Form Oic-1 - Offer In Compromise Application

Form Oic-1 - Offer In Compromise Application - 2001 Page 2

OIC-1 (Rev 12/01)

Page 2

If any or all of the amount offered is from a loan or gift, provide the name of the lender or donor.

If any or all of the amount offered is from a source other than a loan or gift, provide the name of the source.

10. Summary Statement Supporting Reason for Offer (Required)

11. If you are represented by an attorney, accountant or agent, please provide the following contact information:

Name

Firm

Mailing Address

Phone Number (

)

(Attach Power of Attorney – Use Department of Revenue Form RD-1061 Only)

Form Oic-1 - Offer In Compromise Application - 2001 Page 2