Form Oic-11 - Offer In Compromise Application Fee Waiver Request - Georgia Department Of Revenue

Form OIC-11 (Rev 7/05)

Georgia Department of Revenue

Offer in Compromise Application Fee Waiver Request

(For Individual Taxpayers Only)

If you are not required to submit the fee based on your income level, you must

complete this form and attach both it and the worksheet to the front of your Offer

in Compromise application (Form OIC-1).

Your name (Please print)

Social Security Number

Spouse’s name (Please print)

Social Security Number

Signature Certification

I certify under penalty of perjury that I am not required to submit an offer in

compromise application fee based on my family unit size and income.

Your Signature

Date

________________________________________________________________

Spouse’s Signature (if submitting a joint offer)

Date

Note: If the Georgia Department of Revenue determines that you were required

to pay a fee, your offer in compromise will be returned without further

consideration.

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Parent category: Financial