Form FS-OIC                                                Indiana Department of Revenue
State Form 50112
(R5 / 9-20)
`  To: Commissioner of Indiana Department of Revenue                                    DOR Received Date

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                                                          7

Your First Name, Middle Initial, Last Name                                              Social Security Number (SSN)
                                                                                                   -            -
                                                                                        Social Security Number (SSN)
                                                                                                   -            -
Your Home Physical Address 

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Is this a new address?                                                                               Yes          No
If yes, would you like us to update our records to this address?                                     Yes          No
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           -
                           Individual Tax Periods <

       Income Tax-Year(s)
       Other State Tax(es) [specify type(s) and period(s)]

       attachment.

If your business is a Corporation, Partnership, LLC, or LLP and you want to compromise those tax debts, you must complete this section. You must 

Business Name

Business Physical Address (Street, City, State, ZIP Code)

                        (Street, City, State, ZIP Code)

                                Name and Title of Primary Contact                       Telephone Number
(EIN)
        -                                                                               (            )  -  
                                Business Tax Periods <

      Income Tax-Year(s)

      Other Federal Tax(es) [specify type(s) and period(s)]

      Note: 
      the attachment.

3
      Doubt as to Collectibility

       Doubt as to Liability -  I do not owe part or all of the assessed tax amount due.
      Economic Hardship

Explanation of Circumstances (Add additional pages, if needed) – DOR understands that there are unplanned events or special circumstances, such as 

Section 4                                        Payment Terms
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Lump Sum Cash

            7R$PRXQW         -                   20% Initial Payment (optional)         =  Remaining Balance
   $                         -                 $                                        = $
         <
         months.
   Amount of payment       $                     payable within                 1         Month after acceptance
   Amount of payment       $                     payable within                 2         Month after acceptance

DOR Use Only

Section 5         Source of Funds, Making Your Payment, Filing Requirements, and Tax Payment Requirements
Source of Funds
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Making Your Payment
                                                 $O
 must be in U.S. dollars. Do not send cash. Down payments are optional and not required.
Filing Requirements
      
                                                                                                                BB
Tax Payment Requirements (check all that apply)
      

                                            HUPV

Terms, Conditions, and Legal    D
Agreement                       W
                                 form. I authorize DOR to amend Section 1 and/or Section 2 if I failed to list any of my assessed tax debt or tax
                                 Indiana Department of Revenue to disclose the existence of any separate liabilities owed.
                                 7H$JUHHPHQW

DOR will keep my payments,      F
fees, and some refunds.         L

                                K2
right to appeal                 L

I must comply with my future    L
tax obligations and understand
I remain liable for the full    W
amount of my tax debt until all D
terms and conditions of this
                                U

                                 assessment of an individual shared responsibility payment.

Section 6 (Continued)                       HUPV

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                                    claim or refund suit for any liability or period listed in Section 1 or Section 2, even if I default the terms of the

I understand what will happen if   O
I fail to meet the terms of my
                                   P
                                    amount DOR determines is due after default.

I agree to waive time limits       P7
provided by law

                                   Q'7
Notice of Federal Tax Lien on      7
my property.                       U

Correction Agreement               R

I authorize the IRS to contact     S
relevant third parties in order to '

                                   T
individual for a joint liability.
                                                                               \7

DOR Use Only. I accept the waiver of the statutory period of limitations on assessment for the Indiana Department of Revenue, as described in 
Section 7(p).
                                      Title                                            Date (mm/dd/yyyy)
2ႈFLDO

Section 7                                                     Signatures

my knowledge and belief, it is true, correct and complete.
7D                                                                    Phone Number                                Today’s Date (mm/dd/yyyy)

`                                                                     (            ) -  
     
7                                                                     Phone Number                                Today’s Date (mm/dd/yyyy)

`                                                                     (            ) -  
      
Section 8                      Paid Preparer Use Only
                                                                      Phone Number                                Today’s Date (mm/dd/yyyy)
                                                                      (            ) -  
     
Name of Paid Preparer                                                 Preparer’s CAF No. or PTIN

Firm’s Name (or yours if self-employed), Address, and ZIP Code

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information. You should also include the current tax year on the form, in the list of applicable years or periods.

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