 433-B) is missing or incomplete, if your offer is based on doubt as to collectibility or effective tax administration

For a more detailed explanation of the information required to complete these forms, see the section entitled, “Financial Information” on page 3.

•	We did not receive collection information statement verification

 Our records show you don’t have a tax liability

Note: We don’t need a collection

information statement for an offer based solely on doubt as to liability.

 Your offer is submitted to delay

collection or cause a delay which will jeopardize our ability to collect the tax

Please complete all applicable items on Form 656 and provide all required documentation. We may contact you for any missing required information. If we don’t receive a response to
our request or receive the required information, we won’t recommend your offer for acceptance and will return your Form 656 to you by mail. We will explain our reason(s) for returning your offer in our letter. The reasons for return are:

Note: You should personally sign

•	The pre-printed terms and

your offer and any required collection information statements unless unusual circumstances prevent you from doing so. If someone with an authorized power of attorney signs your offer because of unusual circumstances, you must include a completed
Form 2848, Power of Attorney and Declaration of Representative, with your offer.

conditions listed on Form 656 have changed

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What You Should Do If You Want to

Submit an Offer in Compromise

Determine Your Offer Amount

All offer amounts (doubt as to liability, doubt as to collectibility, or effective tax administration) must exceed $0.00.

from your future income. Please see page 8, Terms and Definitions, for more detailed definitions of these and other terms.

•	Doubt as to Liability

If special circumstances cause you to offer an amount less than the RCP, you must also complete Item 9, Explanation of Circumstances, on Form 656, explaining your situation. Special circumstances may include factors such as advanced age, serious illness from which recovery is unlikely, or unusual circumstances that impact upon your ability to pay the total RCP and continue to provide for the necessary expenses for you and your family.

Complete Item 9, Explanation of Circumstances, on Form 656, explaining why, in your judgment, you don’t owe the tax liability you want to compromise. Offer the correct tax, penalty, and interest owed based on your judgment.

•	Doubt as to Collectibility

Complete Form 433-A, Collection Information Statement for Wage Earners and Self-Employed Individuals, or Form 433-B, Collection Information Statement for Businesses, as appropriate, and attach to your Form 656. For assistance in determining your offer amount, visit our website at www.irs.ustreas.gov/ind info/oic/ index.html. If you are a wage earner or self-employed individual, figure your offer amount by completing the worksheet on pages 10–11.

 Effective Tax Administration

Complete Form 433-A or Form 433-B, as appropriate, and attach to Form 656.

Complete Item 9, Explanation of Circumstances, on Form 656, explaining your exceptional circumstances and why requiring payment of the tax liability in full would either create an economic hardship or would be unfair and inequitable.

You must offer an amount greater than or equal to the “reasonable collection potential” (RCP). The RCP equals the net equity of your assets plus the amount we could collect

Enter your offer amount on Item 7 of Form 656.

Financial

Note: Wedonotrequirethisinformation

also request Forms 433-A from corporate officers or individual partners.

Information

if your offer is based solely on doubt as to liability.

You must provide financial information when you submit offers based on doubt as to collectibility and effective tax administration.

You must send us current information that reflects your financial situation for at least the past six months. Collection information statements must show all your assets and income, even those unavailable to us through direct collection action, because you can use them to fund your offer. The offer examiner needs this information to evaluate your offer and may ask you to update it or verify certain financial information. We may also return offer packages without complete collection information statements.

If you are submitting an offer as a
wage earner or self-employed individual, you must file Form 433-A, Collection Information Statement for Wage Earners and Self-Employed Individuals, with your Form 656. If you are a corporation or other business taxpayer, you must file Form 433-B, Collection Information Statement for Businesses. We may

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When only one spouse has a tax liability but both have incomes, only the spouse responsible for the debt is required to prepare the necessary collection information statements. In states with community property laws, however, we

require collection information statements from both spouses. We may also request financial information on the non-liable spouse for offer verification purposes, even whencommunitypropertylawsdonotapply.

Determine Your Payment Terms

There are three payment plans you and the IRS may agree to:

ten-year statutory period for collection, whichever is less).

•	Cash (paid in 90 days or less)

You can pay the short-term deferred payment plan in three ways:

•	Short-Term Deferred Payment (more than 90 days, up to 24 months)

Plan One

•	Deferred Payment (offers with

 Full payment of the realizable value of your assets within 90 days from the date we accept your offer, and

payment terms over the remaining statutory period for collecting the tax).

Cash Offer

•	Payment within two years of

You must pay cash offers within 90 days of acceptance.

acceptance of the amount we could collect over 60 months (future income) or the remaining life of the collection statute, whichever is less.

You should offer the realizable value of your assets plus the total amount we could collect over 48 months of payments (or the remainder of the ten-year statutory period for collection, whichever is less).

Plan Two

 Cash payment for a portion of the

realizable value of your assets within 90 days from the date we accept your offer, and

Note: We require full payment of

accepted doubt as to liability offers at the time of mutual agreement of the corrected liability. If you’re unable to pay the corrected amount, you must also request compromise on the basis of doubt as to collectibility.

 The balance of the realizable value

plus the amount we could collect over 60 months (future income) or the remaining life of the collection statute, whichever is less, within two years of acceptance.

Plan Three

•	The entire offer amount in monthly

Short-Term Deferred Payment Offer

payments extending over a period not to exceed two years from date of acceptance (e.g., four payments within 120 days of acceptance).

This payment plan requires you to pay the offer within two years of acceptance.

The offer must include the realizable value of your assets plus the amount we could collect over 60 months of payments (or the remainder of the

For example, on a short-term deferred payment total offer of $16,000, you might propose to pay your realizable value of assets (e.g., $13,000) within 90 days of

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acceptance and the amount of your future income (e.g., $50 per month for 60 months, or $3,000) over 6 monthly payments of $500 each, beginning the first month after acceptance.

 Your “future income” in monthly

payments during the remaining life of the collection statute

Plan Two

We may file a Notice of Federal Tax Lien on tax liabilities compromised under short-term deferred payment offers.

 Cash payment for a portion of the

realizable value of your assets within 90 days from the date we accept your offer, and

Deferred Payment Offer

 Monthly payments during the

This payment plan requires you to pay the offer amount over the remaining statutory period for collecting the tax.

remaining life of the collection statute for both the balance of the realizable value and your future income

The offer must include the realizable value of your assets plus the amount we could collect through monthly payments during the remaining life of the collection statute.

Plan Three

 The entire offer amount in monthly

payments over the life of the collection statute

For wage earners and self-employed individuals who want to submit a deferred payment offer, we will help you determine your future income amount. To compute this amount, we must calculate the remaining time left on the collection statute for each period of the tax liability.

For example, on a deferred payment offer with 7 years (84 months) remaining on the statutory period for collection and a total offer of $25,000, you might propose to pay your realizable value of assets (e.g., $10,000) within 90 days and your future income (e.g., $179 per month for 7 years, or $15,000) in 84 monthly installments of $179. Alternately, you could also pay the same total $25,000 offer in 84 monthly installments of $298.

in this calculation.

––
•	Call 1–8008291040 to assist you

•	Using Form 433-A Worksheet,

multiply the amount from Item 12, Box O, by the number of months remaining on the collection statute. Add that amount to Item 11, Box N, and use the total as the basis for your offer amount in Item 7 of Form 656.

Just as with short-term deferred payment offers, we may file a Notice of Federal Tax Lien.

Note: The worksheet on page 10

You can pay the deferred payment plan in three ways:

instructs wage earners and self-employed individuals how to figure the appropriate amount for a Cash, Short-Term Deferred Payment, or Deferred Payment Offer.

Plan One

•	Full payment of the realizable value of your assets within 90 days from the date we accept your offer, and

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How We

An offer examiner will evaluate your offer and may request additional documentation from you to verify financial or other information you provide. The examiner will then make a recommendation to accept it or reject the offer. The examiner may also

return your offer if you don’t provide the requested information.

Consider

Your Offer

The examiner may decide that a larger offer amount is necessary to justify acceptance. You will have the opportunity to amend your offer.

Additional

When you submit certain offers, we may also request that you sign an additional agreement requiring you to:

 Pay a percentage of your future earnings

Agreements

 Waive certain present orfuture tax benefits

Withholding

We will withhold collection activities while we consider your offer. We will not act to collect the tax liability:

The above do not apply if we find any indication that you submitted your offer to delay collection or cause a delay which will jeopardize our ability to collect the tax.

Collection

Activities

•	While we investigate and evaluate your offer

•	For 30 days after we reject an offer

If you currently have an installment agreement when you submit an offer, you must continue making the agreed upon monthly payments while we consider your offer.

•	While you appeal an offer rejection

If We Accept

If we accept your offer, we will notify you by mail. When you receive your acceptance letter, you must:

release of a lien, you can submit certified funds with a request letter.

Your Offer

•	Promptly pay any unpaid amounts

In the future, not filing returns or paying taxes when due could result in the default of an accepted offer (see Form 656,
Item 8(d), the future compliance provision). If you default your agreement, we will reinstate the unpaid amount of the original tax liability, file a Notice of Federal Tax Lien on any tax liability without a filed notice,
and resume collection activities. The future compliance provision applies to offers based on doubt as to collectibility. In certain cases, the future compliance provision may apply to offers based on effective tax administration.

that become due under the terms of the offer agreement

•	Comply with all the terms and

conditions of the offer, along with those of any additional agreement

•	Promptly notify us of any change of

address until you meet the conditions of your offer. Your acceptance letter will indicate which IRS office to contact if your address changes. Your notification allows us to contact you immediately regarding the status of your offer

We will release all Notices of Federal Tax Lien when you satisfy the payment terms of the offered amount. For an immediate

We won’t default your offer agreement when you have filed a joint offer with your spouse or ex-spouse as long as you’ve kept or are keeping all the terms of the agreement, even if your spouse orex-spouse violates the future compliance provision.

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Form 656

IRS RECEIVED DATE

Offer in Compromise

Item 1 — Taxpayer’s Name and Home or Business Address

www.irs.gov

Form 656 (Rev. 5-2001)

Catalog Number 16728N

Name

Name

Street Address

City

State

ZIP Code

Mailing Address (if different from above)

Street Address

DATE RETURNED

City

State

ZIP Code

Item 2 — Social Security Numbers

Item 6 — I/We submit this offer for the reason(s) checked below:

(a) Primary

Doubt as to Liability — “I do not believe I owe this amount.”

(b) Secondary

You must include a detailed explanation of the reason(s) why you believe you do not owe the tax in Item 9.

Doubt as to Collectibility — “I have insufficient assets and

Item 3 — Employer Identification Number (included in offer)

income to pay the full amount.” You must include a complete Collection Information Statement, Form 433-A and/or Form 433-B.

Effective Tax Administration — “I owe this amount and have

Item 4 — Other Employer Identification Numbers (not

sufficient 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.” You must include a complete Collection Information Statement, Form 433-A and/or

included in offer)

Form 433B and complete Item 9.

Item 7

Item 5 — To: Commissioner of Internal Revenue Service

I/We offer to pay $

(must be more than zero).

I/We (includes all types of taxpayers) submit this offer to compromise the tax liabilities plus any interest, penalties, additions to tax, and additional amounts required by law (tax liability) for the tax type and period marked below: (Please mark an “X” in the box for the correct description and fill-in the correct tax period(s), adding additional periods if needed).

Complete item 10 to explain where you will obtain the funds to make this offer.

Check one of the following:

Cash Offer (Offered amount will be paid in 90 days or less.)

Balance to be paid in:

10;

30;

60; or

90 days from

1040/1120 Income Tax — Year(s)

written notice of acceptance of the offer.

