Form         Indiana Department of Revenue 
                 FS-OIC       Offer in Compromise
              State Form 50112
                 (R4 / 8-15)

                              Financial Statement for Offer in Compromise
Please refer to pages 5 to 6 of this document to determine your eligibility and the requirements for this program. Your failure to fol-
low all instructions provided and submit all required documentation will result in your application being rejected. You will be 
notified within 15 to 20 working days, or less, if you have been accepted into or rejected from the Offer in Compromise program.
                              Personal Information

Name                                                     Spouse’s Name

Social Security Number                                   Spouse’s Social Security Number

Address                                                  Address

City, State, ZIP                                         City, State, ZIP

Home Telephone                                           Home Telephone

Cell Phone                                               Cell Phone

Email Address                                            Email Address

Date of Birth                                            Date of Birth
                                  Dependents
                            Please list the name, age, and relationship of all dependents who live with you.

                 Name         Age                                                Relationship

                              Employment Information

Your Employer’s Name                                     Spouse’s Employer’s Name

Years Employed                                           Years Employed

Address                                                  Address

City, State, ZIP                                         City, State, ZIP

Telephone                                                Telephone
                              Bank Account(s) Information
                       Please include all checking, savings, credit union accounts, Certificates of Deposit, 
                              and safety deposit boxes held by you, your spouse, and dependents.
     Type of Account          Financial Institution Name        Account Number                              Current Balance

                                                         Page 1

Schedule 1                                         Monthly Household Income

Your net pay ...........................................................................................................................................................$  ______________
Your spouse’s net pay ............................................................................................................................................$  ______________
Rents paid to you (list property rent is being derived from) ....................................................................................$  ______________
Pensions .................................................................................................................................................................$  ______________
Social Security benefits ..........................................................................................................................................$  ______________
Social Security disability .........................................................................................................................................$  ______________
Profit from your business (must attach Federal Schecule C, E, F or any other pertinent schedules) ............$  ______________
Commissions ..........................................................................................................................................................$  ______________
Alimony/Child support received ..............................................................................................................................$  ______________
Welfare/Food Stamp assistance .............................................................................................................................$  ______________
Other income (please list source)  ..........................................................................................................................$  ______________
Total Monthly Income  ..........................................................................................................................................$  ______________

Schedule 2                                         Monthly Household Expenses

Rent/Mortgage  .......................................................................................................................................................$  ______________
Alimony/Child support paid  ....................................................................................................................................$  ______________
Groceries  ...............................................................................................................................................................$  ______________
Electricity  ...............................................................................................................................................................$  ______________
Heat (oil, gas, etc.)  ................................................................................................................................................$  ______________
Water/Sewer  ..........................................................................................................................................................$  ______________
Telephone  ..............................................................................................................................................................$  ______________
Transportation (gasoline, bus fare, etc.)  ................................................................................................................$  ______________
Medical expenses (physician’s bills, medication not paid by insurance)  ..............................................................$  ______________
Insurance cost -
Automobile  ...........................................................................................................$  _______________
Health/Hospitalization ...........................................................................................$  _______________
Life ........................................................................................................................$  _______________
Homeowner’s/Renter’s  .........................................................................................$  _______________
Total cost of insurance (auto, health, life, home, rental, etc.) .................................................................................$  ______________
Total cost of credit card payments (list card information on Schedule 3) ...............................................................$  ______________
Total loan payments (list loan information on schedule 4) ......................................................................................$  ______________
Other expenses (please itemize and explain below)   ........................................................................................$  ______________
Total Monthly Expenses  ......................................................................................................................................$  ______________

                                                   Other Expenses
                          Itemized Monthly Expenses and Explanations (attach additional sheets as needed)

                                                   Page 2

Schedule 3                                     Credit Card Information
List all credit card, lines of credit, and check overdraft protection held by you, your spouse, and/or your dependents (attach additonal 
sheet as needed)

Name                                           Credit Limit                      Total Balance Due Monthly Payment

Schedule 4                                     Loan Information
                                    List all loans that are currently outstanding

Name of Financial Institution                        Monthly Payment             Total Balance Due

Schedule 5                                     Motor Vehicle Information

Year                                Make/Model             Financed Through                        Current Value

Schedule 6                                     Real Estate Information

Address                                              Financed Through                              Current Value

                                               Other assets
List other items that  you, your spouse, and/or your dependents own or are currently buying (i.e. stocks, bonds, boats, furniture, 
jewelry, mechanic’s tools, RV, etc.)

                                               Page 3

                                            Support Assistance (if applicable)
If you are currently living with another individual, family or friend, and are paying no monthly expenses, that individual must read and 
understand the statement below and then sign and date this form. 

Under penalties of perjury, I declare that the named individual(s) on this Financial Statement are currently residing with me and pay 
no monthly living expenses. 

___________________________________          ___________________________________            ________________________
Printed Name                                    Signature                                  Date

                                                 Additional Information

                                            Offer in Compromise Information
List your offer in compromise and the payment thereof.                                                

Compromise Amount:  $  _______________________         Paid in full within:   _________________ days

Down Payment:  $  _______________________              Monthly Payment: $ ________________

Please explain how you determined these figures:

Before submitting your application, please review the following final checklist:
□ Completed the Form FS-OIC in its entirety.
□ Included a Letter of Circumstance. 
□ Attached all of the required supporting documentation (including proof of income and expenses).

