Form Packet S Fillable Application for Settlement of Tax Liability
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

Acceptance of an Offer in Compromise by the Internal Revenue Service does not automatically guarantee (: Accrual) Unchecked (: Cash) Unchecked (: Completed) Unchecked (: Corp Officers) Unchecked (: Corp) Unchecked (: Corporation) Unchecked (: Deposit) Unchecked (: Divorced) Unchecked (: Employee) Unchecked (: Individual) Unchecked (: Married) Unchecked (: No) Unchecked (: No) Unchecked (: No) Unchecked (: No) Unchecked (: No) Unchecked (: No) Unchecked (: No) Unchecked (: No) Unchecked (: No) Unchecked (: Officer) Unchecked (: Other) Unchecked (: Own) Unchecked (: Paid Full) Unchecked (: Partner) Unchecked (: Partnership) Unchecked (: Pending) Unchecked (: Proprietor) Unchecked (: Proprietorship) Unchecked (: Rent) Unchecked (: Seperated) Unchecked (: Settlement) Unchecked (: Single) Unchecked (: Trust) Unchecked (: Yes) Unchecked (: Yes) Unchecked (: Yes) Unchecked (: Yes) Unchecked (: Yes) Unchecked (: Yes) Unchecked (: Yes) Unchecked (: Yes) Unchecked (: Yes) Unchecked (1) The applicant is not adequately identified (name address ID# etc ) or required signatures are not provided (2) The settlement offer includes an amount already collected or subject to refund (3) The tax liability is not adequately identified (4) The settlement agreement application does not include a statement supporting the reason for the settlement (5) Financial statements or other documentation have not been included or are incomplete (6) The Commission's records indicate noncompliance with filing of required returns (7) The applicant is currently under bankruptcy court jurisdiction (8) Power of Attorney Form BT 129 if required has not been included (Amounts may need to be adjusted to avoid duplication of asset and income values ) (as of date) (Attach Power of Attorney Form BT 129) (Attach Power of Attorney Form BT 129) (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (Date of death if Estate Tax) (If additional space is needed attach separate sheet) (Notary Public) (Please Type or Print) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) 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is not available if the taxpayer does not meet one of the four grounds for settlement listed 1) The tax liability must be final; 10 If you are represented by an attorney accountant or agent please provide the following contact information: 10 Last Federal Income Tax Return Filed Tax Year Beginning 10 Occupation 10) Total Collection Potential (line 8 plus 9) = 11 Disclosure Agreement for Offer in Compromise 11 Information About Owner Partners Officers Major Shareholders etc 11 Length of Employment 11) Total Value for Individuals (line 5 above) 12 Cash On Hand TOTAL (Enter also on Page 3 Item 24 A) $ 12 Terms and Conditions 12 Work Relationship 12) Total Value for Businesses (line 10 above) + 13 Bank Accounts (General Operating Payroll Savings Certificate of Deposits etc ) 13 Spouse's Employer or Business Name and Address 13) Total Collection Potential (line 11 plus 12) = 14 Bank Credit Available (Line of Credit etc ) 14 Employer Phone Number 15 Occupation 15 Real Property (Including Investment Property Unimproved Land etc ) 16 Length of Employment 16 Vehicles (Excluding Leased Vehicles) 17 Accounts Receivable 17 Work Relationship 18 Loans From Business To Proprietor Partners Officers Shareholders or Others 18 Taxpayer's Part time and Previous Employment 19 Machinery and Equipment (Including Furniture Fixtures Business Machines etc ) 19 Spouse's Part time and Previous Employment 2 Applicant(s) Mailing Address (If different from above) 3 Applicant(s) Legal Structure 2 Daytime Phone Number 2) All administrative remedies and appeals must be exhausted; 2) Multiply line 1 by: x48 x60 2) Trust fund taxes collected but not remitted to the Tax Commission can not be settled for less than the amount of 20 Dependent Name (Other Than Spouse) Social SecurityNumber Date of Birth Relationship Monthly Income 20 Merchandise Inventory (Goods Held for Sales and/or Raw Materials Used in Manufacture Fabricaton of Production) 21 Investments (Stocks Bonds Mutual Funds Government Securities Money Market Funds etc ) 22 Bank or Credit Union Accounts (Checking Savings Certificate of Deposit etc ) 22 Other Assets 23 Investments (Stocks Bonds Mutual Funds IRA Government Securities Money Market Funds etc ) 23 Liabilities 24 Assets 24 Real Property (Personal Residence Vacation or Second Home Investment Property Unimproved Land etc ) 25 Liabilites $ 25 Vehicles Excluding Leased Vehicles (Including Motor Homes Campers Motorcycles Boats Trailers etc ) 2501 lincoln boulevard 2501 lincoln boulevard 26 Net Worth ( Total Assets Minus Liabilities ) $ 26 Other Assets 27 Average Monthly Business Income and Expenses for the Periods Beginning and Ending 27 Liabilities (Do not include any amounts owed listed in Section IV above) 28 Assets 28 Average Monthly Net Income (Income minus Expenses) $ 29 Is this business currently in filing compliance with all Oklahoma taxes? 