Short-Term Deferred Payment Offer (Offered amount will

941 Employer’s Quarterly Federal Tax Return — Quarterly

be paid in MORE than 90 days but within 24 months from written notice of acceptance of the offer.)

period(s)

$

within

days (not more than 90

940 Employer’s Annual Federal Unemployment (FUTA) Tax

—

See Instructions Section, Determine Your Payment Terms)

Return — Year(s)

from written notice of acceptance of the offer; and

beginning in the

of the offer, $

on the

day of each

(enter corporation name)

month for a total of

months. (Cannot extend more than

24 months from written notice of acceptance of the offer.)

for failure to pay withholding and Federal Insurance

Contributions Act Taxes (Social Security taxes), for period(s)

Deferred Payment Offer (Offered amount will be paid over

ending

the life of the collection statute.)

Other Federal Tax(es) [specify type(s) and period(s)]

$

within

days (not more than

90 — See Instructions Section, Determine Your Payment Terms) from written notice of acceptance of the offer; and

Note: If you need more space, use another sheet titled

“Attachment to Form 656 Dated

beginning in the first month after written notice of acceptance of

Sign and date the attachment following the listing of the tax periods.

the offer, $

on the

day of each month

for a total of

months.

NOTE: Signature(s) of taxpayer required on last page of Form 656

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□

□

□
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□
□
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□

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Trust Fund Recovery Penalty as a responsible person of

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Item 8 — By submitting this offer, I/we understand and agree to the following conditions:

(a) I/We voluntarily submit all payments made on this offer.

waiver. The amount of any Federal tax due for the periods described in Item 5 may be assessed at any time prior to the acceptance of this offer or within one year of the rejection of this offer.

(b) The IRS will apply payments made under

the terms of this offer in the best interest of the government.

(f)

The IRS will keep all payments and credits made, received or applied to the total original tax liability before submission of this offer. The IRS may keep any proceeds from a levy served prior to submission of the offer, but not received at the time the offer is submitted. If I/we have an installment agreement prior to submitting the offer, I/we must continue to make the payments as agreed while this offer is pending. Installment agreement payments will not be applied against the amount offered.

(c) If the IRS rejects or returns the offer or I/we

withdraw the offer, the IRS will return any amount paid with the offer. If I/we agree in writing, IRS will apply the amount paid with the offer to the amount owed. If I/we agree to apply the payment, the date the IRS received the offer remittance will be considered the date of payment. I/We understand that the IRS will not pay interest on any amount I/we submit with the offer.

(d) I/We will comply with all provisions of

the Internal Revenue Code relating to filing my/our returns and paying my/our required taxes for 5 years or until the offered amount is paid in full, whichever is longer. In the case of a jointly submitted offer to compromise joint tax liabilities, I/we understand that default with respect to the compliance provisions described in this paragraph by one party to this agreement will not result in the default of the entire agreement. The default provisions described in Item 8(n) of this agreement will be applied only to the party failing to comply with the requirements of this paragraph. This provision does not apply to offers based on Doubt as to Liability.

(g) As additional consideration beyond the

amount of my/our offer, the IRS will keep any refund, including interest, due to me/ us because of overpayment of any tax or other liability, for tax periods extending
through the calendar year that the IRS accepts the offer. I/We may not designate an overpayment ordinarily subject to refund, to which the IRS is entitled, to be applied to estimated tax payments for the following year. This condition does not apply if the offer is based on Doubt as to Liability.

(h) I/We will return to the IRS any refund

identified in (g) received after submission of this offer. This condition does not apply to offers based on Doubt as to Liability.

(e) I/We waive and agree to the suspension of any statutory periods of limitation (time limits provided for by law) for the IRS assessment of the tax liability for the periods identified in Item 5. I/We understand that I/we have the right not to waive these statutory periods or to limit the waiver to a certain length or to certain issues. I/We understand, however, that the IRS may not consider this offer if I/we refuse to waive the statutory periods for assessment or if we provide only a limited

(i)

The IRS cannot collect more than the full amount of the tax liability under this offer.

(j)

I/We understand that I/we remain responsible for the full amount of the tax liability, unless and until the IRS accepts the offer in writing and I/we have met all the terms and conditions of the offer. The IRS will not remove the original amount of the tax liability from its records until I/we have met all the terms of the offer.

NOTE: Signature(s) of taxpayer required on last page of Form 656

(k) I/We understand that the tax I/we offer

 immediately file suit to collect an amount equal to the original amount of the tax liability as liquidating damages, minus any payment already received under the terms of this offer

to compromise is and will remain a tax liability until I/we meet all the terms and conditions of this offer. If I/we file bankruptcy before the terms and conditions of this offer are completed, any claim the IRS files in the bankruptcy proceedings will be a tax claim.

 disregard the amount of the offer and apply all amounts already paid under the offer against the original amount of the tax liability

(l)

Once the IRS accepts the offer in writing, I/we have no right to contest,
in court or otherwise, the amount of the tax liability.

 file suit or levy to collect the original

amount of the tax liability, without further notice of any kind.

(m) The offer is pending starting with the

The IRS will continue to add interest, as Section 6601 of the Internal Revenue Code requires, on the amount the IRS determines is due after default. The IRS will add interest from the date the offer is defaulted until I/we completely satisfy the amount owed.

date an authorized IRS official signs this form. The offer remains pending until an authorized IRS official accepts, rejects, returns or acknowledges withdrawal of the offer in writing. If I/we appeal an IRS rejection decision on the offer, the IRS will continue to treat the offer as pending until the Appeals Office accepts or rejects the offer in writing. If I/we don’t file a protest within 30 days of the date the IRS notifies me/us of the right to protest the decision, I/we waive the right to a hearing before the Appeals Office about the offer in compromise.

(o) The IRS generally files a Notice of Federal

Tax Lien to protect the Government’s interest on deferred payment offers. This tax lien will be released when the payment terms of the offer agreement have been satisfied.

(p) I/We understand that the IRS employees

(n) If I/We fail to meet any of the terms and conditions of the offer and the offer defaults, then the IRS may:

may contact third parties in orderto respond to this request and I authorize the IRS to makesuch contacts. Further, byauthorizing the Internal Revenue Service to contact third parties, I understand that I will not receive notice, pursuant to section 7602(c) of theInternal RevenueCode, of third parties contacted in connection with this request.

 immediately file suit to collect the entire unpaid balance of the offer

NOTE: Signature(s) of taxpayer required on last page of Form 656

Item 9 — Explanation of Circumstances
I am requesting an offer in compromise for the reason(s) listed below:

Note: If you are requesting compromise based on doubt as to liability, explain why you don’t believe you owe the tax.

If you believe you have special circumstances affecting your ability to fully pay the amount due, explain your situation. You may attach additional sheets if necessary.

Item 10 — Source of Funds
I/we shall obtain the funds to make this offer from the following source(s):

Item 11

For Official Use Only

If I/we submit this offer on a substitute form, I/we affirm that this form is a verbatim duplicate of the official Form 656, and I/we agree to be bound by all the terms and conditions set forth in the official Form656.

I accept the waiver of the statutory period of limitations for the Internal Revenue Service.

Signature of Authorized Internal Revenue Service Official

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.

Title

Date

11(a) Signature of Taxpayer

Date

11(b) Signature of Taxpayer

Date

NOTE: Signature(s) of taxpayer required on last page of Form 656

Form 656

IRS RECEIVED DATE

Offer in Compromise

Item 1 — Taxpayer’s Name and Home or Business Address

www.irs.gov

Form 656 (Rev. 5-2001)

Catalog Number 1 6728N

Name

Name

Street Address

City

State

ZIP Code

Mailing Address (if different from above)

Street Address

DATE RETURNED

City

State

ZIP Code

Item 2 — Social Security Numbers

Item 6 — I/We submit this offer for the reason(s) checked below:

(a) Primary

Doubt as to Liability — “I do not believe I owe this amount.”

(b) Secondary

You must include a detailed explanation of the reason(s) why you believe you do not owe the tax in Item 9.

Doubt as to Collectibility — “I have insufficient assets and

Item 3 — Employer Identification Number (included in offer)

income to pay the full amount.” You must include a complete Collection Information Statement, Form 433-A and/or Form 433-B.

Effective Tax Administration — “I owe this amount and have

Item 4 — Other Employer Identification Numbers (not

sufficient 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.” You must include a complete Collection Information Statement, Form 433-A and/

included in offer)

or Form 433B and complete Item 9.

Item 7

Item 5 — To: Commissioner of Internal Revenue Service

I/We offer to pay $

(must be more than zero).

I/We (includes all types of taxpayers) submit this offer to compromise the tax liabilities plus any interest, penalties, additions to tax, and additional amounts required by law (tax liability) for the tax type and period marked below: (Please mark an “X” in the box for the correct description and fill-in the correct tax period(s), adding additional periods if needed).

Complete item 10 to explain where you will obtain the funds to make this offer.

Check one of the following:

Cash Offer (Offered amount will be paid in 90 days or less.)

Balance to be paid in:

10;

30;

60; or

90 days from

1040/1120 Income Tax — Year(s)

written notice of acceptance of the offer.

Short-Term Deferred Payment Offer (Offered amount will

941 Employer’s Quarterly Federal Tax Return — Quarterly

be paid in MORE than 90 days but within 24 months from written notice of acceptance of the offer.)

period(s)

$

within

days (not more than 90

940 Employer’s Annual Federal Unemployment (FUTA) Tax

—

See Instructions Section, Determine Your Payment Terms)

Return — Year(s)

from written notice of acceptance of the offer; and

beginning in the

of the offer, $

on the

day of each

(enter corporation name)

month for a total of

months. (Cannot extend more than

24 months from written notice of acceptance of the offer.)

for failure to pay withholding and Federal Insurance

Contributions Act Taxes (Social Security taxes), for period(s)

Deferred Payment Offer (Offered amount will be paid over

ending

the life of the collection statute.)

Other Federal Tax(es) [specify type(s) and period(s)]

$

within

days (not more than

90 — See Instructions Section, Determine Your Payment Terms) from written notice of acceptance of the offer; and

Note: If you need more space, use another sheet titled

“Attachment to Form 656 Dated

beginning in the first month after written notice of acceptance of

Sign and date the attachment following the listing of the tax periods.

the offer, $

on the

day of each month

for a total of

months.

NOTE: Signature(s) of taxpayer required on last page of Form 656

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□
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Trust Fund Recovery Penalty as a responsible person of

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Item 8 — By submitting this offer, I/we understand and agree to the following conditions:

(a) I/We voluntarily submit all payments made on this offer.

waiver. The amount of any Federal tax due for the periods described in Item 5 may be assessed at any time prior to the acceptance of this offer or within one year of the rejection of this offer.

(b) The IRS will apply payments made under

the terms of this offer in the best interest of the government.

(f)

The IRS will keep all payments and credits made, received or applied to the total original tax liability before submission of this offer. The IRS may keep any proceeds from a levy served prior to submission of the offer, but not received at the time the offer is submitted. If I/we have an installment agreement prior to submitting the offer, I/we must continue to make the payments as agreed while this offer is pending. Installment agreement payments will not be applied against the amount offered.

(c) If the IRS rejects or returns the offer or I/we

withdraw the offer, the IRS will return any amount paid with the offer. If I/we agree in writing, IRS will apply the amount paid with the offer to the amount owed. If I/we agree to apply the payment, the date the IRS received the offer remittance will be considered the date of payment. I/We understand that the IRS will not pay interest on any amount I/we submit with the offer.

(d) I/We will comply with all provisions of

the Internal Revenue Code relating to filing my/our returns and paying my/our required taxes for 5 years or until the offered amount is paid in full, whichever is longer. In the case of a jointly submitted offer to compromise joint tax liabilities, I/we understand that default with respect to the compliance provisions described in this paragraph by one party to this agreement will not result in the default of the entire agreement. The default provisions described in Item 8(n) of this agreement will be applied only to the party failing to comply with the requirements of this paragraph. This provision does not apply to offers based on Doubt as to Liability.

