TID#:
NEVADA DEPARTMENT OF TAXATION                                                                     Date: 

OFFER IN COMPROMISE                                                                                    Dept. Rcvd Stamp 

SECTION 1 YOUR CONTACT INFORMATION 

First Name, Middle Initial, Last Name: 
                                                                  SSN:                                 Phone:
If a Joint Offer, Spouse's First Name, Middle Initial, Last Name: 
                                                                  SSN:                                 Phone:
Physical Home Address (Street, City, State, and ZIP Code): 

Mailing Address (if different from above or Post Office Box number): 

Business Name / DBA: 

Business Address: 

Taxpayer Identification Number (TID):                             Secondary TID (if any) 

Federal Identification Number   (FID):                            Secondary FID (if any) 

SECTION 2 TAX AND PERIODS 

In the following agreement, the pronoun "we" may be assumed in place of "I" when there are joint liabilities and both parties 
are signing this agreement. 
I submit this offer to compromise the tax liabilities plus any interest, penalties, additions to tax, and additional amounts 
required by law for the tax type and period(s) marked below: 

Sales and/ or Use Tax: 

Modified Business Tax: 

Live Entertainment Tax: 

Short Term Lessor/ Governmental Service Tax: 

Other Tobacco Products Tax: 

Net Proceeds of Minerals: 

Other Excise Tax [specify type(s) and period(s)]: 

Note: If you need more space, use an attachment sheet.  Make sure to sign and date the attachment 

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SECTION 3  REASON FOR OFFER - (Check appropriate box) 

 Doubt as to Collectability – 
(a) The  assets  and  income  of  the  taxpayer  are  less  than  the  full  amount  of  the  liability  of  the  taxpayer  either  paid  in  a  single
    installment or pursuant to a reasonable installment payment plan; and
(b) The taxpayer will not have, in the foreseeable future, the money, assets or means to pay the liability of the taxpayer, after the
    taxpayer  has  paid  for  the  basic  living  expenses  of  the  taxpayer,  considering  the  guidelines  adopted  by  the  Internal  Revenue
    Service relating to national and local standards for living expenses.

 Doubt as to Liability – 
(a) The amount or existence of the liability of the taxpayer is dependent upon the outcome of a good faith dispute over the relevant
    facts or applicable law; and
(b) The amount of the liability of the taxpayer:
         (1) Has  become  due to the State,  as determined  by the date  upon which the taxpayer is required to pay  a tax, contribution,
           premium, fee, interest or penalty to the State pursuant to any provision of NRS; and
         (2) Has not been reviewed by the Commission, if applicable.

 Consideration of Equity and Fairness – 
(a) The medical condition of the taxpayer or the medical condition of the spouse, parent, sibling or child of the taxpayer to whom the
    taxpayer provides full-time medical care or living assistance was such that the taxpayer was unable to manage the financial affairs
    of the taxpayer during the period in which the liability of the taxpayer was incurred;
(b) The taxpayer incurred the liability, in whole or in part, as a result of the misconduct of an employee of the taxpayer of which the
    taxpayer was unaware;
(c) Notwithstanding the conduct which gives rise to the liability of the taxpayer for which a compromise is sought, the taxpayer and
    any business entities managed, operated or controlled by the taxpayer have a history of compliance with all applicable filing and
    payment requirements; or
(d) The taxpayer was the victim of a crime, natural disaster or other unforeseeable occurrence that significantly impacted the ability of
    the taxpayer to:
         (1) Pay the financial obligations of the taxpayer as such obligations came due in the ordinary course of business; or
         (2) Challenge  or petition for review  in  a timely  manner the  determination  of the  liability  of the taxpayer  when the liability was
           initially assessed by the Department.

Explanation of Circumstances: 
An offer to compromise the liability of a person submitted must include: 
(a) A statement of the grounds upon which the compromise is sought and any other information to support the offer;
(b) Copies  of such financial information  and  documentation  as may be required  by the Department, including, without  limitation, financial
statements,  bank  records,  accounting  ledgers  and  a  statement  or  explanation  of  any  assets  that  may  be  acquired  by  the  person
pursuant  to  the  resolution  of  a  pending  claim,  cause  of  action,  settlement  or  insurance  disbursement,  inheritance  or  an  unsatisfied
judgment or court order;
(c) An affirmation, signed under penalty of perjury, attesting to the truthfulness and accuracy of all information and documentation submitted
with the offer to compromise; and
(d) A written statement signed by the person consenting to suspend any and all statutory periods of limitation relevant to the collection of
the liability of the taxpayer or the seizure, attachment, garnishment or execution upon property or assets of the taxpayer to satisfy the
liability of the taxpayer during the period in which the Commission considers whether to accept or reject the offer of compromise.

(Attach additional pages if required) 

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SECTION 4  PAYMENT TERMS 

Enter the amount of your offer: $      It cannot be Zero. Indicate how long it will take you to pay your 
offer in full by checking one of the payment options below. 

Payment Option 1          Check here if you will pay your offer in five or fewer payments: 
Amount of payment 1 $                                       date 
Amount of payment 2 $                                       date 
Amount of payment 3 $                                       date 
Amount of payment 4 $                                       date 
Amount of payment 5 $                                       date 

Payment Option 2       Check here if you will pay your offer in full in more than five months and pay 
in monthly installments. Enclose a check for one month's installment: 

$    is being submitted with this form; and 

$    On the      (day) of each month thereafter for a total of               months. 
Total payments must equal the total Offer Amount. 

