Form                                         Offer in Compromise for Wage Earners

 A-212 (OIC)                                                   and Self-Employed Individuals
In this form, "you" refers to an individual, married couples, or business who have tax debt at the Wisconsin Department of Revenue.
The department cannot compromise non-tax debt certified to the department for collection by state agencies and local
governments.
Use this form if you are:
• An individual or married couple who owes individual income tax
• An individual who is self-employed or has self-employment income and owes business taxes
• An individual who operates as a disregarded single member limited liability company (LLC) taxed as a sole proprietor and owes 
 business taxes
Anindividualwhoissubmittinganofferonbehalfofadeceasedpersonwhoowestaxes
• An individual with personal responsibility for sales and use tax, withholding tax, motor fuel tax, premier resort area tax, local 
 exposition area tax, or rental vehicle fee from a business
• An individual who is personally responsible for partnership liability

 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:

Part 1:  Financial Statement
Note:  Include attachments if additional space is needed to respond to any question.

 Section 1                               Personal and Household Information
 Last Name                               First Name                              Date of Birth (mm/dd/yyyy) Social Security Number
                                                                                                                 -               -
 Marital Status  Home Address                                                    Mailing Address (If different from Home Address)

 Single
                 City                        State             Zip Code          City                       State                Zip Code
 Married

 Do you:                                                                         County of Residence        Primary Phone
 Own your home        Rent    Other (e.g., share rent, live with relative, etc.)                            ( )
                                                                                 Secondary Phone            Fax Number
                                                                                 ( )                        ( )

Provide information about your spouse, if applicable.
Spouse's Last Name                       Spouse's First Name                     Date of Birth (mm/dd/yyyy) Social Security Number
                                                                                                                 -               -

Provide information for all other persons in the household or claimed as a dependent.
                                                                                 Claimed as a    Contributes to                  Lives at home
                 Name                    Age Relationship               dependent on your            household                   address listed
                                                                                 income return       income                       above
                                                                                 Yes  No             Yes    No                   Yes     No

                                                                                 Yes  No             Yes    No                   Yes     No

                                                                                 Yes  No             Yes    No                   Yes     No

                                                                                 Yes  No             Yes    No                   Yes     No

A-212 (R. 02-20)                                                                                                Wisconsin Department of Revenue 

 Section 2                          Employment Information for Wage Earners

Complete this section if you or your spouse are wage earners and received a Form W-2. If you or your spouse have self-employment 
income(youfileaScheduleC,E,F,etc.)insteadof,orinadditiontowageincome,youmustalsocompleteBusinessInformationin
Sections 4, 5, and 6. Add an attachment to list multiple employers.
Your Employer Name                                                                 Your Occupation

Do you have ownership interest in this business?           If yes, check the business interest that applies: How long with this employer?
  Yes            No                                        Partner         Officer Sole Proprietor           (yrs.)             (months)
Spouse's Employer Name                                                             Spouse's Occupation

Does your spouse have ownership interest in this business? If yes, check the business interest that applies: How long with this employer?
  Yes            No                                        Partner         Officer Sole Proprietor           (yrs.)             (months)

 Section 3                                       Personal Asset Information

Include all assets owned by you and/or your spouse, if any. If additional space is needed, include attachments. 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 your assets would be worth if you were to sell them. Enter the total amounts avail-
able below. Round to the nearest dollar. Do not enter a negative number. If any line item is a negative number, enter "0" on that line.

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), investment and retirement accounts (IRAs, Keogh, 401(k) plans, stocks, 
bonds, mutual funds, certificates of deposit), life insurance policies, and safe deposit boxes. Attach a list if needed.

REQUIRED VERIFICATION
Attach complete copies of bank, investment, retirement, and life insurance policy account statements for the three most 
recent months. If you are self-employed, provide statements for the last six months.

