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OFFERINCOMPROMISE
FORMOTR‐10
OFFERINCOMPROMISE
OFFICEOFTAXANDREVENUE
ApplicationForWageEarners,Self‐Employed
Individuals,andBusinesses
1a.FullNameofTaxpayerandSpouse(ifapplicable)
_______________________________________________________________
1c.HomePhone
()______________________
1d.CellPhone
()________________________
1b.MailingAddress(Street,City,State,ZipCode)
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
1e.BusinessPhone
()______________________
1f.BusinessCellPhone
()________________________
2a.MaritalStatus:MarriedUnmarried(Single,DivorcedorWidowed)
_______________________________________________________________
2b.Name,Age,andrelationshipofdependant(s)
_______________________________________________________________
_______________________________________________________________
3a.NamesandSocialSecurityNumbersofallpersonssubmittingthisoffer
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3b.BusinessTaxNumber(s),includedwiththisoffer
_______________________________________________________________
_______________________________________________________________
3c.OtherBusinessTaxNumber(s)notincludedwiththisoffer
______________________________________________________________
4a.I/We(IndividualTaxTypeTaxpayers)submitthisoffertocompromisethe
tax liabilities plus any interest, penalties, additions to tax, and additional
amountsrequiredbylaw(taxliability)forthetaxtypeandperiodbelow:
IndividualIncomeTax
TaxPeriod(s):____________________________________________________
________________________________________________________________
________________________________________________________________
4b.I/We(
BusinessTaxTypeTaxpayers)submitthisoffertocompromise the
tax liabilities plus any interest, penalties, additions to tax, and additional
amountsrequiredbylaw(taxliability)forthetaxtypeandperiodbelow:
Sales&Use
WithholdingTax
OtherTax(es)/Fee(s)
PleaseSpecifyTaxPeriod(s):
________________________________________________________________
________________________________________________________________
5.I/Wesubmitthisofferforthereason(s)checkedbelow:
DoubtastoLiability‐Ifyoubelieveyoudon’towetheamountdue,you
mustincludewithaFormOTR‐10adetailedexplanationofthereason(s)
youbelieveyoudon’towethetax.
InsufficientResources‐Ifyoudon’thaveenoughassetsorincometopay
thefullamount,youmustincludewithFormOTR‐10acompletefinancial
statement,FormPA‐1forindividualsand/orPA‐2forbusinesses.
EconomicorOtherHardship‐Ifyouhaveenoughassetstopaythefull
amount,butbelievethatbecauseofyourexceptionalcircumstances
requiringfullpaymentwouldcauseaneconomichardshiporwouldbe
unfairandinequitable,youmustincludewithFormOTR‐10acomplete
financialstatement,FormPA‐1and/orPA‐2.
6.I/Weoffertopaythefollowing:
LumpSum–100%‐$______________________
6b.I/Weoffertopayusingthefollowingterms:
PeriodicPayment–20%initialpayment‐$_____________________
Otherproposedpaymentterms–20%initialpayment
$_____________________
Pleasespecify:__________________________________________________
_______________________________________________________________
7.ExplanationofCircumstances‐Iamrequestinganofferincompromiseforthereason(s)listedbelow: