Form
                                                                      Offer in Compromise for Business
    A-213 (OIC)
In the following form, the pronoun "you" is used to refer to the business who has tax debt at the Wisconsin Department of Revenue.
Use this form if your business is a:
•  Business Trust   •  Corporation                                                •  Limited Liability Partnership •  Unincorporated Association
•  Common Law Trust •  General Partnership                                        •  Limited Partnership
•  Cooperative      •  Limited Liability Company (LLC)                            •  Statutory Trust
If your business is a sole proprietor or a disregarded single member LLC taxed as a sole proprietor (filing Schedule C, D, E, F, etc.), 
complete Form A-212 (OIC) Offer In Compromise for Wage Earners and Self-Employed Individuals.

 Failure to resolve this debt is due to the following cause(s):

 I have filed all required tax returns.   Yes                 No (If unable to file, please contact the department)  Explain:

 Is this business still active?       Yes No (If not, when did it cease operations?)  Date:

Part 1:  Financial Statement

Note:  Include attachments if additional space is needed to respond to any question.

 Section 1                                                      Business Information
 Business Name                                                                    Employer Identification Number

 Business Location Address (street, city, state, zip code)                        DBA or "Trade Name"

                                                                                  Description of Business

 Mailing Address (if different from above or Post Office Box number)              Primary Phone                              Secondary Phone
                                                                                  ( )               -                        ( ) -
                                                                                  Business Website Address

                                                                                  Fax Number
                                                                                  ( )               -

Provide information about all members, partners, officers, directors, trustees, shareholders (or stockholders) or managers 
associated with the business. Include attachments if additional space is needed.
 Last Name                                                 First Name                                   Title

 Percent of Ownership & Annual Salary                      Social Security Number Home Address (Street, City, State, Zip Code)
                                                              -       -
 Primary Phone                                             Secondary Phone
 (  )            -                                         (  )        -
 Last Name                                                 First Name                                   Title

Percent of Ownership & Annual Salary                       Social Security Number Home Address (Street, City, State, Zip Code)
                                                              -       -
 Primary Phone                                             Secondary Phone
 (  )            -                                         (  )        -
A-213 (R. 02-20)                                                                                                               Wisconsin Department of Revenue 

 Section 2                                 Business Asset Information

Gather the most current statement from banks, lenders on loans, mortgages (including second mortgages), monthly payments, loan 
balances, and accountant's depreciation schedules, if applicable. Also, include make/model/year/mileage of vehicles and current 
value of business assets. To estimate the current  value, you may consult resources like Kelley Blue Book (www.kbb.com), NADA 
(www.nada.com), local real estate postings for properties similar to yours, and any other websites or publications that show what 
business  assets would be worth if you were to sell them. Enter the total amounts available below.  Attach additional pages if 
necessary.
Cash and Investments
Use the most current statement for each type of account, such as checking, savings, money market and online accounts, stored 
value cards (such as a payroll card from an employer), and investments. 

REQUIRED VERIFICATION
Attach complete copies of bank and investment account statements for the six most recent months. Also, include copies 
of the Corporate Resolution, if applicable.

Bank and Investment Account Information
 Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative, enter "0" on that line.
1a   Cash        Checking          Savings Money Market/CD              Online Account Stored Value Card        Balance
     Bank Name                                                Account Number                                1a $

1b   Cash        Checking          Savings Money Market/CD              Online Account   Stored Value Card
     Bank Name                                                Account Number                                1b $

1c   Cash        Checking          Savings Money Market/CD              Online Account   Stored Value Card
     Bank Name                                                Account Number                                1c $

1d  Total amount from bank accounts as shown on attachments =  .................................            1d $

1    Total (Add lines 1a through 1d) =  ......................................................              1  $

2a  Investment Account:     Stocks         Bonds      Other:
     Name of Financial Institution                            Account Number

     Current Market Value $                           Minus Loan Balance $                         = 2a        $

2b  Investment Account:     Stocks         Bonds      Other:
     Name of Financial Institution                            Account Number