29 Liabilities $ 3 Marital Status (Check One) 3 Type of Business 3) Appointed or elected officials are not eligible to seek relief 3) Income Potential = 3) The taxpayer must be current with all tax return filing requirements of the Commission; 30 Has this business disposed of any assets or property by sale transfer exchange gift or in any other manner during the past 18 months? 30 Net Worth ( Total Assets Minus Liabilities ) $ 31 Are you currently in filing compliance with all Oklahoma taxes? 31 Is a foreclusure proceeding pending on any real estate equipment or other property that this business owns or has an interest in? 32 If the tax liability was incurred in the operation of a business has the business been discontinued? 32 Is another party holding any assets on behalf of this business? 33 Have you disposed of any assets or property by sale transfer exchange gift or in any other manner during the past 18 months? 33 Is this business a party to any lawsuit now pending? 34 Is a foreclosure proceeding pending on any real estate that you own or have an interest in? 34 Is this business currently under bankruptcy court jurisdiction? 35 Does the business have credit available on credit cards? (i e Visa MasterCard American Express) If yes attach a schedule of available credit 35 Is anyone holding any assets on your behalf? 36 Are you a party to any lawsuit now pending? 37 Is there a likelihood that you will receive assets or income from an estate in probate? 38 Have you previously petitioned the Commission for settlement of any tax liability? 39 Are you or any business that you own currently under bankruptcy court jurisdiction? 4 Daytime Phone Number 4 I/We agree to pay the amount of $ to settle the tax liabilities listed in Section 5 below and will pay thisamount in the following manner: (Check One Only) 4 Social Security Number: 4) Net Worth + 4) The taxpayer must not be the subject of an open bankruptcy proceeding 40 Do you have income sources other than your business or employer? 41 Do you anticipate any increase in household income in the next two years? 42 Do you have credit available on credit cards? (i e Visa MasterCard) If yes attach schedule indicating the amount available on each card 43 Monthly Household Disposable Income 44 Net Monthly Household Disposable Income ( Combined Monthly Income Minus Total Monthly Living Expenses ) 5 Date of Birth: 5 Description of Tax Liabilities To Be Settled 5 Number of Employees 5) The taxpayer must not be the subject of a State tax related criminal investigation or prosecution 5) Total Collection Potential (line 3 plus 4) = 6 Grounds for settlement: 6 Previous Address If At Current Address Less Than Two Years 6 Type of Ownership 6) Average Monthly Net Business Income $ 7 Federal Employer Identification Number / Social Security Number 7 If any or all of the amount offered is from a loan or gift provide the name of the lender or donor 7 Income Tax Return Information 7) Multiply line 1 by: x48 x60 8 Beginning Date of Business 8 If any or all of the amount offered is from a source other than a loan or gift provide the name of the source 8 Taxpayer's Employer or Business Name and Address 8) Income Potential = 9 1 If you marked Grounds A or B on page one or are requesting a settlement based in part on financial hardship 9 2 If you marked Grounds C or D on page one provide a detailed explanation of the nature of the events that resulted inthe tax liability You may also include any other information that supports your grounds for settlement 9 Employer Phone Number 9 Ending Date of Business (If Closed) 9) Net Worth + A Cash $ A Collection of the tax with interest and penalties would reasonably result in the taxpayer declaring bankruptcy A complete inventory of the content of all safe deposit boxes in which you have an interest including fair market A deposit of $ is attached the balance to be paid within 30 days from acceptance A list of all accounts and loans receivable showing the payer amount due age and status of each account A list of all stocks bonds and/or other securities you own along with the current market value for each Provide A list of all your business