Offer-in-Compromise IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY QUESTION, 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 APPLICATION. REVISED 12/16/2014 PAGE 1 OF 17 PLEASE NOTE: FAILURE TO COMPLETE THIS ENTIRE DOCUMENT WILL RESULT IN THE IMMEDIATE REJECTION OF YOUR OFFER-IN-COMPROMISE. PLEASE MAIL THIS APPLICATION TO THE ADDRESS BELOW SINGLE SIDED PAGES DO NOT FAX OR EMAIL ADDRESS: OHIO ATTORNEY GENERAL COLLECTIONS OFFER IN COMPROMISE 150 E. GAY STREET 21ST FLOORCOLUMBUS, OH 43215 Collections Enforcement Off ice 614 - 466 - 8360 OIC Unit 614 - 779 - 0105 150 East Gay Street, 21 st Floor Columbus, Ohio 43215 www.OhioAttorneyGeneral.gov American LegalNet, Inc. www.FormsWorkFlow.com Offer-in-Compromise Item 1 Applicant Name and Home Address Name Street Address City State Zip Code County ( ) Home Telephone N umber ( ) Cellular Telephone Number Social Security Number Social Security Number Additional Space: Business Information On Trust Tax liabilities (Sales, Withholding) you must also provide Responsible Party names, contact information, and social security numbers. If you n eed more room, please include this information on a separate sheet of paper. Name of Business Street Address City State Zip Code ( ) Telephone Number Federal Tax ID / Employer Identification Number Name and Title of Corporate Officer/Responsible Party Social Security Number Name and Title of Corporate Officer/Responsible Party Social Security Number Additional Contact Information IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY QUESTION, 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 APPLICATION. REVISED 12/16/2014 PAGE 2 OF 17 American LegalNet, Inc. www.FormsWorkFlow.com Offer-in-Compromise Item 2 - Debt Owed 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 (s) marked below: periods if needed). Individual Income Tax Year(s): School District Tax Year(s): Employer Withholding No. : Period(s): Liquor License(s) Permit No(s). Sales Tax (s) . : Period(s): Commercial Activity Tax Account No. : Year(s): Other Department of Taxation Tax(es) (Motor Fuel, Corporate Franchise Type(s) : Tax Identification No (s) . : Period(s) : IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY QUESTION, 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 APPLICATION. REVISED 12/16/2014 PAGE 3 OF 17 American LegalNet, Inc. www.FormsWorkFlow.com Offer-in-Compromise Item 2 - Debt Owed (continued) 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: All other liabilities due to the State of Ohio Tax Specify types, periods/years, and amounts owed. Type(s) Risk No. Period(s) Ohio Department of Job and Family Services Tax Type(s) Employer Identificatio n No. Period(s) (a) Have you filed an appeal with the Board of Tax Appeals (BTA) on any liability listed, or not listed, above? If yes, what was the BTA Case Number? (b) Were any of the above liabilities incurred during the ownership or operation of a business? (b.2) If yes to (b), is your business still in operation? If your business is no longer in operation, state the last day of business. (b.3) If no to (b.2), explain how the and attach the appropriate supporting documentation. IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY QUESTION, 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 APPLICATION. REVISED 12/16/2014 PAGE 4 OF 17 American LegalNet, Inc. www.FormsWorkFlow.com Offer-in-Compromise 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 Doubt as to Liability insufficient assets and income to believe I owe this amount and /or I did pay the full amount and requiring not receive service of the full payment would cause severe assessment (s) Innocent Spouse, see Innocent Spouse Public Doc ument Item 4 Please explain in detail why you are submitting this offer at this time and why you believe your offer should be accepted. Explain each reason you have marked in item 3 independently. Be sure to cite to and attach any and all supporting documentation. Item 5 Applicant(s) offer to pay $. Item 6 Please explain where you will obtain the funds to make the offer listed in item 5 . IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY QUESTION, 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 APPLICATION. REVISED 12/16/2014 PAGE 5 OF 17 American LegalNet, Inc. www.FormsWorkFlow.com Offer-in-Compromise Item 7 Financial Documentation, Part 1 Please attach documentation of all income, assets, and applicable items listed below. If any items cannot be provided, we require a notarized affidavit from the applicant(s) explaining why the applicant cannot produce the requested financial documentation. 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 relation to your Federal Offer in Compromise including, but not limited to, Forms 656, 433-A, and/ or 433-B, and any correspondence from the Internal Revenue Service regarding whether or not your offer was accepted. 7(a) If you and/or your spouse are a wage earner or are self-employed, please provide the following information for you and/or your spouse, if applicable. All documentation must be as current as possible. two , including all two s including A credit report dated within the past year for each applicant. One credit report per year is available free of charge at www.annualcreditreport.com . three three complete bank statements for any and all open accounts at all banks, credit unions, and any and all other financial institutions. C three complete credit card statements for any and all open credit cards. Copies of all insurance policies and/or most recent renewal declaration pages, including homeowners, renters, automobile, etc. If applicable, a copy of an official statement of social security or other government benefits received by each applicant. If applicable, list any bankruptcy cases filed and attach bankruptcy discharge documents. Applicant monthly budget including a list of all monthly income and a list of all monthly living expenses. (continued on page 7) IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY QUESTION, 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 APPLICATION. REVISED 12/16/2014 PAGE 6 OF 17 American LegalNet, Inc. www.FormsWorkFlow.com Offer-in-Compromise o udget items listed including lease agreement(s), mortgage statement(s), utility bills, car payments, etc. List of each ap List of any other debt that is currently in collections, i.e. medical bills, credit cards, pay day loans, utilities, etc. o Documentation, if applicable, showing payment on the above debts. List, and provide documentation of, any collection proceedings that have been filed against the applicant(s), including, but not limited to wage or bank garnishments. List all civil/criminal cases, including court and case number, in which any applicant is a party. List any professional licenses from any and all state or federal agencies for each application. o Please specify if any of these licenses are impaired because of the other reason. FAILURE TO PROVIDE ANY DOCUMENTATION REQUESTED IN ITEM 7(a), IF APP