(g) As additional consideration beyond the

amount of my/our offer, the IRS will keep any refund, including interest, due to me/ us because of overpayment of any tax or other liability, for tax periods extending
through the calendar year that the IRS accepts the offer. I/We may not designate an overpayment ordinarily subject to refund, to which the IRS is entitled, to be applied to estimated tax payments for the following year. This condition does not apply if the offer is based on Doubt as to Liability.

(h) I/We will return to the IRS any refund

identified in (g) received after submission of this offer. This condition does not apply to offers based on Doubt as to Liability.

(e) I/We waive and agree to the suspension of any statutory periods of limitation (time limits provided for by law) for the IRS assessment of the tax liability for the periods identified in Item 5. I/We understand that I/we have the right not to waive these statutory periods or to limit the waiver to a certain length or to certain issues. I/We understand, however, that the IRS may not consider this offer if I/we refuse to waive the statutory periods for assessment or if we provide only a limited

(i)

The IRS cannot collect more than the full amount of the tax liability under this offer.

(j)

I/We understand that I/we remain responsible for the full amount of the tax liability, unless and until the IRS accepts the offer in writing and I/we have met all the terms and conditions of the offer. The IRS will not remove the original amount of the tax liability from its records until I/we have met all the terms of the offer.

NOTE: Signature(s) of taxpayer required on last page of Form 656

(k) I/We understand that the tax I/we offer

 immediately file suit to collect an amount equal to the original amount of the tax liability as liquidating damages, minus any payment already received under the terms of this offer

to compromise is and will remain a tax liability until I/we meet all the terms and conditions of this offer. If I/we file bankruptcy before the terms and conditions of this offer are completed, any claim the IRS files in the bankruptcy proceedings will be a tax claim.

 disregard the amount of the offer and apply all amounts already paid under the offer against the original amount of the tax liability

(l)

Once the IRS accepts the offer in writing, I/we have no right to contest,
in court or otherwise, the amount of the tax liability.

 file suit or levy to collect the original

amount of the tax liability, without further notice of any kind.

(m) The offer is pending starting with the

The IRS will continue to add interest, as Section 6601 of the Internal Revenue Code requires, on the amount the IRS determines is due after default. The IRS will add interest from the date the offer is defaulted until I/we completely satisfy the amount owed.

date an authorized IRS official signs this form. The offer remains pending until an authorized IRS official accepts, rejects, returns or acknowledges withdrawal of the offer in writing. If I/we appeal an IRS rejection decision on the offer, the IRS will continue to treat the offer as pending until the Appeals Office accepts or rejects the offer in writing. If I/we don’t file a protest within 30 days of the date the IRS notifies me/us of the right to protest the decision, I/we waive the right to a hearing before the Appeals Office about the offer in compromise.

(o) The IRS generally files a Notice of Federal

Tax Lien to protect the Government’s interest on deferred payment offers. This tax lien will be released when the payment terms of the offer agreement have been satisfied.

(p) I/We understand that the IRS employees

(n) If I/We fail to meet any of the terms and conditions of the offer and the offer defaults, then the IRS may:

may contact third parties in orderto respond to this request and I authorize the IRS to makesuch contacts. Further, byauthorizing the Internal Revenue Service to contact third parties, I understand that I will not receive notice, pursuant to section 7602(c) of theInternal RevenueCode, of third parties contacted in connection with this request.

 immediately file suit to collect the entire unpaid balance of the offer

NOTE: Signature(s) of taxpayer required on last page of Form 656

Item 9 — Explanation of Circumstances
I am requesting an offer in compromise for the reason(s) listed below:

Note: If you are requesting compromise based on doubt as to liability, explain why you don’t believe you owe the tax.

If you believe you have special circumstances affecting your ability to fully pay the amount due, explain your situation. You may attach additional sheets if necessary.

Item 10 — Source of Funds
I/we shall obtain the funds to make this offer from the following source(s):

Item 11

For Official Use Only

If I/we submit this offer on a substitute form, I/we affirm that this form is a verbatim duplicate of the official Form 656, and I/we agree to be bound by all the terms and conditions set forth in the official Form656.

I accept the waiver of the statutory period of limitations for the Internal Revenue Service.

Signature of Authorized Internal Revenue Service Official

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.

Title

Date

11(a) Signature of Taxpayer

Date

11(b) Signature of Taxpayer

Date

NOTE: Signature(s) of taxpayer required on last page of Form 656

Collection Information Statement for Wage Earners and Self-Employed Individuals

Complete all entry spaces with the most current data available.
Important! Write “N/A” (not applicable) in spaces that do not apply. We may require additional information

www.irs.gov

to support “N/A” entries.

Form 433-A (Rev. 5-2001) Catalog Number 20312N

Failure to complete all entry spaces may result in rejection or significant delay in the resolution of your account.

Section 1

1. Full Name(s)

1a. Home

Best Time To Call:

Personal

Telephone (	)

am

pm

Information

Street Address

(Enter Hour)

2. Marital Status:

City

State

Zip

Married

Separated

County of Residence

How long at this address?

Unmarried (single, divorced, widowed)

3. Your Social Security No.(SSN)

3a. Your Date of Birth (mm/dd/yyyy)

4. Spouse’s Social Security No.

4a. Spouse’s Date of Birth (mm/dd/yyyy)

5.

Own Home

Rent

Other (specify, i.e. share rent, live with relative)

6. List the dependents you can claim on your tax return: (Attach sheet if more space is needed.)

First Name	Relationship Age

Does this person

First Name	Relationship

Age

Does this person

live with you?

live with you?

Check this box

No

Yes

No

Yes

when all spaces in

Sect. 1 are filled in.

No

Yes

No

Yes

Section 2

7. Are you or your spouse self-employed or operate a business? (Check “Yes” if either applies)

Your

No

Yes If yes, provide the following information:

Business

7a. Name of Business

7c. Employer Identification No., if available :

Information

7b. Street Address

7d. Do you have employees?

No

Yes

City

State

Zip

7e. Do you have accounts/notes receivable?

No

Yes

Check this box

If yes, please complete Section 8 on page 5.

when all spaces in

Sect. 2 are filled in

ATTACHMENTS REQUIRED: Please include proof of self-employment income for the prior 3 months (e.g., invoices, commissions, sales records, income statement).

and attachments

provided.

Section 3

8. Your Employer

9. Spouse’s Employer

Street Address

Street Address

Employment

Information

City

State

Zip

City

State

Zip

Work telephone no.

Work telephone no

May we contact you at work?

No

Yes

May we contact you at work?

No

Yes

8a. How long with this employer?

9a. How long with this employer?

9b. Occupation

Check this box

when all spaces in

ATTACHMENTS REQUIRED: Please provide proof of gross earnings and deductions for the past 3 months from each employer (e.g., pay stubs, earnings statements). If year-to-date information is available, send only 1 such statement as long as a minimum of 3 months is represented.

Sect. 3 are filled in

and attachments

provided.

Section 4

10. Do you receive income from sources other than your own business or your employer? (Check all that apply.)

Other

Income

Pension

Social Security

Other (specify, i.e. child support, alimony, rental)

Information

Check this box

when all spaces in

ATTACHMENTS REQUIRED: Please provide proof of pension/social security/other income for the past 3 months from each payor, including any statements showing deductions. If year-to-date information is available, send only 1 such statement as long as a minimum of 3 months is represented.

Sect. 4 are filled in

and attachments

provided.

Page 1 of 6

Section 5 begins on page 2

(Rev. 5-2001)

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Collection Information Statement for Wage Earners and Self-Employed Individuals

Form 433-A

Name

SSN

Banking,

Investment,

and Life

Insurance

Information

Complete all

entry spaces

with the most

current data

available.

:() Current

Value:

Indicate the

amount you

could sell the

asset for

today.

Section 5 11. CHECKING ACCOUNTS. List all checking accounts. (If you need additional space, attach a separate sheet.)

Type of

Full Name of Bank, Savings & Loan, Credit Union or Financial Institution

Bank

Bank

Current

Account

Routing No.

Account No.

Account Balance

Cash, Credit, 11a. Checking

Name

$

Street Address

City/State/Zip

11 b. Checking

Name

$

Street Address

City/State/Zip

11 c. Total Checking Account Balances $

12. OTHER ACCOUNTS. List all acounts, including brokerage, savings, and money market, not listed on line 11.

Type of

Full Name of Bank, Savings & Loan, Credit Union or Financial Institution

Bank

Bank

Current

Account

Routing No.

Account No.

Account Balance

12a.

Name

$

Street Address

City/State/Zip

12b.

Name

$

Street Address

City/State/Zip

12c. Total Other Account Balances

ATTACHMENTS REQUIRED: Please include your current bank statements (checking, savings, money market, and brokerage accounts) for the past three months for all accounts.

13. INVESTMENTS. List all investment assets below. Include stocks, bonds, mutual funds, stock options, certificates of deposits, and retirement assets such as IRAs, Keogh, and 401(k) plans. (If you need additional space, attach a separate sheet.)

Name of Company

Shares / Units

Number of

:()Current

Value

Amount

Loan

on loan?

Used as collateral

13a.

$

$

No

Yes

13b.

No

Yes

13c.

No

Yes

13d. Total Investments

$

14. CASH ON HAND. Include any money that you have that is not in the bank.

14a. Total Cash on Hand

$

15. AVAILABLE CREDIT. List all lines of credit, including credit cards.

Full Name of

Credit Institution

Credit Limit

Amount Owed

Available Credit

15a. Name

$

Street Address

City/State/Zip

15b. Name

$

Street Address

City/State/Zip

15c. Total Credit Available	$

Page 2 of 6

Section 5 continued on page 3

(Rev. 5-2001)

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Collection Information Statement for Wage Earners and Self-Employed Individuals

Form 433-A

Name

SSN

Section 5

continued

Check this box

when all spaces in

Sect. 5 are filled in

and attachments

provided.

16. LIFE INSURANCE. Do you have life insurance with a cash value?

No

Yes

(Term Life insurance does not have a cash value.)

If yes:

16a. Name of Insurance Company

16b. Policy Number(s)

1 6c. Owner of Policy

16d. Current Cash Value $

16e. Outstanding Loan Balance $

Subtract “Outstanding Loan Balance“ line 16e from “Current Cash Value” line 16d = 16f $

ATTACHMENTS REQUIRED: Please include a statement from the life insurance companies that includes type and cash/loan value amounts. If currently borrowed against, include loan amount and date of loan.

Section 6

Other

Information

Check this box

Sect. 6 are filled in.

17. OTHER INFORMATION. Respond to the following questions related to your financial condition: (Attach sheet if you need more space.)

17a. Are there any garnishments against your wages?

No

Yes

If yes, who is the creditor?

Date creditor obtained judgement

Amount of debt $

17b. Are there any judgments against you?

No

Yes

If yes, who is the creditor?

Date creditor obtained judgement

Amount of debt $

17c. Are you a party in a lawsuit?

No

Yes

If yes, amount of suit $

Possible completion date

Subject matter of suit

17d. Did you ever file bankruptcy?

No

Yes

If yes, date filed

Date discharged

17e. In the past 10 years did you transfer any
name for less than

assets out of lyou?r their actual va

No

Yes

If yes, what asset?

Value of asset at time of transfer $

When was it transferred?

To whom was it transferred?

17f. Do you anticipate any increase in household income in the next two years?

No

Yes

If yes, why will the income increase?

(Attach sheet if you need more space.)

How much will it increase? $

17g. Are you a beneficiary of a trust or an estate?

No

Yes

If yes, name of the trust or estate

Anticipated amount to be received $

When will the amount be received?

when all spaces in 17h. Are you a participant in a profit sharing plan?

No

Yes

If yes, name of plan

Value in plan $

Section 7

Assets and

Liabilities

() Current

Value:

Indicate the

amount you

could sell the

asset for

today.

18. PURCHASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s, motorcycles, trailers, etc. (If you need additional space, attach a separate sheet.)