     Current Market Value $                           Minus Loan Balance $                         = 2b        $

2c  Investment Account:     Stocks         Bonds      Other:
     Name of Financial Institution                            Account Number

     Current Market Value $                           Minus Loan Balance $                         = 2c        $

2d  Total value of items listed as shown on attachments (current market value minus loan balance(s))  ..... 2d $

2   Total  (Add lines 2a through 2d) = ......................................................  2               $

Accounts and/or Notes Receivable
Do you have accounts and/or notes receivable, including e-payment, factoring companies, and any bartering or online auction
accounts?        Yes     No

If yes, attach a current listing that includes name(s) and amount of accounts receivable.

A-213 (R. 02-20)                                            2                                               Wisconsin Department of Revenue 

 Section 2                            Business Asset Information (Continued)

Real Estate
Enter information about any building, commercial property, vacant land, etc., that the business owns or is buying.

REQUIRED VERIFICATION:        Attach copies of a recent appraisal or property tax bill to verify the fair market value for 
each property owned. 
Property Address (Street Address, City, State, Zip Code) Description of Property

                                                         Date Purchased

County and Country                                       Name of Creditor                Date of Final Payment

     Current Market Value             Minus Loan Balance
                                                         (Total Value of Real Estate) =   . . . . . . . . . . . . . .
3a   $                           – $                                                                                              3a   $
Property Address (Street Address, City, State, Zip Code) Description of Property

                                                         Date Purchased

County and Country                                       Name of Creditor                Date of Final Payment

     Current Market Value             Minus Loan Balance
                                                         (Net Value of Real Estate) =  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
3b   $                           – $                                                                                              3b   $

3c  Total value of property(s) as shown on attachments (current market value minus loan balances(s)) =  ....                        3c $

3   Total (add lines 3a through 3c) = ........................................................                                      3  $

Vehicles
Enter information about any cars, trucks, boats, motorcycles, trailers, campers, ATV's, snowmobiles, etc., that you own, are buying, 
or lease.

REQUIRED VERIFICATION:  Attach copies of a recent appraisal or other documentation to verify the fair market value 
for each vehicle owned or leased.
Year     Vehicle Make & Model                              Date Purchased               Mileage or Use Hours

   Lease Name of Creditor                                  Date of Final Payment        Monthly Lease/Loan Amount
Loan                                                                                    $
         Current Market Value         Minus Loan Balance   Net Value of Vehicle (If the vehicle
4a       $                       – $                       is leased, enter 0 as the total value) = .......                       4a   $
Year     Vehicle Make & Model                              Date Purchased               Mileage or Use Hours

   Lease Name of Creditor                                  Date of Final Payment        Monthly Lease/Loan Amount
Loan                                                                                    $
         Current Market Value         Minus Loan Balance   Net Value of Vehicle (If the vehicle
4b       $                       – $                       is leased, enter 0 as the total value) = ......                        4b   $

4c  Total value of vehicle(s) as shown on attachments (current market value minus loan balances(s)) =  .....                        4c $

4   Total (add lines 4a through 4c) = ........................................................                                      4  $

A-213 (R. 02-20)                                         3                                                                        Wisconsin Department of Revenue 

 Section 2                               Business Asset Information (Continued)

Other Business Equipment
Enter information about any other business equipment that you own/lease/rent such as, livestock, animals, tools, books, machinery, 
and equipment.
REQUIRED VERIFICATION:  Attach copies of a recent appraisal or other documentation to verify the fair market value 
for items owned or leased.
Type of Equipment                                           Date Purchased     Purchase Price
                                                                               $
    Current Market Value               Minus Loan Balance   Net Value of Item (If the item is
5a  $                            – $                        leased, enter 0 as the total value) = .......                                                         5a   $
Type of Equipment                                           Date Purchased     Purchase Price
                                                                               $
    Current Market Value               Minus Loan Balance   Net Value of Item (If the item is
5b  $                            – $                        leased, enter 0 as the total value) = .......                                                         5b   $
5c  Total value of other business equipment as shown on attachments (current market value minus loan balances(s)) =                                               5c   $
5    Total (add lines 5a through 5c) = ........................................................                                                                   5    $

