Form 21 - Offer In Compromise Individual Request For Settlement
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4Commonwealth of Virginia
Department of Taxation
OFFER IN COMPROMISE
INDIVIDUAL REQUEST FOR SETTLEMENT
Name / Address of Taxpayer(s)
Social Security Number(s)
TO: TAX COMMISSIONER
I/We submit this offer to settle tax, interest, and penalties for the periods indicated below.
Individual income or fiduciary income for the year(s):
I/We offer to pay $
Payment attached
If you are unable to enclose the full amount offered, state when the full payment will be received.
Example: within ten (10) days from the date the offer is accepted.
__________________________________________________________________________________
I/We submit this offer for the reason checked below:
Doubt as to collectibility. My financial statement is attached.
Doubt as to liability. My detailed explanation is attached.
Request for waiver of penalty due to reasonable cause. My detailed explanation is attached.
*See following page for terms and conditions.
I/We, the undersigned, declare that I/we have examined this offer, including accompanying schedules
and statements, and to the best of my/our knowledge, it is true, accurate, and complete. I/We hereby
grant the power of attorney to act for me/us to compromise the above referenced liability(ies) to
_____________________________________. Also, I/we grant authorization to verify any financial data
by use of a credit report.
Signature of Taxpayer(s)
Date: ____________
Daytime Phone: ________________________
Signature of Taxpayer’s Representative
Date: ____________
Daytime Phone: ________________________
Form 21
OIC-IND
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