Bank, Investment and Retirement Account Information
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  Total amount from bank accounts as shown on attachments =  .................................             1c                $

1   Total (add lines 1a through 1c) =            .......................................................     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  Total amount of investment accounts as shown on attachments (current market value minus loan balance(s)) =  $

2   Total (add lines 2a through 2c) =            ....................................................... 2                     $

A-212 (R. 02-20)                                                   2                                         Wisconsin Department of Revenue 

 Section 3                                      Personal Asset Information (Continued)

3a  Retirement Account:                401K IRA          Other (list):
    Name of Financial Institution                                       Account Number

    Current Market Value $                               Minus Loan Balance $                                  = 3a          $

3b  Retirement Account:                401K IRA          Other (list):
    Name of Financial Institution                                       Account Number
    Current Market Value $                               Minus Loan Balance $                                  = 3b          $

3c  Total amount of retirement accounts as shown on attachments (current market value minus loan balance(s)) =            3c $

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

4a  Life Insurance Policies
    Name of Insurance Company                                           Policy Number
    Current Cash Value $                                 Minus Loan Balance $                                  = 4a          $

4b  Total cash value of life insurance
    policies from attachment $                                Minus Loan Balance $                             = 4b          $

4   Total (add lines 4a and 4b) =  .......................................................... 4                              $

Real Estate
Enter information about any house, condo, co-op, vacant land, time share, cabin, etc., regardless of location, that you wholly or 
partially own or are buying. Attach a list if necessary.
REQUIRED VERIFICATION:                 Attach copies of a recent appraisal or property tax bill to verify the fair market value for 
each property owned. Provide any rental or lease agreements for rental properties and copies of registration, if applicable.
Property Address (Street Address, City, State, Zip Code)      Primary Residence      Yes  No

                                                              Date Purchased             Monthly Payment Amount
                                                                                         $
County                                                        Description of Property

How title is held (joint tenancy, etc.)

       Current Market Value                 Minus Loan Balance
                                                              (Net Value of Real Estate) =  . . . . . . . . . . . . . . .
5a     $                                    – $                                                                           5a $
Property Address (Street Address, City, State, Zip Code)      Primary Residence      Yes  No

                                                              Date Purchased             Monthly Payment Amount
                                                                                         $
County                                                        Description of Property

How title is held (joint tenancy, etc.)

       Current Market Value                 Minus Loan Balance
5b     $                                    – $               (Net Value of Real Estate) =  . . . . . . . . . . . . . . . 5b $

5c  Total value of property(s) as shown on attachments (current market value minus loan balances(s)) = .... 5c               $

5   Total (add lines 5a through 5c) =       ........................................................ 5                       $

A-212 (R. 02-20)                                                      3                                                   Wisconsin Department of Revenue 

 Section 3                              Personal Asset Information (Continued)

Vehicles
Enter information about any cars, trucks, boats, motorcycles, trailers, campers, ATVs, snowmobiles, planes, etc., that you wholly or 
partially 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.
Vehicle Make & Model                                     Year   Date Purchased        Current Mileage

   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
6a       $                          – $                         is leased, enter 0 as the total value) =  . . . . 6a $
Vehicle Make & Model                                     Year   Date Purchased        Current Mileage

   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
6b       $                          – $                         is leased, enter 0 as the total value) =  . . . . 6b $
Vehicle Make & Model                                     Year   Date Purchased        Current Mileage

   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
6c       $                          – $                         is leased, enter 0 as the total value) =  . . . . 6c $

6d  Total value of vehicle(s) as shown on attachments (current market value minus loan balances(s)) = ..... 6d       $

6   Total (add lines 6a through 6d) = ........................................................ 6                     $

Other Valuable Items
Artwork,antiques,collections,firearms,jewelry,itemsofvalueinsafedepositboxes,interestinacompanyorbusinessthatisnotpub-
licly traded, etc. NOTE:  Do not include clothing, furniture, and other personal effects or any one item less than $1,000 in value.

REQUIRED VERIFICATION:  Attach copies of a recent appraisal or other documentation to verify the fair market value 
for each item.

Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative, enter "0" on that line.
Description of Asset

         Current Market Value         Minus Loan Balance
7a       $                          – $                         (Net Value of Real Estate) =  . . . . . . . . . . 7a $
Description of Asset

         Current Market Value         Minus Loan Balance
7b       $                          – $                         (Net Value of Real Estate) =  . . . . . . . . . . 7b $

7c  Total value of item(s) as shown on attachments (current market value minus loan balances(s)) =  ....... 7c       $

7   Total (add lines 7a through 7c) = ........................................................                    7  $

    (Do not include amount on the lines with a letter beside the number)
    Total of Section 3 (add lines 1 through 7 and enter the amount) = .....................                          $

A-212 (R. 02-20)                                              4                                                   Wisconsin Department of Revenue 

 Section 4                                               Self Employment Information
If you or your spouse are self-employed, Sections 4, 5 and 6 must be completed before continuing with Section 7. If you or 
your spouse are not self-employed, skip to Section 7 and continue.
Ifyouoryourspouseareself-employed(e.g.,filesSchedule(s)C,E,F,etc.)completethissection.
Is your business a sole proprietorship?                                        Address of Business (if other than personal residence)
 Yes             No
Name of Business

Business Telephone Number      EmployerIdentificationNumber                    Business Website
( )
Trade Name or DBA                                                              Description of Business

Do you or your spouse have any other business interests?                       Business Address (Street, City, State, Zip Code)
Include any interest in an LLC, LLP, corporation, partnership, etc.
 Yes (Percentage of Ownership:          %)
  Title: 
 No
Business Name                                                                  Business Telehphone Number EmployerIdentificationNumber
                                                                               ( )

Type of Business (check one): Partnership       LLC                Corporation   Other

 Section 5                              Business Asset Information (for Self-Employed)
List business assets such as bank accounts, livestock, animals, tools, books, machinery, equipment, business vehicles and real prop-
erty that is owned/leased/rented. If additional space is needed, attach a list of items. Do not include personal assets listed in Section 3.
REQUIRED VERIFICATION:  Attach complete copies of bank and investment account statements for the six most recent 
months. Attach copies of a recent appraisal or other documentation to verify the fair market value for each additional asset.
Bank 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.
8a   Cash           Checking            Savings          Money Market/CD          Online Account          Stored Value Card              Balance
    Bank Name                                                                    Account Number                                      8a $

8b   Cash           Checking            Savings          Money Market/CD          Online Account          Stored Value Card
    Bank Name                                                                    Account Number                                      8b $

8c  Total of bank accounts as shown on attachments = ........................................... 8c                                     $

8   Total (add lines 8a through 8c) =     ........................................................                                   8  $
Description of Asset

     Current Market Value                 Minus Loan Balance
9a   $                                    – $                                    (Total Value) =   . . . . . . . . . . . . . . . . . 9a $
Description of Asset

     Current Market Value                 Minus Loan Balance
9b   $                                    – $                                    (Total Value) =   . . . . . . . . . . . . . . . . . 9b $
9c  Total value of item(s) as shown on attachments (current market value minus loan balances(s)) =  ....... 9c                          $

9   Total (add lines 9a through 9c) =     ........................................................ 9                                    $
A-212 (R. 02-20)                                                               5                                                     Wisconsin Department of Revenue 

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.

 Section 6           Business Income and Expense Information (for Self-Employed)

Attach a current 36-month profit and loss (P & L) statement and move to Section 7. If you are unable to provide this statement, 
complete Section 6 in place of the statement.

REQUIRED VERIFICATION:  Copies of the most recent statement for each expense claimed, outstanding loan/mortgage/
credit card balances. Copies of all lease agreements where you are lessee or lessor.

Business Income (Average the last 12 months income/receipts to determine your gross monthly income/receipts.)
  Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative, enter "0" on that line.

10  Gross receipts   ....................................................................... 10                                                                       $

11  Gross rental income  ...................................................................                                                                      11  $

12  Interest income  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 $

13  Dividends  ........................................................................... 13                                                                         $

14  Other income .........................................................................                                                                        14  $

15  Total Business Income  (add lines 10 through 14) =  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                           15  $

Business Expenses (Average the last 12 months expenses to determine your monthly expenses.)
  Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative, enter "0" on that line.