 Section 3                       Business Income and Expense Information
Attach a current 36-month profit and loss (P & L) statement and move to Section 4. If you are unable to provide this statement, 
complete Section 3 in full.
REQUIRED  VERIFICATION:          Copies  of  the  most  recent  statement  for  each  expense  claimed,  and  outstanding  loan/
mortgage/credit card balances. Copies of all lease agreements where you are lessee or lessor.
Business Income:    Enter the average gross monthly income of your business. To determine your gross monthly income use the 
most recent 6-12 months documentation of commissions, invoices, gross receipts from sales/services, earnings statements, point of 
sale transactions, etc., from every source of income. Round to the nearest whole dollar. Do not enter a negative number. If any 
line item is a negative, enter "0" on that line.
  6 Gross receipts   .......................................................................                                                                        6  $
  7 Gross rental income  ...................................................................                                                                      7    $
  8 Interest income  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8  $
  9 Dividends  ...........................................................................                                                                          9  $
10  Other income (specify on attachment)  .....................................................                                                                   10   $
11  Total Business Income  (add lines 6 through 10) =  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                          11   $

Business Expenses: Enter the average gross monthly expenses for your business using your most recent 6-12 months state-
ments, bills, receipts, or other documents showing monthly recurring expenses.
12  Materials purchased (e.g., items directly related to the production of a product or service) .............                                                      12 $
13  Inventory purchased (e.g., goods bought for resale) ...........................................                                                               13   $
14  Gross wages and salaries ...............................................................                                                                        14 $
15  Rent ................................................................................                                                                           15 $
16  Supplies (items used to conduct business and used up within one year, e.g., books, office supplies,
    professional equipment, etc.).............................................................                                                                      16 $
17  Utilities/telephones  ....................................................................                                                                      17 $
18  Vehicle costs (gas, oil, repairs, maintenance) ................................................                                                               18   $
19  Insurance  ...........................................................................                                                                          19 $
20  Current business taxes (e.g. Real estate, excise, franchise, occupational, personal property, sales and
    employer's portion of employment taxes)  ...................................................                                                                  20   $
21  Secured debts (not credit cards) ..........................................................                                                                   21   $
22  Other business expenses (include a list)  ...................................................                                                                 22   $
23  Total Business Expenses (add lines 12 through 22)  =  ......................................                                                                    23 $
A-213 (R. 02-20)                                          4                                                                                                       Wisconsin Department of Revenue 

 Section 4                                     Other Information

Additional information needed to consider settlement of your tax debt.
Attach additional pages as needed.

1.  If this business is currently in a bankruptcy proceeding, the business is not eligible to apply for an offer.
 a.  Is this business the beneficiary of any life insurance policy or any other source?   .......................                                           Yes   No
 b.  Is this business currently in bankruptcy?   ......................................................                                                     Yes   No
 c.  Has this business ever filed bankruptcy?   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes   No
  Date Filed                      Location Filed
                 (mm/dd/yyyy)

  Discharge/Dismissal Date                          Petition Number
                                  (mm/dd/yyyy)

2.  We may require documentation of the complaint, orders, or judgements.
 a.  Is this business currently, or has this business been a party to a lawsuit in the last five years?  .............                                      Yes   No
  If yes, please provide details for each lawsuit, including county, case number, short description, your role
  (plaintiff, defendant), amount sued for, and date the lawsuit was resolved, and if not resolved, the status of the
  lawsuit:

3.  Provide either the federal form 709 or documentation of sale, transfer, exchange or gift.
 a.  In the past four years, has this business transferred any assets valued at $1,000 or more for less than 
  their full market value by sale, transfer, exchange, gift or in any other manner?  .......................                                                Yes   No
  If yes, list:   Type of asset                               Date the asset was transferred
                                                                                                       (mm/dd/yyyy)