SECTION 5  SOURCE OF FUNDS 

Tell us where you will obtain the funds to pay your offer. You may consider taking out a loan, selling assets or 
borrowing from friends and/or family: 

SECTION 6  OFFER IN COMPROMISE TERMS 

                 a)      I request that the Nevada Tax Commission accept the offer amount listed in this offer application as payment
                         of my outstanding tax debt (including interest, penalties, and any additional amounts required by law) as of
                         the  date  listed  on this form.  I  authorize the Department  of  Taxation to  amend  Section 2  on  page  1  in the
                         event I failed to list any of my assessed tax debt.

                 b)      Once an authorized Department of Taxation official signs this form, my offer is considered pending as of that
                         signature date and it remains pending until the Commission accepts, rejects, returns, or terminates my offer
                         or  I  withdraw  my  offer.    An  offer  will  be  considered  withdrawn  when  the  Department  receives  my  written
                         notification of withdrawal by personal delivery or certified mail or when I inform the Department of Taxation of
                         my withdrawal by other means and the Department acknowledges in writing my intent to withdraw the offer.
                 c)      I will file tax returns and pay required taxes for the five year period beginning with the date of acceptance of
                         this offer, or until my offer is paid in full, whichever is longer. If this is an offer being submitted for joint tax
                         debt,  and  one  of  us  does  not  comply  with  future  obligations,  only  the  non-compliant  taxpayer  will  be  in
                         default of this agreement.
                 d)      The Department will not remove the original amount of my tax debt from its records until I have met all the
                         terms and conditions of this offer. Penalty and interest will continue to accrue until all payment terms of the
                         offer have been met. If I file for bankruptcy before the terms are fully met, any claim the Department files in
                         the bankruptcy proceedings will be a tax claim.
                 e)      Once  the  Commission  accepts  my  offer  in  writing,  I  have  no  right  to  contest,  in  court  or  otherwise,  the
                         amount of the tax debt.

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                             f) If I fail to meet any of the terms of this offer, the Department of Taxation may levy or sue me to collect any
 I understand what will         amount ranging from the unpaid  balance  of the  offer to the  original  amount  of the tax  debt  without further
 happen if I fail to meet       notice of any kind. The Department of Taxation will continue to add interest, pursuant to NRS 360.419, on
 the terms of my offer          the amount the Department is due after default. The Department will add interest from the date I default until
 (e.g., default).  
                                I completely satisfy the amount owed.
                             g) A  written  statement  must  be  provided  signed  by  the  person  consenting  to  suspend  any  and  all  statutory
 I agree to waive time          periods  of  limitation  relevant  to  the  collection  of  the  liability  of  the  taxpayer  or  the  seizure,  attachment,
 limits provided by law.        garnishment or execution upon property or assets of the taxpayer to satisfy the liability of the taxpayer during
                                the period in which the Commission considers whether to accept or reject the Offer of Compromise.
 I understand the            h) The Department may file a Notice of Tax Lien during the offer investigation. Generally, the Department files a
 Department may file a          Notice of Tax Lien to protect the Government's interest on offers that will be paid over time. This tax lien will
 Notice of Tax Lien on 
 my property.                   be released when the payment terms of the accepted offer have been satisfied.

 I authorize the 
 Department to contact       i) By authorizing the Department to contact third parties including credit bureaus, I understand that I will not be
 relevant third parties 
 in order to process my         notified of which third parties the Department contacts as part of the offer application process.
 offer.  
                             j) I  understand if the  liability sought to  be compromised  is the joint  and  individual  liability  of  me  and  my co-
 I am submitting an             obligor(s)  and  I  am  submitting  this  offer  to  compromise  my  individual  liability  only,  then  if  this  offer  is
 offer as an individual         accepted,  it  does  not release  or discharge  my co-obligor(s) from  liability.  The  Department  of Taxation still
 for a joint liability.  
                                reserves all rights of collection against a co-obligator(s).

SECTION 7               OFFER IN COMPROMISE WAIVER OF LIMITATION 

 The  taxpayer  shown  above  has  requested  an  offer  to  compromise  a  liability  pursuant  to  NRS  360.263,  NAC 
 360.437,  and  NAC  360.438.    Taxpayer  hereby  agrees  to  suspend  any  and  all  statutory  periods  of  limitation 
 relevant to the collection of the liability of the taxpayer or the seizure, attachment, garnishment or execution upon 
 property or assets of the taxpayer to satisfy the liability of the taxpayer during the period in which the Nevada Tax 
 Commission considers whether to accept or reject the Offer of Compromise. 

 SECTION 8              SIGNATURES 

 Under penalties of perjury, I declare that I have examined this offer, including accompanying 
 schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. 

 Signature of Taxpayer                                               Date (mm/dd/yyyy) 

 X 
 Signature of Taxpayer                                               Date (mm/dd/yyyy) 

 X 

SECTION 9               THIRD PARTY DESIGNEE 

 Do you want to allow another person to discuss this offer with the Department of Taxation? 
  Yes                     No 
 If yes, provide designee's name: 
 Telephone Number: 

SECTION 10   DEPARTMENT OF TAXATION USE ONLY 
 I accept the waiver of the statutory period of limitations on assessment for the Department of Taxation: 
 Print Name: 
 Signature of Authorized Department Employee:                                               Official Title: 

 X 
 Date (mm/dd/yyyy): 

                         To email, save this form to your computer and email the attachment to: 
                         nevadaolt@tax.state.nv.us with the subject of 'Offer In Compromise'.

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