equipment office furniture and other business assets including fair market value of A statement from the insurance company for each life insurance policy showing the current cash loan value A Year of Last Filed Federal Income Tax Return a) I/We voluntarily submit any payment made with this application above and all of the eligibility requirements accept or reject the offer The Division may request additional documentation to verify financial or other information acceptance by the State An application for settlement agreement tendered to the Commission will be reviewed acceptance The applicant will have the opportunity to amend the application if indicated accepted settlement amount will be released and mailed upon full payment of the settlement amount Payment of the Account Maintenance Division AMW Account Maintenance Divison AMW Accounting Method: (Check One) Cash Accrual Other: accumulated dividends and interest dates and amounts of policy loans and the amount of loan additional information and documents along with your initial application Address Address Address Address City Administrative rules for the settlement process are found at 710:1 5 80 et seq of the Oklahoma Administrative Code Advertising $ agreement agreement are met If I/we file bankruptcy before the terms and conditions of the settlement agreement arecompleted any claim the Commission files in a bankruptcy proceeding will be a tax claim Alimony and Child Support All income amounts are to be reported at Gross Amount except Rental Income All information and statements provided by the applicant are subject to verification and are submitted under oath Am I Eligible? Amount Amount Amount Accepted $ or Declined $ Amount Owed amount paid with the application as payment toward the outstanding tax liability unless refund of thepayment is requested An Application for Settlement of Tax Liability OTC 600 must be submitted to the Oklahoma Tax Commission An application submitted pursuant to the provisions of Title 68 O S Section 219 1 will require an in depth analysis of your financial condition To expedite this process it is necessary that you provide the following and evaluated on its own merits and penalty will continue to accrue on any unpaid tax debt while the settlement offer is being considered Any collection by the Commission prior to the Settlement Agreement or any refund to which the Commission is Any payment made with the Application for Settlement of Tax Liability will be applied to the outstanding liability Applicant's Signature Applicant's Signature Date Applicant's Signature Date Applicant's Signature Date application Application for Settlement of Tax Liability Application for Settlement of Tax Liability Application for Settlement of Tax Liability Form OTC 600 Applications submitted by individuals who are self employed or are business owners must include Statements of Appraised Value Appraised Value Appraised Value Description Current or As attorney(s) in fact to represent taxpayer before the Oklahoma Tax Commission and/or acquire any tax form(s) and/or Attachments and Schedules are true and correct to the best of my knowledge and belief Authorization to Release Financial Data Authorization to Release Financial Data Form OTC 600 E B Bank Accounts $ B Bank or Credit Union Accounts $ B Federal Adjusted Gross Income From Last Return B The tax liability is uncollectible due to the insolvency of the taxpayer resulting from factors beyond the control of thetaxpayer or other similar factors b) The Commission will apply any payment made with the application to the oldest existing tax liabilities Bad Debts $ Bank Revolving Credit/Credit Card Debt $ bankruptcy and the settlement amount offered reasonably reflects collection potential; Bankruptcy Case Number: be made by the payment due date as indicated on the acceptance letter Any issued and recorded tax lien subject to the be requested based on individual circumstances be settled for less than the amount of tax collected ) Before calculating collection potential deduct monthly state tax payment amounts from expenses used to determine disposable by (1) the appropriate Statement(s) of Financial Condition for Individuals and/or Businesses (2) a Worksheet for By my/our signature(s) below I/we authorize the Oklahoma Tax Commission and the Internal Revenue Service to exchange By submitting this application and signing below I/we are requesting from the Oklahoma Tax Commission settlement of tax C Bank Credit Available $ C Investments $ C The tax liability is the result of actions of a person other than the taxpayer and to hold taxpayer liable for the tax