4.  Provide documentation of sale, transfer, exchange or gift.
 a.  In the past four years, has this business transferred any real property (land, house, etc.)?  ..............                                           Yes   No
  If yes, list:  Type of property                                        Date of transfer
                                                                                                       (mm/dd/yyyy)

5.  Provide a listing of which parties owe money and how much is owed by each.
 a.  Do any related parties (e.g., partners, officers, employees) owe money to the business?  ...............                                               Yes   No
  If yes, total amount due to business $

6.  Provide documentation for line 6a only.
 a.  Does the business have any funds being held in trust by a third party? ..............................                                                  Yes   No
  If yes, how much $                           Where

 b.  Does the business have any locations outside of Wisconsin?   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                 Yes No
  Where                                        Time Period

 c.  Does this business have other business affiliations (e.g. subsidiary, parent companies or affiliate)? .........                                          Yes No
  List:

 d.  Does the business have any lines of credit?  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .     Yes No
  If yes, credit limit $                       Amount owed $
  What property secures the line of credit?

A-213 (R. 02-20)                                              5                                            Wisconsin Department of Revenue 

Part 2:  Offer in Compromise

I/we submit this application to compromise the tax liabilities plus any costs, interest, penalties, and fees required by law for the tax 
type(s) and period(s) marked in Section 1 below.

 Section 1                                       Liability Information

 Tax Periods:  Check each tax type included in your offer and list periods in right hand column.  Attach additional page if needed.
                 Tax Type                                                   Tax Periods

   Corporate or Partnership Income Tax

   Sales and Use Tax

   Withholding Tax

   Premier Resort Area Tax

   Local Exposition Area Tax

   Rental Vehicle Tax Fee

   Other (list):

   Other (list):

   Successor Liability (list company name):

   Additional page attached

 Section 2                                      Offer and Payment Terms

 Total Amount Offered (cannot be left blank) ..............................        $

 Payment Terms:  Check one of the payment options below to indicate how you will pay your offer if accepted.
   Check here if you will submit full payment of the amount offered in guaranteed funds (cash, cashier's check, or money order) 
   within 10 days from the date of acceptance.
   Check here if you will make installment payments. Installment payments must be made by electronic funds transfer (EFT). 
   We recommend proposing terms to resolve in full in no more than 24 months. The first payment will be due no later than 30 
   days from the date of acceptance.

   Proposed Payment Amount:  $                     Proposed Frequency:             Monthly      Weekly            Bi-Weekly

   Preferred due date:      Enter day of the month (1-28) payment should be due. Date cannot be the 29 th   - 31stdays of the month.

 Section 3       Source of Funds, Filing Requirements, and Tax Payment Requirements
 Source of Funds:  Tell us where you will obtain funds to pay your offer. You may consider borrowing from friends or family, taking 
 out a loan, or selling assets. Documentation may be required.

 Tax Payment Requirements (check all that apply)
   I have made all required estimated income tax payments for the current tax year.

   I am not required to make any estimated income tax payments for the current year.

A-213 (R. 02-20)                                              6                                     Wisconsin Department of Revenue 

 Section 4                          Offer Terms

  By submitting this offer, I have read, understand, and agree to the following terms and conditions:
 Terms and Conditions
This offer in compromise will apply only to tax liability including costs, interest, penalties, and fees assessed as of the date my offer 
is accepted.
I am liable for the full amount of tax, cost, interest, penalty and fees, until the offer is accepted in writing, the offer is paid in full, and 
I have met all the terms and conditions of the offer. No adjustment to the balance due will be made and penalty and interest will 
continue to accrue until all the terms of the offer have been met.
If I file for bankruptcy before the terms and conditions of the offer are met, I agree that the department may file a claim for the full 
amount of the tax liability, accrued penalties and interest, and that any claim filed in the bankruptcy proceeding will be a tax claim.
The department reserves the right to reopen the compromise and order full payment if within three years from the date this offer is 
accepted, the Department discovers I have sufficient income or property to pay the remainder of the tax, cost, interest, penalty and 
fees in full.
If the department determines that a compromise order was granted based on an application that was untrue, incorrect, or incomplete, 
the order will be null and void.
If I fail to meet any of the terms of an accepted offer, the offer will be withdrawn, and the department will pursue collection of the full 
amount due.

