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Offer In Compromise - Ohio
| Offer In Compromise Form. This is a Ohio form and can be used in Business Services Attorney General Office Statewide . |
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Offer in Compromise ____________________________________________ Item 1 Applicant's Name and Home Address ____________________________________________ Name ____________________________________________ Spouse's Name ____________________________________________ Street Address ____________________________________________ City State Zip Code ( ) Telephone Number __ Spouse's Date of Birth Business Information On Trust Tax liabilities (Sales, Withholding) you must also provide Responsible Party names, contact information, and social security numbers. ___________________________________________________ Name of Business ___________________________________________________ Street Address ___________________________________________________ City State Zip Code ( ) Telephone Number Date of Birth Federal Tax ID/ Employer Identification Number ____________________________________________ Social Security Number ____________________________________________ Social Security Number of Spouse and/or Additional Responsible Party Name and Title of Corporate Officer(s) Item 2- To: Attorney General Applicant(s) submit this offer to compromise the liabilities plus any interest, penalties, forfeitures and any additional amounts required by law (tax liability) for the debt type and period marked below: (Please mark an "X" in the box for the correct description and fill in the correct debt period(s), adding additional periods if needed). Individual Income Tax Year(s). _____________________________________ Period(s)._______________________________ _____________________________________ Sales Tax Vendor's License No._____________________ IF YOU NEED ADDITIONAL SPACE, PLEASE ATTACH AND SIGN AN ADDITIONAL SHEET LABELED "ATTACHMENT" WITH CORRESPONDING ITEM NUMBER(S). PLEASE NOTE "N/A" IF THE INQUIRY IS NOT APPLICABLE TO YOUR LIABILITIES. EFFECTIVE 3/14/06 PAGE 1 OF 9 American LegalNet, Inc. www.FormsWorkflow.com School District Tax Year(s)._______________________________ Employer's Withholding Tax Employer Withholding No.___________________________________ Period(s)._____________________________ Corporate Franchise Tax Account No.____________________________ Year(s) ._______________________________ Other Department of Taxation Tax(es) (Motor Fuel, Commercial Activity Tax, etc...) Type(s)_____________________________ Tax Identification No.________________________________ Period(s)_________________________ Bureau of Worker's Compensation Tax Type(s)_____________________________ Risk No.__________________________ All other liabilities due to the State of Ohio. Specify types, periods/years, and amounts owed. ____________________________________ ____________________________________ ____________________________________ ____________________________________ Liquor License Permit No.___________________________ Period(s)_________________________ Ohio Department of Job and Family Services Tax Type(s)_____________________________ Employer Identification No.________________________________ Period(s)_________________________ If any of the above liabilities are liabilities incurred during the ownership or operation of a business, please indicate whether or not your business is still in operation. ____________________________________________________________________________________ If you have indicated that your business is no longer in operation, please state your last day of business. ____________________________________________________________________________________ If you have indicated that your business is no longer in operation, please explain how the business assets were disposed (foreclosure, bankruptcy, etc...) and attach the appropriate supporting documentation. _____________________________________________________________________________________ IF YOU NEED ADDITIONAL SPACE, PLEASE ATTACH AND SIGN AN ADDITIONAL SHEET LABELED "ATTACHMENT" WITH CORRESPONDING ITEM NUMBER(S). PLEASE NOTE "N/A" IF THE INQUIRY IS NOT APPLICABLE TO YOUR LIABILITIES. EFFECTIVE 3/14/06 PAGE 2 OF 9 American LegalNet, Inc. www.FormsWorkflow.com Documentation must be submitted to support your responses in items 3-6. Statements not fully justifying why you are limited to paying the offered amount will be rejected. ___________________________________________________________________________________________ Item 3 Applicant(s) submit this offer for the reason(s) checked below: Economic Hardship "I have insufficient assets and income to pay the full amount and requiring full payment would cause severe economic hardship." Doubt as to Liability "I do not believe I owe this amount and did not receive service of assessment." ____________________________________________________________________________________________________ Item 4 Applicant(s) offer to pay $_________________________. ____________________________________________________________________________________________________ Item 5 Please explain in detail why you are submitting this offer at this time and why you believe your offer should be accepted. Please explain each reason you have marked in item 3 independently. Be sure to cite to and attach any and all supporting documentation. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________________________ IF YOU NEED ADDITIONAL SPACE, PLEASE ATTACH AND SIGN AN ADDITIONAL SHEET LABELED "ATTACHMENT" WITH CORRESPONDING ITEM NUMBER(S). PLEASE NOTE "N/A" IF THE INQUIRY IS NOT APPLICABLE TO YOUR LIABILITIES. EFFECTIVE 3/14/06 PAGE 3 OF 9 American LegalNet, Inc. www.FormsWorkflow.com Item 6 Please explain where you will obtain the funds to make the offer listed in item 4. ______________________________________________________________________________________ _______________________________________________________________________________________________ Item 7 Please attach documentation of current income and all assets as stated below. Further, if you have submitted an Offer in Compromise to the Internal Revenue Service, attach a completed copy of each and every document submitted to or received from the Internal Revenue Service in
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