liabilitywould be inequitable C Year of Last Filed Oklahoma Income Tax Return c) If the Commission rejects the application or if the application is withdrawn the Commission will treat any Calculating Gross Monthly Wages and Salaries: Cash Surrender Value of Life Insurance $ Charitable contributions; Child Care City State Zip Code City State Zip Code City State Zip Code Clothing and Personal Grooming Collectibles Antiques or Artwork $ Collection of the tax and interest and penalties accruing thereto would reasonably result in the taxpayer declaring Combined Monthly Income Commissions $ Completed Computation of Collection Potential and (3) all documentation required to support the facts and figures on those concerning the application The financial investigation may require verification of financial data by visual inspection Continued Copies of any judgements or legal decrees (excluding bankruptcy) for past six years Copies of expenses including utilities rent insurance property taxes for last ninety days Copies of medical bills not covered by insurance and documentation from insurance company indicating theitems are not covered Corporate Income Tax Corporation Other (Specify) County County Do you own or rent ? Court Ordered Payment Current Current Current Market Current Taxes $ D In case of trust fund taxes the applicant must show that the tax was not collected and that the applicant had a good faithbelief that collection of the taxes was not required (Trust fund taxes collected but not remitted to the Commission can not D Real Property $ d) I/We will remain in compliance with all tax return filing and payment provisions of Oklahoma Statutes while data on those forms are for the three most current periods Computations of the proposed settlement amount must Date Date Date discontinued: Date Power of Attorney Signature DatePower of Attorney Signature Daytime Phone Number(area code and number) Description Address Current Market Description Current MarketValue Amount Owed Equity in Inventory Description Current MarketValue Amount Owed Equity inMach and Equip Description Make Model Year Tag Description Make Model Year TagNumber Description of Tax Document Description Total Amount Owed Description Total Amount Owed different than the collection potential calculated on Form OTC 600 C Dividends and Capital Gain Distribution $ Dividends Interest and Investments Do not deduct payroll withholdings allotments or other items you elect to take out of your pay such as insurance Document Checklist Document Checklist Form OTC 600 D documentation may be requested for verification of information documents that taxpayer would be entitled to receive E Vehicles $ e) The application remains pending until an authorized Commission official issues notification of acceptance or each item copies of documents etc Education or Student Loans $ Electric Employee Proprietor Employer's Name Employment Dates Employer's Name Employment Dates entitled cannot be considered part of the settlement amount Equipment Leases (not listed above) $ Equity inProperty Equity inVehicle Estate Trust and Royalty Income Estimated Quarterly Tax (If Applicable) Exceptions may be granted for expenses if you can prove that they are necessary for the health and welfare of you oryour family or for the production of income Expenses Generally Not Allowed: F Accounts Receivable $ F Other Assets $ f) I/We understand that collection activities may continue during the review process however the Commission Federal Employer Identification Number FEI Number Financial Condition for both individuals and businesses Financial Condition for Businesses must be completed signed and attached along with the required supporting documentationand a Worksheet for Computation of Collection Potential in order for this offer to be processible In all cases additional Firm: for any of the Following Reasons: For Businesses for Computation of Collection Potential are required Additional documentation in support of the taxpayer's claim may For individual taxpayers that apply for settlement on grounds A or B proof of employment income commissions fees For Individuals A B For Self Employed Individuals and Business Owners for Settlement for the purpose of delaying collection or otherwise jeopardizing the Commission's ability to collect the tax debt Any Form BT 129 Form OTC 600 (Page 1) Form OTC 600 (Page 2) Form OTC 600 (Page 3) Form OTC 600 (Page 4) Form OTC 600 A (Page 1) Form OTC 600 A (Page 2) Form OTC 600 A (Page 3) Form OTC 600 A (Page 4) Form OTC 600 A (Page 5) Form OTC 600 A (Page 6) Form OTC 600 B (Page 1) Form OTC 600 B (Page 2) Form OTC 600 