Filing and Payments of Tax Returns
I must file and pay in full any required tax returns or assessments that become due during consideration of this application.

Collection Actions
Collection actions initiated prior to receipt of this Offer in Compromise will not be withdrawn until the offer is accepted in writing, the 
offer is paid in full, and I have met all the terms and conditions of the offer.
The department will offset any overpayment, including interest, during consideration of this application.

Tax Warrants
The department may file a tax warrant while considering my offer.
If my offer is accepted, the department may file a tax warrant if I require more than 30 days to meet the requirements of the compro-
mise agreement.
The department will satisfy outstanding tax warrants within 45 days of full satisfaction of all requirements of the compromise agreement.

Internet Posting
Within five days of receipt of an Offer in Compromise, the debtor's name will be removed from the Delinquent Taxpayers Internet 
Posting. If the offer is rejected, or I fail to meet all terms and conditions of the offer, my liability may be reposted.

 Section 5                          Signatures
In accordance with sec. 71.92(3), 73.13 and 77.62(5) of the Wis. Stats., this petition is submitted by the undersigned who declares 
under penalties of perjury that this petition, including accompanying schedules and statements, is true, correct, and complete to 
the best of my knowledge and belief.
Signature of Authorized Officer                                     Authorized Officer Phone Number       Date (mm/dd/yyyy)
                                                                    (           )   -
Authorized Officer Name                                             Title of Officer

Business Name                                                       Business Phone Number                 Date (mm/dd/yyyy)
                                                                    (           )   -

 Section 6                          Preparer Use Only
Preparer's Name                                                     Preparer's Phone Number               Date (mm/dd/yyyy)

Firm's Name                                                         Address

City                                                                                                State Zip Code

A-213 (R. 02-20)                                                  7                                       Wisconsin Department of Revenue 

 Mail completed application and supporting documents to:
 Wisconsin Department of Revenue
  PO Box 8901
  Madison WI 53708-8901

 For overnight delivery, mail completed application and supporting documents to:
  Wisconsin Department of Revenue
  2135 Rimrock Rd
  Madison WI 53713

 Section 7                        Required Attachments

The following required documents are attached to your Offer in Compromise (check each line as attached or indicate n/a):

Failure to attach required documentation may result in rejection of your Offer in Compromise.

Verification of Income
 Current profit and loss (P & L) statement if not entered in Section 3

Verification of Assets
 Complete copies of bank statements for the six most recent months

 Copies of the most recent statement of each investment account

 List of accounts/notes receivable

 Copies of a recent appraisal or property tax bill to verify the fair market value for each property owned

 Copies of a recent appraisal to verify the fair market value for each vehicle owned

 Copies of  recent appraisal or other verification of the value of other business equipment
 
 Copies of current rental agreements where this business is the lessor or lessee
 
Verification of Expenses
 Complete copies of the most recent statement from lenders on loans such as mortgages, vehicles, equipment, and credit cards 
 showing monthly payments, loan payoffs, balances and recent activity

 Copies of the most recent billing statement for each utility expense (gas, electric, phone, water, cable/internet, etc.)

 Copies of the most recent billing statements for insurance

 Complete copies of the most recent statements for other expenses claimed

 Verification of delinquent federal, other state agency, or local tax liability

Other Documentation
 Form A-222, Power of Attorney, if you would like another person such as an attorney or CPA to represent you, and you do not 
 have one on file

 Any additional information to support your request

 Documentation as described in Part 1, Section 4 regarding any lawsuit(s) 
 
A-213 (R. 02-20)                                           8                                              Wisconsin Department of Revenue