Description

()C urrent

Current

Name of

Purchase

Amount of

Monthly

(Year, Make, Model, Mileage)

Value

Loan

Balance

Lender

Date

Payment

18a. Year

Make/Model

Mileage

$

$

18b. Year

Make/Model

Mileage

$

$

$

18c. Year

Make/Model

Mileage

$

$

$

Page 3 of 6

Section 7 continued on page 4

(Rev. 5-2001)

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Collection Information Statement for Wage Earners and Self-Employed Individuals

Form 433-A

Name

SSN

continued

:( )Current

Value:

Indicate the

amount you

could sell the

asset for

today.

* Date of

Final Pay‑

ment:

Enter the date

the loan or

lease will be

fully paid.

provided.

Section 7 19. LEASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s, motorcycles, trailers, etc. (If you need additional space, attach a separate sheet.)

Name and

Amount of

Description

(Year, Make, Model)

Lease

Balance

Address of

Lessor

Lease

Date

Monthly

Payment

19a. Year

Make/Model

$

$

19b. Year

Make/Model

$

$

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly car payment amount and current balance of the loan for each vehicle purchased or leased.

20. REAL ESTATE. List all real estate you own. (If you need additional space, attach a separate sheet.)

Amount of

*Date

Street Address, City, State, Zip, and County

Date

Purchase

:( )Current

Loan

Name of Lender

Monthly

of Final

Purchased Price

Value

Balance

or Lien Holder

Payment

Payment

20a.

$

$

$

20b.

$

$

$

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly payment amount and current balance for each piece of real estate owned.

21. PERSONAL ASSETS. List all Personal assets below. (If you need additional space, attach separate sheet.)

Furniture/Personal Effects includes the total current market value of your household such as furniture and appliances. Other Personal Assets includes all artwork, jewelry, collections (coin/gun, etc.), antiques or other assets.

Amount of

 Date of

:( )Current

Loan

Monthly

Final

Description

Value

Balance

Name of Lender

Payment

Payment

21a. Furniture/Personal Effects

$

Other: (List below)

21 b. Artwork

$

$

$

21c. Jewelry

21 d.

21e.

22. BUSINESS ASSETS. List all business assets and encumbrances below, include Uniform Commercial Code (UCC) filings. (If

you need additional space, attach a separate sheet.) Tools used in Trade or Business includes the basic tools or books used to conduct your business, excluding automobiles. Other Business Assets includes any other machinery, equipment, inventory or other assets.

Amount of

 Date of

:( )Current

Loan

Monthly

Final

Description

Value

Balance

Name of Lender

Payment

Payment

22a. Tools used in Trade/Business $

$

$

Other: (List below)

22b. Machinery

$

$

$

Check this box 22c. Equipment

when all spaces in

Sect. 7 are filled in 22d.

and attachments 22e.

Page 4 of 6

Section 8 begins on page 5

(Rev. 5-2001)

□

Collection Information Statement for Wage Earners and Self-Employed Individuals

Form 433-A

Name

SSN

Use only if

needed.

Check this

8 not needed.

Check this box

when all spaces in

Sect. 8 are filled in.

Section 8 23. ACCOUNTS/NOTES RECEIVABLE. List all accounts separately, including contracts awarded, but not Accounts/
Notes
Receivable

started. (If you need additional space, attach a separate sheet.)

Description

Amount Due

Date Due

Age of Account

$

0 - 30 days

23a. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

box if Section23b. Name

$

0 - 30 days

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

23c. Name

$

0 - 30 days

Street Address

30 - 60 days

City/State/Zip

60 - 90 days

90+ days

$

0 - 30 days

23d. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23e. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23f. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

23g. Name

$

0 - 30 days

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23h. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23i. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23j. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

23k. Name

$

0 - 30 days

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23l. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

Add “Amount Due” from lines 23a through 23l = 23m

$

Page 5 of 6

Section 9 begins on page 6

(Rev. 5-2001)

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Collection Information Statement for Wage Earners and Self-Employed Individuals

Form 433-A

Name

SSN

Section 9 Total Income

Total Living Expenses

Monthly

Source

Gross Monthly

Expense Items 4

Actual Monthly

Income and 24. Wages (Yourself)'

$

35. Food, Clothing and Misc.5

$

25. Wages (Spouse)'

36. Housing and Utilities6

Expense

Analysis

26. Interest - Dividends

37. Transportation7

27. Net Income from Business2

38. Health Care

If only one

28. Net Rental Income3

39. Taxes (Income and FICA)

spouse has a

29. Pension/Social Security (Yourself)

tax liability, but

40. Court ordered payments

30. Pension/Social Security (Spouse)

both have

41. Child/dependent care

income, list the 3'. Child Support

42. Life insurance

total household 32. Alimony

43. Other secured debt

income and

33. Other

44. Other expenses

expenses.

34. Total Income

$

45. Total Living Expenses

$

' Wages, salaries, pensions, and social security: Enter your gross monthly wages and/or salaries. Do not deduct withholding or allotments you elect to take out of your pay, such as insurance payments, credit union deductions, car payments etc.

To calculate your gross monthly wages and/or salaries:

If paid weekly - multiply weekly gross wages by 4.3. Example: $425.89 x 4.3 = $1,831.33
If paid bi-weekly (every 2 weeks) - multiply bi-weekly gross wages by 2.17. Example: $972.45 x 2.17 = $2,110.22
If paid semi-monthly (twice each month) - multiply semi-monthly gross wages by 2. Example: $856.23 x 2 = $1,712.46

2 Net Income from Business: Enter your monthly net business income. This is the amount you earn after you pay ordinary and necessary monthly business expenses. This figure should relate to the yearly net profit from your Form 1040 Schedule C. If it is more or less than the previous year, you should attach an explanation. If your net business income is a loss, enter “0”. Do not enter a negative number.

3 Net Rental Income: Enter your monthly net rental income. This is the amount you earn after you pay ordinary and necessary monthly rental expenses. If your net rental income is a loss, enter “0”. Do not enter a negative number.

4 Expenses not generally allowed: We generally do not allow you to claim tuition for private schools, public or private college expenses, charitable contributions, voluntary retirement contributions, payments on unsecured debts such as credit card bills, cable television and other similar expenses. However, we may allow these expenses, if you can prove that they are necessary for the health and welfare of you or your family or for the production of income.

5 Food, Clothing and Misc.: Total of clothing, food, housekeeping supplies and personal care products for one month.

6 Housing and Utilities: For your principal residence: Total of rent or mortgage payment. Add the average monthly expenses for the following: property taxes, home owner’s or renter’s insurance, maintenance, dues, fees, and utilities. Utilities include gas, electricity, water, fuel, oil, other fuels, trash collection and telephone.

7 Transportation: Total of lease or purchase payments, vehicle insurance, registration fees, normal maintenance, fuel, public transportation, parking and tolls for one month.

ATTACHMENTS REQUIRED: Please include:
•	A copy of your last Form 1040 with all Schedules.

•	Proof of all current expenses that you paid for the past 3 months, including utilities, rent, insurance, property taxes, etc.

•	Proof of all non-business transportation expenses (e.g., car payments, lease payments, fuel, oil, insurance, parking, registration).

Check this

•	Proof of payments for health care, including health insurance premiums, co-payments, and other out-of-pocket expenses, for the past 3 months.

box when all

• Copies of any court order requiring payment and proof of such payments (e.g., cancelled checks, money orders, earning statements showing such deductions) for the past 3 months.

spaces in Sect. 9

are filled in and

attachments

provided.

Check this box

when all spaces in

Failure to complete all entry spaces may result in rejection or significant delay in the resolution of your

all sections are

filled in and all

account.

attachments

provided.

Certification: Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities, and other information is true, correct and complete.

Your Signature

Spouse’s Signature

Date

Page 6 of 6

(Rev. 5-2001)

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Collection Information Statement for Wage Earners and Self-Employed Individuals

Complete all entry spaces with the most current data available.
Important! Write “N/A” (not applicable) in spaces that do not apply. We may require additional information

www.irs.gov

to support “N/A” entries.

Form 433-A (Rev. 5-2001) Catalog Number 20312N

Failure to complete all entry spaces may result in rejection or significant delay in the resolution of your account.

Section 1

1. Full Name(s)

1a. Home

Best Time To Call:

Personal

Telephone (	)

am

pm

Information

Street Address

(Enter Hour)

2. Marital Status:

City

State

Zip

Married

Separated

County of Residence

How long at this address?

Unmarried (single, divorced, widowed)

3. Your Social Security No.(SSN)

3a. Your Date of Birth (mm/dd/yyyy)

4. Spouse’s Social Security No.

4a. Spouse’s Date of Birth (mm/dd/yyyy)

5.

Own Home

Rent

Other (specify, i.e. share rent, live with relative)

6. List the dependents you can claim on your tax return: (Attach sheet if more space is needed.)

First Name	Relationship Age

Does this person

First Name	Relationship

Age

Does this person

live with

live with you?

Check this box

No

Yes

No

Yes

when all spaces in

Sect. 1 are filled in.

No

Yes

No

Yes

Section 2

7. Are you or your spouse self-employed or operate a business? (Check “Yes” if either applies)

Your

No

Yes If yes, provide the following information:

Business

7a. Name of Business

7c. Employer Identification No., if available :

Information

7b. Street Address

7d. Do you have employees?

No

Yes

City

State

Zip

7e. Do you have accounts/notes receivable?

No

Yes

Check this box

If yes, please complete Section 8 on page 5.

when all spaces in

Sect. 2 are filled in

ATTACHMENTS REQUIRED: Please include proof of self-employment income for the prior 3 months (e.g., invoices, commissions, sales records, income statement).

and attachments

provided.

Section 3

8. Your Employer

9. Spouse’s Employer

Street Address

Street Address

Employment

Information

City

State

Zip

City

State

Zip

Work telephone no.

Work telephone no

May we contact you at work?

No

Yes

May we contact you at work?

No

Yes

8a. How long with this employer?

9a. How long with this employer?

8b. Occupation

9b. Occupation

Check this box

when all spaces in

ATTACHMENTS REQUIRED: Please provide proof of gross earnings and deductions for the past 3 months from each employer (e.g., pay stubs, earnings statements). If year-to-date information is available, send only 1 such statement as long as a minimum of 3 months is represented.

Sect. 3 are filled in

and attachments

provided.

Section 4

10. Do you receive income from sources other than your own business or your employer? (Check all that apply.)

Other

Income

Pension

Social Security

Other (specify, i.e. child support, alimony, rental)

Information

Check this box

when all spaces in

ATTACHMENTS REQUIRED: Please provide proof of pension/social security/other income for the past 3 months from each payor, including any statements showing deductions. If year-to-date information is available, send only 1 such statement as long as a minimum of 3 months is represented.

Sect. 4 are filled in

and attachments

provided.

Page 1 of 6

Section 5 begins on page 2

(Rev. 5-2001)

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Collection Information Statement for Wage Earners and Self-Employed Individuals

Form 433-A

Name

SSN

Banking,

Investment,

and Life

Insurance

Information

Complete all

entry spaces

with the most

current data

available.

:() Current

Value:

Indicate the

amount you

could sell the

asset for

today.

Section 5 11. CHECKING ACCOUNTS. List all checking accounts. (If you need additional space, attach a separate sheet.)

Type of

Full Name of Bank, Savings & Loan, Credit Union or Financial Institution

Bank

Bank

Current

Account

Routing No.

Account No.

Account Balance

Cash, Credit, 11a. Checking

Name

$

Street Address

City/State/Zip

11b. Checking

Name

$

Street Address

City/State/Zip

11 c. Total Checking Account Balances

$

12. OTHER ACCOUNTS. List all acounts, including brokerage, savings, and money market, not listed on line 11.

Type of

Full Name of Bank, Savings & Loan, Credit Union or Financial Institution

Bank

Bank

Current

Account

Routing No.

Account No.

Account Balance

12a.

Name

$

Street Address

City/State/Zip

12b.