B (Page 3) Form OTC 600 B (Page 4) Form OTC 600 B (Page 5) Form OTC 600 B for businesses should be completed before calculating the amount of collection potential Form OTC 600 C Form OTC 600 D Form OTC 600 E forms If the Total Collection Potential is greater than the total liability the applicant may be considered to have financialresources sufficient to pay in full and should not apply for settlement Furniture/Personal Effects $ G Loans From Business to Proprietor Partners Officers Shareholders or Others $ g) Payments and refunds applied prior to receipt of the application by the Commission cannot be consideredpart of the settlement offer and are not subject to refund Gift or Loan Proceeds Give Us a Call or Visit! Groceries Gross Monthly Income Gross Receipts from Sales Services etc $ Gross Rental Income $ H Machinery and Equipment $ h) I/We understand that the tax owed will remain a tax liability until all the terms and conditions of the settlement Hereby appoints: House or Rent Payment I Merchandise Inventory $ I/We have examined this Statement of Financial Condition for Businesses and hereby affirm that to the best of my/ourknowledge and belief it is true correct and complete I/We have examined this Statement of Financial Condition for Individuals and hereby affirm that to the best of my/ourknowledge and belief it is true correct and complete If No identify tax type and period: If paid bi weekly (every 2 weeks) multiply bi weekly gross wages by 2 17 If paid semi monthly (twice each month) multiply semi monthly gross wages by 2 If paid weekly multiply weekly gross wages by 4 33 If signed by a corporate officer partner or fiduciary on behalf of the taxpayer I certify that I have the authority to execute If the Settlement Agreement Is Accepted If the Settlement Is Declined If the settlement is requested exclusively on grounds C or D no Statements of Financial Condition or Worksheet If the settlement is requested on grounds A or B an Application for Settlement of Tax Liability must be accompanied If the settlement will be paid in more than 90 days but less than two years use the totals from Column B If the settlement will be paid within 90 days use the totals from Column A If the Total Collection Potential is greater than the total liability the applicant is considered to have financial resources sufficient to pay in full If Yes from whom? If Yes from whom? Relationship: If Yes how much will the income increase? $ Why will it increase? If Yes identify tax type and period: If Yes identify type of assets and value: Relationship of asset holder: If Yes identify: In cases of nonpayment of trust fund taxes the taxes were not collected by the taxpayer from its customer and the in Last Three Years In State Toll Free (800) 522 8165 extension 1 3160 In the event the amount abated exceeds $10 000 00 the settlement agreement must be approved by Oklahoma CountyDistrict Court In cases that require district court approval lien releases will not be issued until the taxpayer fulfills allrequriements of the agreement and provides the Division with a certified copy of the Oklahoma County District Court'sorder approving the agreement in the Last Three Years Income Amount Expenses Amount income and deduct the amount of the state tax debt from liabilities used to determine net worth Income Sources Income Taxes (Federal State FICA) Individual Income Tax Individual Proprietorship Information for Completing the Statement of Financial Condition for Individuals information from their respective files regarding my/our pending or completed offer in Compromise Information You Need to Know Before Submitting the Installment and Lease Payments $ Installment or Personal Loans $ installment payment arrangement already in effect will be continued while the settlement offer is considered Interest Instructions Insurance $ Insurance: Interest and Investment Income $ IRS Agent Assigned is paid in full J Investments $ Jewelry $ Judgements Payable $ Judgments or Settlements Receivable $ K Other Assets $ Liability liability as authorized by O S 68 Section 219 1 I/we understand and agree to the Terms and Conditions of the Application for Loans Payable (not secured by assets) $ Looking for Additional Information? m c connors building m c connors building Mail the completed application along with all supporting schedules and documents to: Mail to: Oklahoma Tax Commission Mailing Address: Making an Offer for Settlement of Tax Liability Materials Purchased $ may suspend its collection efforts if the interests of the State will not be compromised Medical Expenses and Prescriptions Monthly Expenses Monthly