Under penalties of perjury, I declare that this statement of assets and liabilities and all other information included in this document or 
attached thereto are true and correct to the best of my knowledge and belief. I authorize the Indiana Department of Revenue to verify 
any and all facts included in this document.

________________________________             _________________    ____________________________        ______________
Your Signature                              Date                 Spouse’s Signature                  Date

                                                          Page 4

                                 Indiana Department of Revenue
                                 Offer in Compromise

What Is an Offer in Compromise? 

An Offer in Compromise (offer) is an agreement between you (the taxpayer) and the Indiana Department 
of Revenue (IDOR) that settles a debt for less than the full amount due to date. To be considered for a 
compromise, you generally must make a reasonable offer based on your total debt and your earnings potential. 
Submitting an offer does not ensure that the IDOR will accept it.  

Collection activities will continue during the offer evaluation process. This can result in additional interest, fees, 
damages, and/or costs accruing. In addition, if your offer is accepted and will be paid through a payment plan  
agreement, you must make a 20% down payment. The IDOR keeps any proceeds from a levy served prior to 
your offer’s acceptance.

If the IDOR accepts your offer, you will be required to sign a legal and binding Offer in Compromise 
Agreement. If all parties have agreed to a payment plan agreement for the compromised amount, the IDOR 
will periodically review your case and you will be required to update all information previously submitted to this 
office. 

Please note: You must file all future tax returns timely and pay all future tax due timely. If you are issued a 
new tax liability or fail to file a timely return, the following will occur:
 •  Your Offer in Compromise payment plan agreement will be cancelled. 
 •  Your case will be closed. 
 •  Normal collection activities will resume. 
In addition, any penalties, interest, fees, costs, and damages previously waived will be added back to the 
amount due.

Who Might Qualify for an Offer in Compromise?
 •  Taxpayers who are facing financial difficulties
 •  Taxpayers who have a terminal and/or critical illness within the immediate family
 •  Taxpayers who have experienced personal devastation resulting from a natural disaster or an 
    uncontrollable economic event

What Is Required to Apply for an Offer in Compromise?
 •  You must complete an application, Form FS-OIC, and include all required supporting documents (see 
    instructions).
 •  You must be current with all tax filings for both Individual Income Tax and any Business Taxes if 
    applicable.
 •  Any bankruptcy filings must have already been discharged or dismissed.

Please note: Your Offer in Compromise will be rejected if you do not submit all the required forms and 
supporting documentation with your application.

                        Instructions for Submitting an Offer in Compromise
 
To submit an Offer in Compromise, do the following:
 •  Complete the Offer in Compromise, Form FS-OIC, in its entirety.
 •  Submit documented supporting evidence for all income, expenses, and accounts listed on  
    Form FS-OIC for the most recent month. If you fail to submit documented evidence with Form FS-OIC, 
    your offer will be automatically rejected. Accepted documents include
        ○ Income – Copies of paystubs, earnings statements, Social Security Administration benefit letters, 
         pension statements, bank statements reflecting direct deposits, etc. 

                                                   Page 5

     ○ Expenses – Copies of utility statements, credit card or loan billings, medical bills, etc.
     ○ Accounts – Copies of all statements for bank, retirement, and investment accounts. 

 •  Submit a Letter of Circumstance explaining in detail what prevented you from paying the taxes when 
     they were due and what is currently preventing you from entering into a payment plan agreement with 
     the IDOR. In addition, include any information that is pertinent to your requested offer, as well as the 
     source of the compromise funds.
 •  Include a medical statement from your physician detailing the diagnosis and prognosis of your and/or 
     your family member’s medical conditions(s), if applicable.
 •  Include a Bankruptcy Discharge or Dismissal Notice, if applicable.
 •  If you are requesting a payment plan agreement, you must also request a specific down payment and 
     monthly payment amount.

Note: The only expense items that the bank statements (debits) can be used for as supporting documentation 
are food and transportation (gas), and must be identified and clearly marked on the statement. With the 
exception of food and transportation (gas), copies of actual billing statement must be provided.

What the Offer in Compromise Cannot Do for You
 •  Cannot cancel or discharge your outstanding liabilities with no payment.
 •  Cannot leave your liabilities on hold indefinitely.
 •  Cannot reinstate a revoked Registered Retail Merchant Certificate. 
 •  Cannot release a professional license, permit, or tax lien until the approved Offer in Compromise 
     amount due is paid in full.
 •  Cannot intervene when a legal action has been filed, such as a wage garnishment, bank account levy, 
     collection suit, or court-ordered appearance. 

What the Offer in Compromise Can Do for You
 •  Can establish a settlement for a lesser amount with a compromise agreement that is signed by all 
     parties involved.
 •  Can accept a lump sum payment to satisfy your liabilities in full.
 •  Can accept a short-term payment plan agreement with the required 20% down payment to satisfy your 
     liabilities in full.

Before submitting your application, please review the following final checklist:
  Completed the Form FS-OIC in its entirety.
  Included a Letter of Circumstance.
  Attached all of the required supporting documentation (proof of income and expenses).
     DO NOT send originals; documents are not returned.

If you have any questions, you can contact us at (317) 232-4692 or by email at taxadvocate@dor.in.gov.

Please allow 15 to 20 days for processing.

Please mail your completed form and required documentation to:

                         Office of the Taxpayer Advocate
                         Indiana Department of Revenue
                         P.O. Box 6155
                         Indianapolis, IN 46206-6155

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