Name

$

Street Address

City/State/Zip

12c. Total Other Account Balances

$

ATTACHMENTS REQUIRED: Please include your current bank statements (checking, savings, money market, and brokerage accounts) for the past three months for all accounts.

13. INVESTMENTS. List all investment assets below. Include stocks, bonds, mutual funds, stock options, certificates of deposits, and retirement assets such as IRAs, Keogh, and 401(k) plans. (If you need additional space, attach a separate sheet.)

Name of Company

Shares / Units

Number of

:()Current

Value

Amount

Loan

on loan?

Used as collateral

13a.

$

$

No

Yes

13b.

No

Yes

13c.

No

Yes

13d. Total Investments

$

14. CASH ON HAND. Include any money that you have that is not in the bank.

14a. Total Cash on Hand

$

15. AVAILABLE CREDIT. List all lines of credit, including credit cards.

Full Name of

Credit Institution

Credit Limit

Amount Owed

Available Credit

15a. Name

$

Street Address

City/State/Zip

15b. Name

$

Street Address

City/State/Zip

15c. Total Credit Available	$

Page 2 of 6

Section 5 continued on page 3

(Rev. 5-2001)

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Collection Information Statement for Wage Earners and Self-Employed Individuals

Form 433-A

Name

SSN

Section 5

continued

Check this box

when all spaces in

Sect. 5 are filled in

and attachments

provided.

16. LIFE INSURANCE. Do you have life insurance with a cash value?

No

Yes

(Term Life insurance does not have a cash value.)

If yes:

16a. Name of Insurance Company

16b. Policy Number(s)

16c. Owner of Policy

16d. Current Cash Value $

16e. Outstanding Loan Balance $

Subtract “Outstanding Loan Balance“ line 1 6e from “Current Cash Value” line 1 6d = 1 6f $

ATTACHMENTS REQUIRED: Please include a statement from the life insurance companies that includes type and cash/loan value amounts. If currently borrowed against, include loan amount and date of loan.

Section 6

Other

Information

Check this box

Sect. 6 are filled in.

17. OTHER INFORMATION. Respond to the following questions related to your financial condition: (Attach sheet if you need more space.)

17a. Are there any garnishments against your wages?

No

Yes

If yes, who is the creditor?

Date creditor obtained judgement

Amount of debt $

17b. Are there any judgments against you?

No

Yes

If yes, who is the creditor?

Date creditor obtained judgement

Amount of debt $

17c. Are you a party in a lawsuit?
If yes, amount of suit $

No

Yes

Possible completion date

Subject matter of suit

17d. Did you ever file bankruptcy?

No

Yes

If yes, date filed

Date discharged

17e. In the past 10 years did you transfer any
name for less than

their actual va

assets out

of lyuoeu?r

No

Yes

If yes, what asset?

Value of asset at time of transfer $

When was it transferred?

To whom was it transferred?

17f. Do you anticipate any increase in household

income in the next two years?

No

Yes

If yes, why will the income increase?

(Attach sheet if you need more space.)

How much will it increase? $

17g. Are you a beneficiary of a trust or an estate?

No

Yes

If yes, name of the trust or estate

Anticipated amount to be received $

When will the amount be received?

when all spaces in 17h. Are you a participant in a profit sharing plan?

No

Yes

If yes, name of plan

Value in plan $

Section 7

Assets and

Liabilities

() Current

Value:

Indicate the

amount you

could sell the

asset for

today.

18. PURCHASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s, motorcycles, trailers, etc. (If you need additional space, attach a separate sheet.)

Description

()C urrent

Current

Name of

Purchase

Amount of

Monthly

(Year, Make, Model, Mileage)

Value

Loan

Balance

Lender

Date

Payment

18a. Year

Make/Model

Mileage

$

$

18b. Year

Make/Model

Mileage

$

$

$

18c. Year

Make/Model

Mileage

$

$

$

Page 3 of 6

Section 7 continued on page 4

(Rev. 5-2001)

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Collection Information Statement for Wage Earners and Self-Employed Individuals

Form 433-A

Name

SSN

continued

:() Current

Value:

Indicate the

amount you

could sell the

asset for

today.

* Date of

Final Pay‑

ment:

Enter the date

the loan or

lease will be

fully paid.

provided.

Section 7 19. LEASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s, motorcycles, trailers, etc. (If you need additional space, attach a separate sheet.)

Name and

Amount of

Description

(Year, Make, Model)

Lease

Balance

Address of

Lessor

Lease

Date

Monthly

Payment

19a. Year

Make/Model

$

$

19b. Year

Make/Model

$

$

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly car payment amount and current balance of the loan for each vehicle purchased or leased.

20. REAL ESTATE. List all real estate you own. (If you need additional space, attach a separate sheet.)

Amount of

*Date

Street Address, City, State, Zip, and County

Date

Purchase

:()Current

Loan

Name of Lender

Monthly

of Final

Purchased Price

Value

Balance

or Lien Holder

Payment

Payment

20a.

$

$

$

$

20b.

$

$

$

$

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly payment amount and current balance for each piece of real estate owned.

21. PERSONAL ASSETS. List all Personal assets below. (If you need additional space, attach separate sheet.)

Furniture/Personal Effects includes the total current market value of your household such as furniture and appliances. Other Personal Assets includes all artwork, jewelry, collections (coin/gun, etc.), antiques or other assets.

Amount of

 Date of

:()Current

Loan

Monthly

Final

Description

Value

Balance

Name of Lender

Payment

Payment

21a. Furniture/Personal Effects

$

$

$

Other: (List below)

21 b. Artwork

$

$

$

21c. Jewelry

21 d.

21e.

22. BUSINESS ASSETS. List all business assets and encumbrances below, include Uniform Commercial Code (UCC) filings. (If

you need additional space, attach a separate sheet.) Tools used in Trade or Business includes the basic tools or books used to conduct your business, excluding automobiles. Other Business Assets includes any other machinery, equipment, inventory or other assets.

Amount of

 Date of

:()Current

Loan

Monthly

Final

Description

Value

Balance

Name of Lender

Payment

Payment

22a. Tools used in Trade/Business $

$

$

Other: (List below)

22b. Machinery

$

$

$

Check this box 22c. Equipment

when all spaces in

Sect. 7 are filled in 22d.

and attachments 22e.

Page 4 of 6

Section 8 begins on page 5

(Rev. 5-2001)

□

Collection Information Statement for Wage Earners and Self-Employed Individuals

Form 433-A

Name

SSN

Use only if

needed.

Check this

8 not needed.

Check this box

when all spaces in

Sect. 8 are filled in.

Section 8 23. ACCOUNTS/NOTES RECEIVABLE. List all accounts separately, including contracts awarded, but not Accounts/
Notes
Receivable

started. (If you need additional space, attach a separate sheet.)

Description

Amount Due

Date Due

Age of Account

$

0 - 30 days

23a. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

box if Section23b. Name

$

0 - 30 days

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

23c. Name

$

0 - 30 days

Street Address

30 - 60 days

City/State/Zip

60 - 90 days

90+ days

$

0 - 30 days

23d. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23e. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23f. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

23g. Name

$

0 - 30 days

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23h. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23i. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23j. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

23k. Name

$

0 - 30 days

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23l. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

Add “Amount Due” from lines 23a through 23l = 23m $

Page 5 of 6

Section 9 begins on page 6

(Rev. 5-2001)

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Collection Information Statement for Wage Earners and Self-Employed Individuals

Form 433-A

Name

SSN

Section 9 Total Income

Total Living Expenses

Monthly

Source

Gross Monthly

Expense Items 4

Actual Monthly

Income and 24. Wages (Yourself)1

$

35. Food, Clothing and Misc.5

$

36. Housing and Utilities6

Expense

25. Wages (Spouse)1

Analysis

26. Interest - Dividends

37. Transportation7

27. Net Income from Business2

38. Health Care

If only one

28. Net Rental Income3

39. Taxes (Income and FICA)

spouse has a

tax liability, but 29. Pension/Social Security (Yourself)

40. Court ordered payments

both have

30. Pension/Social Security (Spouse)

41. Child/dependent care

income, list the 31. Child Support

42. Life insurance

total household 32. Alimony

43. Other secured debt

income and

33. Other

44. Other expenses

expenses.

34. Total Income

$

45. Total Living Expenses

$

1 Wages, salaries, pensions, and social security: Enter your gross monthly wages and/or salaries. Do not deduct withholding or allotments you elect to take out of your pay, such as insurance payments, credit union deductions, car payments etc.

To calculate your gross monthly wages and/or salaries:

If paid weekly - multiply weekly gross wages by 4.3. Example: $425.89 x 4.3 = $1,831.33
If paid bi-weekly (every 2 weeks) - multiply bi-weekly gross wages by 2.17. Example: $972.45 x 2.17 = $2,110.22
If paid semi-monthly (twice each month) - multiply semi-monthly gross wages by 2. Example: $856.23 x 2 = $1,712.46

2 Net Income from Business: Enter your monthly net business income. This is the amount you earn after you pay ordinary and necessary monthly business expenses. This figure should relate to the yearly net profit from your Form 1040 Schedule C. If it is more or less than the previous year, you should attach an explanation. If your net business income is a loss, enter “0”. Do not enter a negative number.

3 Net Rental Income: Enter your monthly net rental income. This is the amount you earn after you pay ordinary and necessary monthly rental expenses. If your net rental income is a loss, enter “0”. Do not enter a negative number.

4 Expenses not generally allowed: We generally do not allow you to claim tuition for private schools, public or private college expenses, charitable contributions, voluntary retirement contributions, payments on unsecured debts such as credit card bills, cable television and other similar expenses. However, we may allow these expenses, if you can prove that they are necessary for the health and welfare of you or your family or for the production of income.

5 Food, Clothing and Misc.: Total of clothing, food, housekeeping supplies and personal care products for one month.

6 Housing and Utilities: For your principal residence: Total of rent or mortgage payment. Add the average monthly expenses for the following: property taxes, home owner’s or renter’s insurance, maintenance, dues, fees, and utilities. Utilities include gas, electricity, water, fuel, oil, other fuels, trash collection and telephone.

7 Transportation: Total of lease or purchase payments, vehicle insurance, registration fees, normal maintenance, fuel, public transportation, parking and tolls for one month.

ATTACHMENTS REQUIRED: Please include:
•	A copy of your last Form 1040 with all Schedules.

•	Proof of all current expenses that you paid for the past 3 months, including utilities, rent, insurance, property taxes, etc.

•	Proof of all non-business transportation expenses (e.g., car payments, lease payments, fuel, oil, insurance, parking, registration).

Check this

•	Proof of payments for health care, including health insurance premiums, co-payments, and other out-of-pocket expenses, for the past 3 months.

box when all

• Copies of any court order requiring payment and proof of such payments (e.g., cancelled checks, money orders, earning statements showing such deductions) for the past 3 months.

spaces in Sect. 9

are filled in and

attachments

provided.

Check this box

when all spaces in

Failure to complete all entry spaces may result in rejection or significant delay in the resolution of your

all sections are

filled in and all

account.

attachments

provided.

Certification: Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities, and other information is true, correct and complete.

Your Signature

Spouse’s Signature

Date

Page 6 of 6

(Rev. 5-2001)

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Collection Information Statement for Businesses

Complete all entry spaces with the most current data available.
Important! Write “N/A” (not applicable) in spaces that do not apply. We may require additional information

www.irs.gov

to support “N/A” entries.

Form 433-B (Rev. 5-2001) Catalog Number 16649P

Failure to complete all entry spaces may result in rejection or significant delay in the resolution of your account.

Section 1

1a. Business Name

3a. Contact Name

Business

Business Street Address

Information

Extension

City

State

Zip

Best Time To Call

am

pm (Enter Hour)

County

3c. Contact’s Home Telephone

1b. Business Telephone (	)

Best Time To Call

am

pm (Enter Hour)

2a. Employer Identification No. (EIN)

3d. Contact’s Other Telephone

2b. Type of Entity (Check appropriate box below)

Telephone Type (i.e. fax, cellular, pager)

Check this box

Partnership

Corporation

Other

3e. Contact’s E-mail Address

when all spaces in

2c. Type of Business

Sect. 1 are filled in.