Living Expenses MonthlySalary or Wage My commission expires: Name and Address Account Number Type of Account Balance Name and Address Social Name Date Due Status Amount Due Name of Institution and Address Account Number Credit Line Amount Owed Credit Available Name of Institution and Address Account Number Type of Account Balance Name Relationship Payoff Date Status Amount Due Name: Net Rental Income Net Rental Income: Enter your monthly net rental income This is the amount remaining after you pay ordinary andnecessary monthly rental expenses If your net rental income is a loss enter 0 Do not enter a negative number Net Wages and Salaries $ No information written in this application shall be construed as granting any legal right to any taxpayer for the No matter what the tax topic from ad valorem taxes to sales tax rates to filing incometaxes online to vehicle tag agent information the Oklahoma Tax Commission has Not only will you find forms publications motor vehicle information and everythingin between but you are also able to reach us via the e mail addresses at the bottomof each page Use the e mail options to send us any questions you have that are notanswered on the website For various tax questions address your e mail to: NOTE: If settlement is requested on grounds A or B the Statement of Financial Condition for Individuals and/or Statement of Note: If you appoint an organization firm or partnership you must also name an individual within the organization to act on your behalf Note: Use $0 00 on Line 1 if the net income calculated on Form OTC 600 A is a negative amount Use $0 00 on Line 4 if Note: Use $0 00 on Line 6 if the net income calculated on Form OTC 600 B is a negative amount Use $0 00 on Line 9 ifthe net worth calculated on Form OTC 600 B is a negative amount Notes Payable $ Notes Payable (not secured by assets) $ Notes Receivable $ Number of corporate officers or business partners of records and personal interview The Division may determine that a larger settlement amount is necessary to justify of Tax Liability of the lien Compliance with all terms and conditions of the settlement agreement is required Offers for settlement based on grounds A or B must complete the Worksheet for Calculation of Collection Potential Oklahoma City 2501 North Lincoln Boulevard (405) 521 3160 Oklahoma City Oklahoma 73126 0800 Oklahoma City Oklahoma 73126 0800 Oklahoma City Oklahoma 73194 Oklahoma City Oklahoma 73194 Oklahoma Tax Commission Oklahoma Tax Commission Oklahoma Tax Commission Oklahoma Tax Commission Oklahoma Tax Commission Oklahoma Tax Commission Office Oklahoma Tax Commission to arrange payment of the entire liability If immediate payment of the entire liability is not Oklahoma Tax Commission U S Postage PaidAccount Maintenance Division AMW Oklahoma City OK 73194 or for other similar cause beyond the control of the taxpayer and the settlement amount offered reasonablyreflects collection potential; otcmaster@tax ok gov Other (Specify) Other (Specify) Other (Specify) $ Other Expenses (Specify) $ Other Income (Specify) $ Other Information Concerning Settlement of Tax Other Liabilities $ Other Liabilities: $ Other similar discretionary expenses Our website address is: www tax ok gov Ownership Interest Packet S Paid in full with this agreement (Make check payable to the Oklahoma Tax Commission ) paid when it was due and (c) the circumstances that presently prevent you from paying in full Partner Officer Partnership Corporation Past Due Federal Taxes $ Past Due Other Taxes $ Past Due State Taxes $ Patents or Copyrights $ payments credit union deductions car payments etc Payments on unsecured debts such as credit card bills; Payments will not be refunded if the Settlement Agreement is declined or withdrawn Pending Pensions Disability and Social Security pensions etc must be provided for the taxpayer spouse and dependants Although the taxpayer may be the only Percent of Permit Number (s) person liable for the tax this information is needed for equitable distribution of cost of living expenses Phone Number Phone Number (area code and number) possible the applicant may request an installment payment arrangement through the Collections Division of the Oklahoma Post Office Box 26800 Post Office Box 26800 Post Office Box 26800 Permit Number 548 Power of Attorney Power of Attorney Form BT 129 Power of Attorney must be submitted in all cases where the taxpayers designate another individual to submit their Power of Attorney Signature Date Property and Ad Valorem Taxes Proprietorship Partnership provide (a) a detailed explanation of the events that resulted in the tax liability (b) why the tax was not filed and/or Provide copies of bank statements for all checking and savings accounts personal and business for the threemost current periods Provide copies of federal income tax returns for three most current years and copy of your IRS Offer in Compromise Provide copies of statements showing the value of your interest in all retirement accounts pensions andprofit sharing plans for the three most current periods Provide proof of gross earnings pension social security and other income including statements showingdeductions for the past three months rejection or until the application is withdrawn by me/us Rent or Mortgage Expenses $ Repairs and Maintenance $ required mark NA Return this document checklist with your Application For Settlement of Liability Statement(s) of FinancialCondition and Worksheet for Calculation of Collection Potential (if needed) For any item above that is not Revised 9 2014 Revised September 2014 right of appeal to any court may be taken from such decision Royalty Income $ Salaries Wages Pensions and Social Security: Enter your gross monthly totals from these income sources Salary Wages Commissions and Tips Sales & Use Tax schedules on all notes payable and/or revolving accounts Section Four of the Application For Settlement of Tax Liability Statement(s) of financial condition Form OTC 600 A for individuals and Section I Business Identification Section I Personal Information Section II Assets Section II Assets (continued) Section II Employment Information Section III Dependent Information Section III Liabilities Section IV Assets Section IV Net Worth Calculation Section V Income and Expense Analysis Section V Liabilities Section VI Net Worth Calculation Section VI Other Information Section VII Other Information Section VIII Income and Expense Analysis Security Number Title Effective Self Employment Income Separated Divorced settlement amount by cash cashier's check money order or charge to an approved credit card will assure faster release settlement of any tax liability The decision of the Commission in denying a settlement offer shall be final and no Settlement of Tax Liability as follows: several methods available to get any additional information you need Signature of or for taxpayer(s) Date Signature Signature Signature Title (if applicable) Date Single Married Social Security Number Social Security Number Social Security Number or FEI Number Social Security/Federal Employer Identification Number(s) Source Spouse Spouse and dependent information are required although only one person may be liable for the tax Spouse: State State Tax Number or Statement from lending institutions and other creditors that clearly indicates current balances owed and payment Statement of Financial Condition for Businesses Statement of Financial Condition for Businesses Form OTC 600 B Statement of Financial Condition for Individuals Statement of Financial Condition for Individuals Form OTC 600 A Statements for all mortgages of real estate you own or have interest in Also appraisals if any on all real estate Subtotal Supplies and Office Expenses $ suspension of collection activity will not be considered if it is determined that the settlement agreement was filed Sworn to and subscribed before me on the date of first above written tax collected Tax Commission Oklahoma law makes no provision for appeal of a declined application Tax liens will be released only after an application for a settlement agreement is accepted and the amount offered Tax Period(s) Covered Tax Type Account Number Period(s) Tax Year Ended Taxable Income Taxpayer Taxpayer 1 Name Taxpayer 2 Name taxpayer had a good faith belief that collection of the taxes was not required; Taxpayer(s) Name(s) Taxpayer: Taxpayers are eligible to file an application for settlement if they believe they qualify for settlement on one or more of thegrounds referenced above and the following eligibility requirements are met: Taxpayers must provide an extensive explanation of their exceptional circumstances if they wish to offer an amount Telephone Number that the principal(s) can receive with respect to the above specified matter(s) unless exceptions are noted below: The Account Maintenance Division will evaluate the application and make a recommendation to the Commission to The applicant may submit the Collection Information Statements from the IRS Offer in Compromise if the financial The attorney(s) in fact (or either of them) are authorized until written revocation is received to represent the taxpayer before The Commission may consider additional circumstances when