Section 2 4. PERSON RESPONSIBLE FOR DEPOSITING PAYROLL TAXES

Business

4a. Full Name

Title

Social Security Number

Personnel

Home Street Address

Home Telephone (	)

and

City

State

Zip

Ownership Percentage & Shares or Interest

Contacts

5. PARTNERS, OFFICERS, MAJOR SHAREHOLDERS, ETC.

5a. Full Name

Title

Social Security Number

Home Street Address

Home Telephone (	)

City

State

Zip

Ownership Percentage & Shares or Interest

5b. Full Name

Title

Social Security Number

Home Street Address

Home Telephone (	)

City

State

Zip

Ownership Percentage & Shares or Interest

5c. Full Name

Title

Social Security Number

Home Street Address

Home Telephone (	)

City

State

Zip

Ownership Percentage & Shares or Interest

5d. Full Name

Title

Social Security Number

Check this box

Home Street Address

Home Telephone (	)

when all spaces in

Sect. 2 are filled in.

City

State

Zip

Ownership Percentage & Shares or Interest

Section 3 6. ACCOUNTS/NOTES RECEIVABLE. List all contracts separately, including contracts awarded, but not started.

Accounts/

Description

Amount Due

Date Due

Age of Account

Notes

$

0 - 30 days

Receivable

6a. Name

30 - 60 days

See page 6

Street Address

60 - 90 days

for additional

City/State/Zip

90+ days

space, if

$

0 - 30 days

needed.

6b. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

6c

90+ days

6a + 6b

6c

$

Amount from

6p

Page 6 +

Check this box

6c + 6p = 6q

when all spaces in

6q. Total Accounts/ Notes Receivable

=

$

Sect. 3 are filled in.

Page 1 of 6

Section 4 begins on page 2

(Rev. 5-2001)

()

3b. Contact’s Business Telephone

()

()

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Collection Information Statement for Businesses

Form 433-B

Business Name

EIN

Other

Financial

Information

Check this box

when all spaces in

Sect. 4 are filled in.

Business

Assets

( )Current

Value:

Indicate the

amount you

could sell the

asset for today.

Section 4 7.

OTHER FINANCIAL INFORMATION. Respond to the following business financial questions.

7a. Does this business have other business relationships (e.g. subsidiary or parent, corporation, partnership, etc.)?

No

Yes

If yes, list related EIN

Additional EIN

7b. Does anyone (e.g. officer, stockholder, partner or employees) have an outstanding loan borrowed from the business?

No

Yes

If yes, amount of loan $

Date of loan

Current balance $

7c. Are there any judgments or liens against your business?

No

Yes

If yes, who is the creditor?

Date creditor obtained judgment/lien

Amount of debt $

7d. Is your business a party in a lawsuit?

No

Yes

If yes, amount of suit $

Possible completion date

Subject matter of suit

7e. Has your business ever filed bankruptcy?

No

Yes

If yes, date filed

Date discharged

Petition No.

7f.

In the past 10 years have you transferred any assets from your business name for less than their actual value?

No

Yes

If yes, what asset?

Value of asset at time of transfer $

When was it transferred?

To whom or where was it transferred?

7g. Do you anticipate any increase in business income (e.g. contracts bid but not yet awarded)?

No

Yes

If yes, why will the income increase?

(Attach sheet if you need additional space.)

How much will it increase?

When will the business income increase?

7h. Is your business a beneficiary of a trust, an estate or a life insurance policy?

No

Yes

If yes, name of the trust, estate or policy?

Anticipated amount to be received?

When will the amount be received?

Section 5 8.

PURCHASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s, motorcycles, trailers, etc. (If you need additional space, attach a separate sheet.)

Amount of

Description

( )Current

Loan

Name of

Purchase

Monthly

(Year, Make, Model, Mileage)

Value

Balance

Lender

Date

Payment

8a. Year

Make/Model

Mileage

$

$

8b. Year

Make/Model

Mileage

$

8c. Year

Make/Model

Mileage

$

$

9.

LEASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s, motorcycles, trailers, etc. (If you need additional space, attach a separate sheet.)

Amount of

Description

(Year, Make, Model)

Lease

Balance

of Lessor

Name

Lease

Date

Monthly

Payment

9a. Year

Make/Model

$

9b. Year

Make/Model

$

$

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly car payment amount and current balance of the loan for each vehicle purchased or leased.

Page 2 of 6

Section 5 continued on page 3

(Rev. 5-2001)

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Collection Information Statement for Businesses

Form 433-B

Business Name

EIN

continued

:()Current

Value:

Indicate the

amount you

could sell the

asset for today.

*Date of Final

Payment:

Enter the date

the loan or

lease will be

fully paid.

Check this

box if you are

attaching a

depreciation

schedule for

machinery/

equipment in

lieu of

completing

line 11.

Check this box

when all spaces in

Sect. 5 are filled in

and attachments

provided.

Section 5 10. REAL ESTATE. List all real estate owned by the business. (If you need additional space, attach a separate sheet.)

Amount of

*Date

Street Address, City, State, Zip, and County

Date

Purchase

:()Current

Loan

Name of Lender

Monthly

of Final

Purchased Price

Value

Balance

or Lien Holder

Payment

Payment

10a.

$

$

$

$

10b.

$

$

$

$

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly payment amount and current balance for each piece of real estate owned.

11. BUSINESS ASSETS. List all business assets and encumbrances below, include Uniform Commercial Code (UCC) filings. (If you need additional space, attach a separate sheet.) Note: If attaching a depreciation schedule, the attachment must include all of the information requested below.

Amount of

*Date

:()C urrent

Loan

Monthly

of Final

Description

Value

Balance

Name of Lender

Payment

Payment

11a. Machinery

$

$

$

Equipment

Merchandise

Other Assets: (List below)

11b.

$

$

$

11 c.

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly payment amount and current loan balance for assets listed which have an encumbrance.

Investment,

Banking and

Cash

Information

Section 6 12. INVESTMENTS. List all investment assets below. Include stocks, bonds, mutual funds, stock options and certificates of deposits.

Name of Company

Shares / Units

Number of

:()Current

Value

Amount

Loan

on loan?

Used as collateral

12a.

$

$

No

Yes

12b.

No

Yes

12c. Total Investments

$

Page 3 of 6

Section 6 continued on page 4

(Rev. 5-2001)

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Collection Information Statement for Businesses

Form 433-B

Business Name

EIN

Complete all

entry spaces

with the most

current data

available.

Section 6 13. BANK ACCOUNTS. List all checking and savings accounts. (If you need additional space, attach a separate sheet.) continued

Type of

Full Name of Bank, Savings & Loan, Credit Union or Financial Institution

Bank

Bank

Current

Account

Routing No.

Account No.

Account Balance

13a. Checking

Name

$

Street Address

City/State/Zip

13b. Checking

Name

$

Street Address

City/State/Zip

13c. Savings

Name

$

Street Address

City/State/Zip

13d. Total Bank Account

Balances

$

ATTACHMENTS REQUIRED: Please include your current bank statements (checking and savings) for the past three months for all accounts.

14. OTHER ACCOUNTS. List all accounts including brokerage accounts, money market, additional checking and savings accounts not listed on line #13 and any other accounts not listed in this section.

Type of

Full Name of Bank, Savings & Loan, Credit Union or Financial Institution

Bank

Bank

Current

Account

Routing No.

Account No.

Account Balance

14a.

Name

$

Street Address

City/State/Zip

14b.

Name

$

Street Address

City/State/Zip

14c. Total Other Account Balances

$

ATTACHMENTS REQUIRED: Please include your current bank statements (checking, savings, money market, and brokerage accounts) for the past three months for all accounts.

15. CASH ON HAND. Include any money that you have that is not in the bank.

15a. Total Cash on Hand

$

16. AVAILABLE CREDIT. List all lines of credit, including credit cards.

Full Name of

Credit Institution

Credit Limit

Amount Owed

Available Credit

16a. Name

$

Street Address

City/State/Zip

Check this box 1 6b. Name

$

when all spaces in

Sect. 6 are filled in

Street Address

and attachments

provided.

City/State/Zip

1 6c. Total Credit Available	$

Page 4 of 6

Section 7 begins on page 5

(Rev. 5-2001)

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Collection Information Statement for Businesses

Form 433-B

Business Name

EIN

Monthly

Expenses

Complete all

entry spaces

with the most

current data

available.

when all spaces in

Sect. 7 are filled in.

Fiscal Year Period

to

Income and18. Accounting Method Used:

Cash

Accrual

The information included on lines 19 through 39 should reconcile to your business federal tax return.

Total Income

Total Expenses

Source

Gross Monthly

Expense Items

Actual Monthly

19. Gross Receipts

$

27. Materials Purchased 1

$

20. Gross Rental Income

28. Inventory Purchased 2

21. Interest

29. Gross Wages & Salaries

22. Dividends

30. Rent

Other Income (specify in lines 23-25)

31. Supplies 3

23.

32. Utilities / Telephone 4

24.

33. Vehicle Gasoline / Oil

25.

34. Repairs & Maintenance

(Add lines 19 through 25)
TOTAL INCOME

35. Insurance

26.

$

36. Current Taxes 5

Other Expenses

(include installment payments, specify in lines 37-38)

37.

38.

(Add lines 27 through 38)

39.

TOTAL EXPENSES

1Materials Purchased: Materials are items directly related to the production of a product or service.

2 Inventory Purchased: Goods bought for resale.

3 Supplies: Supplies are items used in your business that are consumed or used up within one year, this could be the cost of books, office supplies, professional instruments, etc.

4

Utilities include gas, electricity, water, fuel, oil, other fuels, trash collection and telephone. Ct T
es: Real estate, state and local income tax, excise, franchise, occupational, personal property, sales and the

Check this box 5

employer’s portion of employment taxes.

Check this box

when all spaces in

all sections are

filled in and all

attachments

provided.

Failure

to complete all entry spaces

may result in rejection or significant delay in the resolution of your account.

Certification: Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities, and other information is true, correct and complete.

Print Name

Title

Your Signature

Date

Accounts/Notes Receivable Continuation on page 6

Page 5 of 6

(Rev. 5-2001)

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Section 7 17. The following information applies to income and expenses from your most recently filed Form 1120 or Form 1065.
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Collection Information Statement for Businesses

Form 433-B

Business Name

EIN

Section 3

Accounts/

Notes

Receivable

continued

Use only if

needed.

Check this

box if this

page is not

needed.

Check this box

when all spaces in

Sect. 3 are filled in.

ACCOUNTS/NOTES RECEIVABLE CONTINUATION PAGE. List all contracts separately, including contracts awarded, but not started. (If you need additional space, copy this page and attach to the 433-B package.)

Description

Amount Due

Date Due

Age of Account

$

0 - 30 days

6d. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

6e. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

6f. Name

$

0 - 30 days

Street Address

30 - 60 days

City/State/Zip

60 - 90 days

90+ days

$

0 - 30 days

6g. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

6h. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

6i. Name

$

0 - 30 days

Street Address

30 - 60 days

City/State/Zip

60 - 90 days

90+ days

$

0 - 30 days

6j. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

6k. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

6l. Name

$

0 - 30 days

Street Address

30 - 60 days

City/State/Zip

60 - 90 days

90+ days

$

0 - 30 days

6m. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

6n. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

6o. Name

$

0 - 30 days

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

Add lines 6d through 6o = 6p $

(Add this amount to amount on line 6c, Section 3, page 1)

Page 6 of 6

(Rev. 5-2001)

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Collection Information Statement for Businesses

Complete all entry spaces with the most current data available.
Important! Write “N/A” (not applicable) in spaces that do not apply. We may require additional information

www.irs.gov

to support “N/A” entries.

Form 433-B (Rev. 5-2001) Catalog Number 1 6649P

Failure to complete all entry spaces may result in rejection or significant delay in the resolution of your account.

Section 1

1a. Business Name

3a. Contact Name

Business

Business Street Address

Information

Extension

City

State

Zip

Best Time To Call

am

pm (Enter Hour)

County

3c. Contact’s Home Telephone

(	)

1b. Business Telephone (	)

Best Time To Call

am

pm (Enter Hour)

2a. Employer Identification No. (EIN)

3d. Contact’s Other Telephone

2b. Type of Entity (Check appropriate box below)

Telephone Type (i.e. fax, cellular, pager)

Check this box

Partnership

Corporation

Other

3e. Contact’s E-mail Address

when all spaces in

2c. Type of Business

Sect. 1 are filled in.

Section 2 4. PERSON RESPONSIBLE FOR DEPOSITING PAYROLL TAXES

Business

4a. Full Name

Title

Social Security Number

Personnel

Home Street Address

Home Telephone (	)

and

City

State

Zip

Ownership Percentage & Shares or Interest

Contacts

5. PARTNERS, OFFICERS, MAJOR SHAREHOLDERS, ETC.

5a. Full Name

Title

Social Security Number

Home Street Address

Home Telephone (	)

City

State

Zip

Ownership Percentage & Shares or Interest

5b. Full Name

Title

Social Security Number

Home Street Address

Home Telephone (	)

City

State

Zip

Ownership Percentage & Shares or Interest

5c. Full Name

Title

Social Security Number

Home Street Address

Home Telephone (	)

City

State

Zip

Ownership Percentage & Shares or Interest

5d. Full Name

Title

Social Security Number

Check this box

Home Street Address

Home Telephone (	)

when all spaces in

Sect. 2 are filled in.

City

State

Zip

Ownership Percentage & Shares or Interest

Section 3 6. ACCOUNTS/NOTES RECEIVABLE. List all contracts separately, including contracts awarded, but not started.

Accounts/

Description

Amount Due

Date Due

Age of Account

Notes

$

0 - 30 days

Receivable

6a. Name

30 - 60 days

See page 6

Street Address

60 - 90 days

for additional

City/State/Zip

90+ days

space, if

$

0 - 30 days

needed.

6b. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

6c

90+ days

6a + 6b

6c

$

Amount from

6p

Page 6 +

Check this box

6c + 6p = 6q

when all spaces in

6q. Total Accounts/ Notes Receivable

=

$

Sect. 3 are filled in.

Page 1 of 6

Section 4 begins on page 2

(Rev. 5-2001)

()

3b. Contact’s Business Telephone

()

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Collection Information Statement for Businesses

Form 433-B

Business Name

EIN

Other

Financial

Information

Check this box

Sect. 4 are filled in.

Section 4 7.

OTHER FINANCIAL INFORMATION. Respond to the following business financial questions.

7a. Does this business have other business relationships (e.g. subsidiary or parent, corporation, partnership, etc.)?

No

Yes

If yes, list related EIN

Additional EIN

7b. Does anyone (e.g. officer, stockholder, partner or employees) have an outstanding loan borrowed from the business?

No

Yes

If yes, amount of loan $

Date of loan

Current balance $

7c. Are there any judgments or liens against your business?

No

Yes

If yes, who is the creditor?

Date creditor obtained judgment/lien

Amount of debt $

7d. Is your business a party in a lawsuit?

No

Yes

If yes, amount of suit $

Possible completion date

Subject matter of suit

7e. Has your business ever filed bankruptcy?

No

Yes

If yes, date filed

Date discharged

Petition No.

7f.

In the past 10 years have you transferred any assets from your business name for less than their actual value?

No

Yes

If yes, what asset?

Value of asset at time of transfer $

When was it transferred?

To whom or where was it transferred?

7g. Do you anticipate any increase in business income (e.g. contracts bid but not yet awarded)?

No

Yes

If yes, why will the income increase?

(Attach sheet if you need additional space.)

How much will it increase?

When will the business income increase?

7h. Is your business a beneficiary of a trust, an estate or a life insurance policy?

No

Yes

when all spaces in

If yes, name of the trust, estate or policy?

Anticipated amount to be received?

When will the amount be received?

Business

Assets

:( )Current

Value:

Indicate the

amount you

could sell the

asset for today.

Section 5 8.

PURCHASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s, motorcycles, trailers, etc. (If you need additional space, attach a separate sheet.)

Amount of

Description

:( )Current

Loan

Name of

Purchase

Monthly

(Year, Make, Model, Mileage)

Value

Balance

Lender

Date

Payment

8a. Year

Make/Model

Mileage

$

$

$

8b. Year

Make/Model

Mileage

$

$

$

8c. Year

Make/Model

Mileage

$

$

$

9.

LEASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s, motorcycles, trailers, etc. (If you need additional space, attach a separate sheet.)

Amount of

Description

(Year, Make, Model)

Lease

Balance

of Lessor

Name

Lease

Date

Monthly

Payment

9a. Year

Make/Model

$

9b. Year

Make/Model

$

$

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly car payment amount and current balance of the loan for each vehicle purchased or leased.

Page 2 of 6

Section 5 continued on page 3

(Rev. 5-2001)

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Collection Information Statement for Businesses

Form 433-B

Business Name

EIN

continued

()Current

Value:

Indicate the

amount you

could sell the

asset for today.

*Date of Final

Payment:

Enter the date

the loan or

lease will be

fully paid.

Check this

box if you are

attaching a

depreciation

schedule for

machinery/

equipment in

lieu of

completing

line 11.

Check this box

when all spaces in

Sect. 5 are filled in

and attachments

provided.

Investment,

Banking and

Cash

Information

Section 5 10. REAL ESTATE. List all real estate owned by the business. (If you need additional space, attach a separate sheet.)

Amount of *Date

Street Address, City, State, Zip, and County

Date

Purchase

()Current

Loan

Name of Lender

Monthly

of Final

Purchased Price

Value

Balance

or Lien Holder

Payment

Payment

1 0a.

$

$

$

$

10b.

$

$

$

$

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly payment amount and current balance for each piece of real estate owned.

11. BUSINESS ASSETS. List all business assets and encumbrances below, include Uniform Commercial Code (UCC) filings. (If you need additional space, attach a separate sheet.) Note: If attaching a depreciation schedule, the attachment must include all of the information requested below.

Amount of

*Date

()C urrent

Loan

Monthly

of Final

Description

Value

Balance

Name of Lender

Payment

Payment

11a. Machinery

$

$

$

Equipment

Merchandise

Other Assets: (List below)

11b.

$

$

$

11 c.

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly payment amount and current loan balance for assets listed which have an encumbrance.

Section 6 12. INVESTMENTS. List all investment assets below. Include stocks, bonds, mutual funds, stock options and certificates of deposits.

Name of Company

Shares / Units

Number of

()Current

Value

Amount

Loan

on loan?

Used as collateral

12a.

$

$

No

Yes

12b.

No

Yes

12c. Total Investments

$

Page 3 of 6

Section 6 continued on page 4

(Rev. 5-2001)

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Collection Information Statement for Businesses

Form 433-B

Business Name

EIN

Complete all

entry spaces

with the most

current data

available.

Section 6 13. BANK ACCOUNTS. List all checking and savings accounts. (If you need additional space, attach a separate sheet.) continued

Type of

Full Name of Bank, Savings & Loan, Credit Union or Financial Institution

Bank

Bank

Current

Account

Routing No.

Account No.

Account Balance

13a. Checking

Name

$

Street Address

City/State/Zip

13b. Checking

Name

$

Street Address

City/State/Zip

13c. Savings

Name

$

Street Address

City/State/Zip

1 3d. Total Bank Account Balances

$

ATTACHMENTS REQUIRED: Please include your current bank statements (checking and savings) for the past three months for all accounts.

14. OTHER ACCOUNTS. List all accounts including brokerage accounts, money market, additional checking and savings accounts not listed on line #13 and any other accounts not listed in this section.

Type of

Full Name of Bank, Savings & Loan, Credit Union or Financial Institution

Bank

Bank

Current

Account

Routing No.

Account No.

Account Balance

14a.

Name

$

Street Address

City/State/Zip

14b.

Name

$

Street Address

City/State/Zip

14c. Total Other Account Balances

$

ATTACHMENTS REQUIRED: Please include your current bank statements (checking, savings, money market, and brokerage accounts) for the past three months for all accounts.

15. CASH ON HAND. Include any money that you have that is not in the bank.

15a. Total Cash on Hand

$

16. AVAILABLE CREDIT. List all lines of credit, including credit cards.

Full Name of

Credit Institution

Credit Limit

Amount Owed

Available Credit

16a. Name

$

Street Address

City/State/Zip

Check this box 1 6b. Name

$

when all spaces in

Sect. 6 are filled in

Street Address

and attachments

provided.

City/State/Zip

1 6c. Total Credit Available	$

Page 4 of 6

Section 7 begins on page 5

(Rev. 5-2001)

□

Collection Information Statement for Businesses

Form 433-B

Business Name

EIN

Monthly

Income and

Expenses

Complete all

entry spaces

with the most

current data

available.

when all spaces in

Sect. 7 are filled in.

Fiscal Year Period

to

18. Accounting Method Used:

Cash

Accrual

The information included on lines 19 through 39 should reconcile to your business federal tax return.

Total Income

Total Expenses

Source

Gross Monthly

Expense Items

Actual Monthly

19. Gross Receipts

$

27. Materials Purchased 1

$

20. Gross Rental Income

28. Inventory Purchased 2

21. Interest

29. Gross Wages & Salaries

22. Dividends

30. Rent

Other Income (specify in lines 23-25)

31. Supplies 3

23.

32. Utilities / Telephone 4

24.

33. Vehicle Gasoline / Oil

25.

34. Repairs & Maintenance

(Add lines 19 through 25)
TOTAL INCOME

35. Insurance

26.

$

36. Current Taxes 5

Other Expenses

(include installment payments, specify in lines 37-38)

37.

38.

(Add lines 27 through 38)

39.

TOTAL EXPENSES

$

1Materials Purchased: Materials are items directly related to the production of a product or service.

2 Inventory Purchased: Goods bought for resale.

3 Supplies: Supplies are items used in your business that are consumed or used up within one year, this could be the

cost of books, office supplies, professional instruments, etc.

4 Utilities: Utilities include gas, electricity, water, fuel, oil, other fuels, trash collection and telephone.

Check this box 5 Current Taxes: Real estate, state and local income tax, excise, franchise, occupational, personal property, sales and the

employer’s portion of employment taxes.

Check this box

when all spaces in

all sections are

filled in and all

attachments

provided.

Failure to complete all entry spaces may result in rejection or significant delay in the resolution of your account.

Certification: Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities, and other information is true, correct and complete.

Print Name

Title

Your Signature

Date

Page 5 of 6

 Accounts/Notes Receivable Continuation on page 6

(Rev. 5-2001)

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Section 7 17. The following information applies to income and expenses from your most recently filed Form 1120 or Form 1065.
□
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Collection Information Statement for Businesses

Form 433-B

Business Name

EIN

Section 3

Accounts/

Notes

Receivable

continued

Use only if

needed.

Check this

box if this

page is not

needed.

Check this box

when all spaces in

Sect. 3 are filled in.

ACCOUNTS/NOTES RECEIVABLE CONTINUATION PAGE. List all contracts separately, including contracts awarded, but not started. (If you need additional space, copy this page and attach to the 433-B package.)