determining whether to enter a settlement agreement The Commission May Reject the Application as not Processable The Commission may suspend the enforcement of collection while a settlement offer is being considered However The Division will notify the applicant by mail if the agreement is accepted Payment of the accepted settlement offer must The Division will notify the applicant by mail if the application is declined The applicant should immediately contact the The information requested in this statement should include all household income and expense the most current brokerage statements where available the net worth calculated on Form OTC 600 A is a negative amount the Oklahoma Tax Commission and receive confidential information and to acquire any and all tax form(s) and/or documents The Oklahoma Tax Commission as authorized by Oklahoma Statutes Title 68 Section 219 1 will consider a Settlement ofTax Liability when it is determined that: The settlement amount will be paid in monthly payments of The tax is uncollectible due to insolvency of the taxpayer resulting from factors beyond the control of the taxpayer The tax liability is attributable to actions of a person other than the taxpayer and it would be inequitable to hold thetaxpayer liable for the tax liability; or the taxpayer in economic activity from which the liability originated These circumstances may include but are not limited to: whether the taxpayer has made efforts in good faith to complywith the tax laws of Oklahoma; whether the taxpayer has benefited from nonpayment of the tax; and involvement of this application is pending and during the period of any subsequent pay plan arrangement This Packet Contains: this power of attorney on behalf of the taxpayer This worksheet is used to assist in calculating collection potential and may be used as a basis for the settlement amount offered in Timber Mineral or Drilling Rights $ Timely filing of all tax returns is required while the application is pending and during any pay out period allowed Title (if applicable) To Whom It May Concern: TOTAL (Enter also on Page 3 Item 24 B) $ TOTAL (Enter also on Page 3 Item 24 C) $ TOTAL (Enter also on Page 3 Item 24 D) $ TOTAL (Enter also on Page 3 Item 24 E) $ TOTAL (Enter also on Page 3 Item 24 F) $ TOTAL (Enter also on Page 3 Item 24 G) $ TOTAL (Enter also on Page 3 Item 24 H) $ TOTAL (Enter also on Page 3 Item 24 I) $ TOTAL (Enter also on Page 3 Item 24 J) $ TOTAL (Enter also on Page 3 Item 24 K) $ TOTAL (Enter also on Page 3 Item 25) $ TOTAL (Enter also on Page 3 Item 28 A)21 Cash on Hand $ TOTAL (Enter also on Page 3 Item 28 B) $ TOTAL (Enter also on Page 3 Item 28 C) $ TOTAL (Enter also on Page 3 Item 28 D) $ TOTAL (Enter also on Page 3 Item 28 E) $ TOTAL (Enter also on Page 3 Item 28 F) $ TOTAL (Enter also on Page 3 Item 29) $ Total Assets $ Total Expenses $ Total Income $ Total Monthly Living Expenses Transportation Expense Transportation Expenses $ Travel and Entertainment $ Trust/Estate Corporation Officer(s) Tuition for private secondary schools; Tuition for public or private colleges; Tulsa Branch Office 440 South Houston Fifth Floor (918) 581 2399 Type Current or Type Issuer Quantity orDenomination Type Issuer Quantity orDenomination Current Value Type of Tax(Income Sales Etc ) Type or print your name below if signing for a taxpayer who is not an individual Under penalty of perjury I/we declare that the information contained in this Application for Settlement of Tax Liability use Form OTC 600 C Worksheet to Calculate Collection Potential Utilities $ Utilities: Value Value Value Amount Owed Equity in Property Value Amount Owed Equity in Vehicle value of each item copies of documents etc Vehicle Lease Payment Vehicle Leases $ Vehicle Leases (not listed above) $ Vehicle Loan Payment Vested Retirement Account $ Visit Us on the World Wide Web! Voluntary retirement contributions; Water What Are the Grounds for Requesting a Settlement of Tax Liability? When Am I Not Eligible? When Settlement is requested by a business Statements of Financial Condition for Individuals may also be required Workers' Compensation and Unemployment Worksheet for Calculation of Collection Potential Worksheet to Calculate Collection Potential Form OTC 600 C Year(s) or Period(s) Years Months Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No If No identify tax type(s) and period(s): Yes No If Yes Bankruptcy Case Number: Yes No If Yes identify: Yes No If Yes receiving party: You have my authorization to release any financial data that pertains to me or my company to the Oklahoma Tax Commission you own or have interest in Zip Code