Description

Amount Due

Date Due

Age of Account

$

0 - 30 days

6d. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

6e. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

6f. Name

$

0 - 30 days

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

6g. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

6h. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

6i. Name

$

0 - 30 days

30 - 60 days

Street Address

City/State/Zip

60 - 90 days

90+ days

$

0 - 30 days

6j. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

6k. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

6l. Name

$

0 - 30 days

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

6m. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

6n. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

6o. Name

$

0 - 30 days

Street Address

30 - 60 days

City/State/Zip

60 - 90 days

90+ days

Add lines 6d through 6o = 6p $

(Add this amount to amount on line 6c, Section 3, page 1)

Page 6 of 6

(Rev. 5-2001)

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Except for offers based on doubt as
to liability, the offer agreement requires you to forego certain refunds, and to return those refunds to us if they are issued to you by mistake. These conditions are also listed on Form 656, Items 8(g) and 8(h).

Note: The law requires us to make

certain informationf rom accepted Offers in Compromise available for public inspection and review in your local IRS Territory Office. Therefore, information regarding your Offer in Compromise may become publicly known.

If We Reject

We’ll notify you by mail if we reject your offer. In our letter, we will explain our reason for the rejection. If your offer is rejected, you have the right to:

 Submit another offer. You must

Your Offer

increase an offer we’ve rejected as being too low, when your financial situation remains unchanged. However, you must provide updated financial information when your financial situation has changed or when the original offer is more than six months old.

 Appeal our decision to the Office of Appeals within thirty days from the date of our letter. The letter will include detailed instructions on how to appeal the rejection.

27

Terms and Definitions

Reasonable Collection Potential (RCP) –
The total realizable value of your assets plus your future income. The total is generally your minimum offer amount.

An understanding of the following terms and conditions will help you to prepare your offer.

Fair Market Value (FMV) – The amount you could reasonably expect from the sale of an asset. Provide an accurate valuation of each asset. Determine value from realtors, used car dealers, publications, furniture dealers, or other experts on specific types of assets. Please include a copy of any written estimate with your Collection Information Statement.

Necessary Expenses – The allowable payments you make to support you and your family’s health and welfare and/or the production of income.
This expense allowance does not apply to business entities. Our Publication 1854 explains the National Standard Expenses and gives the allowable amounts. We derive these amounts from the Bureau of Labor Statistics (BLS) Consumer Expenditure Survey. We also use information from the Bureau of the Census to determine local expenses for housing, utilities, and transportation.

Quick Sale Value (QSV) – The amount you could reasonably expect from the sale of an asset if you sold it quickly, typically in ninety days or less. This amount generally is less than fair market value, but may be equal to or higher, based on local circumstances.

Note: If the IRS determines that the facts and

Realizable Value – The quick sale value amount minus what you owe to a secured creditor. The creditor must have priority over a filed Notice of Federal Tax Lien before we allow a subtraction from the asset’s value.

circumstances of your situation indicate that using the scheduled allowance of necessary expenses is inadequate, we will allow you an adequate means for providing basic living expenses. However, you must provide documentation that supports a determination that using national and local expense standards leaves you an inadequate means of providing for basic living expenses.

Future Income – We generally determine the amount we could collect from your future income
by subtracting necessary living expenses from your monthly income over a set number of months. For a cash offer, you must offer what you could pay in monthly payments over forty-eight months (or the remainder of the ten-year statutory period for collection, whichever is less). For a short-term deferred offer, you must offer what you could pay in monthly payments over sixty months (or the remainder of the statutory period for collection, whichever is less). For a deferred payment offer, you must offer what you could pay in monthly payments during the remaining time we could legally receive payments.

Expenses Not Generally Allowed – We typically do not allow you to claim tuition for private schools, public or private college expenses, charitable contributions, voluntary retirement contributions, payments on unsecured debts such as credit card bills, cable television charges and other similar expenses as necessary living expenses. However, we can allow these expenses when you can prove that they are necessary for the health and welfare of you or your family or for the production of income.

8

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29

For use by Wage Earners and Self-Employed Individuals.
Form 433-A Worksheet

Keep this worksheet for your records. Do not send to IRS.

Use this Worksheet to calculate an offer amount using information from Form 433-A.

1. Enter total checking accounts from Item 11 c

A

2. Enter total other accounts from Item 1 2c

B

If less than “0', enter “0'

3.	Enter total investments from Item 1 3d
4.	Enter total cash on hand from Item 14a
5.	Enter life insurance cash value from Item 1 6f
6.	Enter total accounts/notes receivable from Item 23m

Subtotal: Add boxes A through F

7. Purchased Automobiles, Trucks, and Other Licensed Assets

Individual

asset value

Enter current value

Enter loan balance

(if less than “0',

for each asset

for each asset

enter “0')

From line 18a $

x .8 = $

–

$

From line 18b $

x .8 = $

–

$

=

From line 18c $

x .8 = $

–

$

=

Subtotal

H

8. Real Estate

Individual

asset value

Enter current value

Enter loan balance

for each asset

for each asset

(if less than “0', enter “0')

From line 20a $

x .8 = $

–

$

From line 20b $

x .8 = $

–

$

=

Subtotal

I

9. Personal Assets

Individual

Enter current value

Enter loan balance

asset value

(if less than “0',

for each asset

for each asset

enter “0')

From line 21b $

x .8 = $

–

$

From line 21 c $

x .8 = $

–

$

=

From line 21d $

x .8 = $

–

$

=

From line 21e $

x .8 = $

–

$

=

Subtotal

J

From line 21a $

x .8 = $

–

$

Subtract

–

$ 6560.00

Subtotal

K

10. Business Assets

Individual

Enter current value

Enter loan balance

asset value

(if less than “0',

for each asset

for each asset

enter “0')

From line 22b $

x .8 = $

–

$

From line 22c $

x .8 = $

–

$

=

From line 22d $

x .8 = $

–

$

=

From line 22e $

x .8 = $

–

$

=

Subtotal

L

From line 22a $

x .8 = $

–

$

Subtract

–

$ 3280.00

Subtotal

M

2120

G

C		
D		
E		
F		

=

-

=

=

-

=

=

-

-

=

11. Add amounts in Boxes G through M to obtain your total equity and assets

N

12. Enter amount from Item 34
Enter amount from Item 45 and subtract

$

If Box O is “0” or less, STOP. Use the amount from Box N and to base your offer amount in Item 7 of Form 656. Your offer amount must equal or exceed (*) the amount shown in Box N.

–

$

Net Difference

=

O

This amount would be available

to pay monthly on your tax liability.

13.a.

b.

If you will pay the offer amount
in 90 days or less (i.e., cash offer):

If you will pay the offer amount in more than 90 days but less than 2 years
(i.e., short-term deferred payment offer):

Enter amount

Enter amount

from Box O

$

from Box O

$

Multiply by

x 48

Multiply by

x 60

Enter amount

Enter amount

from Box N

+

from Box N

+

Add amounts

Add amounts

in Box P and

in Box S and

Box Q

Use the amount

Box T

Use the amount

from Box R to base

from Box U to base

your offer amount

your offer amount

in Item 7 of Form

in Item 7 of Form

656.

656.

Note: Your offer

Note: Your offer

amount must equal

amount must equal

or exceed (*) the

or exceed (*) the

amount shown in

amount shown in

Box R.

Box U.

Note: Do not compute your offer amount using 13a or 13b if your statute expiration date(s) is less than 5 years from the date of your offer. Instead, refer to page 5 under “Deferred Payment Offer” options 1 through 3.

* Unless you are submitting an offer under effective tax administration or doubt as to collectibility with special circumstances considerations, as described on page 3.

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R

P		
Q		

S		
T		
U		

Completing Form 656, Offer in Compromise

We have included two Offer in Compromise forms. Use one form to submit your offer in compromise. You may use the other form as a worksheet and retain it for your personal records.

Note: If you have any questions about completing this form, you may call

1–800–829–1040 or visit your local IRS office or our website at

www.irs.ustreas.gov/ind_info/oic/index.html. We may return your offer if you don’t follow these instructions.

Item 1:

Enter your name and home or business address. You should also include a mailing address, if it is different from your street address.

and other liabilities jointly (such as income taxes), but only you are submitting an offer, list all tax liabilities on one Form 656. If you owe one liability yourself and another jointly, and both parties submit an offer, complete two Forms 656, one for the individual liability and one for the joint liability.

Show both names on joint offers for joint liabilities. If you owe one liability by yourself (such as employment taxes),

Item 2:

Enter the social security number(s) for the person(s) submitting the offer. For example, enter the social security number of both spouses when

submitting a joint offer for a joint tax liability. However, when only one spouse submits an offer, enter only that spouse’s social security number.

Item 3:

Enter the employer identification number for offers from businesses.

Item 4:

Show the employer identification numbers for all other businesses (excluding corporate entities) that you

own or in which you have an ownership

interest.

Item 5:

Identify your tax liability and enter the tax year or period. Letters and notices from us and Notices of Federal Tax Lien show

the tax periods for trust fund recovery penalties.

Item 6:

Check the appropriate box (es) describing the basis for your offer.

Collection Information Statement for Businesses, if you are a corporation or other business taxpayer.

Doubt as to Liability offers require a statement describing in detail why you think you do not owe the liability. Complete Item 9, “Explanation of Circumstances,' explaining your situation.

Effective Tax Administration offers require you to complete a Form 433-A, Collection Information Statement for Wage Earners and Self-Employed Individuals, if you are an individual taxpayer, or a Form 433-B, Collection Information Statement for Businesses,
if you are a corporation or other business taxpayer. Complete Item 9, “Explanation of Circumstances.'

Doubt as to Collectibility offers require you to complete a Form 433-A, Collection Information Statement for Wage Earners and Self-Employed Individuals, if you are an individual taxpayer, or a Form 433-B,

Note: Staple in the upper left corner the six (6) pages of the collection information statement before you send it to us.

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Item 7:

Enter the total amount of your offer (see page 3, “Determine Your Offer Amount”). Your offer amount cannot include a refund we owe you or amounts you have already paid.

Check the appropriate payment box (cash, short-term deferred payment or deferred payment — see page 4, “Determine Your Payment Terms”) and describe your
payment plan in the spaces provided.

Item 8:

It is important that you understand the requirements listed in this section. Pay particular attention to Items 8(d)

and 8(g), as they address the future compliance provision and refunds.

Item 9:

Explain your reason(s) for submitting your offer in the “Explanation of

Circumstances.” You may attach additional sheets if necessary.

Item 10:

Explain where you will get the funds to pay the amount you are offering.

Item 11:

All persons submitting the offer must sign and date Form 656. Include titles of authorized corporate officers, executors, trustees, Powers of Attorney, etc. where applicable.

Note: Staple in the upper left corner

the four (4) pages of Form 656 before you send it to us.

Where to File

IF YOU RESIDE IN

the states of Alaska, Alabama, Arizona, California, Colorado, Hawaii, Idaho, Kentucky, Louisiana, Mississippi, Montana, Nevada, New Mexico, Oregon, Tennessee, Texas, Utah, Washington, Wisconsin or Wyoming,

AND

AND

You are awageearneroraself-employed individual without employees,

You are OTHER than wage earner or a self-employed individual without employees,

THEN MAIL
Form 656 and attachments to:
Memphis Internal Revenue Service Center COIC Unit
PO Box 30803, AMC
Memphis, TN 38130-0803

THEN MAIL
Form 656 and attachments to: Memphis Internal Revenue Service Center COIC Unit
PO Box 30804, AMC
Memphis, TN 38130-0804

IF YOU RESIDE IN
Arkansas, Connecticut, Delaware, District of Columbia, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, South Dakota, Vermont, Virginia, West Virginia or have a foreign address,

AND

AND

You are a wage earner or a self-employed individual without employees,

You are OTHER than wage earner or a self-employed individual without employees,

THEN MAIL

THEN MAIL

Form 656 and attachments to:

Form 656 and attachments to:

Brookhaven Internal Revenue Service Center COIC Unit

Brookhaven Internal Revenue Service Center COIC Unit

PO Box 9007

PO Box 9008

Holtsville, NY 11742-9007

Holtsville, NY 11742-9008

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