16  Materials purchased (e.g., items directly related to the production of a product or service) ............ 16                                                      $

17  Inventory purchased (e.g., goods bought for resale)..........................................                                                                 17  $

18  Gross wages and salaries .............................................................. 18                                                                        $

19  Rent ............................................................................... 19                                                                           $

20  Supplies(itemsusedtoconductbusinessandusedupwithinoneyear,e.g.,books,officesupplies,
    professional equipment, etc.)............................................................ 20                                                                      $

21  Utilities/telephones  ................................................................... 21                                                                      $

22  Vehicle costs (gas, oil, repairs, maintenance) ...............................................                                                                22  $

23  Business insurance ................................................................... 23                                                                         $

24  Current business taxes (e.g., real estate, excise, franchise, occupational, personal property, sales and
    employer's portion of employment taxes) ..................................................                                                                    24  $

25  Secured debts (not credit cards) .........................................................                                                                    25  $

26  Other business expenses (include a list)  ..................................................                                                                  26  $

27  Total Business Expenses (add lines 16 through 26)  = ..................................... 27                                                                     $

    Total (subtract line 27 from line 15) and enter the amount = ...........................                                                                      27a $

A-212 (R. 02-20)                                         6                                                                                                        Wisconsin Department of Revenue 

 Section 7               Monthly Household Income and Expense Information

Monthly Household Income
Enter your household's gross monthly income.  The information below is for yourself, your spouse and anyone else who contributes 
to your household's income.  The entire household includes spouse, non-liable spouse, partner, children, and others who contribute 
tothehousehold.  ThisisnecessaryfortheDepartmentofRevenuetoaccuratelyevaluateyouroffer.
REQUIRED VERIFICATION - Attach copies of the following:
•  You and your spouse's three most recent pay stubs, earnings statements, etc., from each employer
• The most recent statement from all other sources of income such as pensions, Social Security, rental income, interest and dividends 
 (including any received from a related partnership, corporation, LLC, LLP, etc.), court order for child support, alimony, and rent subsidies
• Lease agreements for rental 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.
   You
        Wages            Social Security           Pension              Other Income (e.g., unemployment)
28 $                +  $                       + $                  + $              Total Income.....= 28                                                   $
   Spouse or Partner
        Wages            Social Security           Pension              Other Income (e.g., unemployment)
29 $                +  $                       + $                  + $              Total Income.....= 29                                                   $

30 Additional sources of income used to support the household ....................................                                                         30 $
31 Other individuals who may contribute to the household income. Relationship                                                                              31 $
32 Interest and dividends ..................................................................                                                               32 $
33 Distributions (e.g., income from partnerships, sub-S corporations, etc.) ............................                                                   33 $
34 Net rental income  .....................................................................                                                                34 $
35 Net business income from 27a  ...........................................................                                                               35 $
36 Child support received ..................................................................                                                               36 $
37 Alimony received ......................................................................                                                                 37 $
   Total (add lines 28 through 37) and enter the amount =         .....................................                                                      $

Monthly Household Expenses
•  Enter your actual average monthly expense amount for each line (38 - 54).
•  Do not enter the IRS standard amount
REQUIRED VERIFICATION - Attach complete copies of the most recent statement or other verification for the following:
 Loan balancessuchasmortgages,vehicles,studentloans,andcreditcardsshowingmonthlypayments,loanpayoffs,balances,and
 recent activity
• Lease agreements
• Each utility expense (gas, electric, phone, water, cable/internet)
• Insurance (home, vehicle, life, health, etc.)
• Child or dependent care provider showing amount paid monthly for ongoing care (e.g., daycare)
• Delinquent federal, other state agency, or local tax liability

 Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative, enter "0" on that line.

38 Food  ...............................................................................                                                                   38 $
39 Clothing and other (e.g., housekeeping supplies, personal care products). A reasonable estimate of these
   expenses may be used  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 $
40 Housing (e.g., rent or mortgage payment and average monthly cost or property taxes, home/rental
   insurance, maintenance, dues and fees) ....................................................                                                             40 $
41 Utilities (e.g., electricity, gas, other fuels, trash collection, water, television, internet, telephone, or cell
 phone) ..............................................................................                                                                     41 $
42 Vehicle loan and/or lease payments  .......................................................                                                             42 $
43 Vehicle operating costs (e.g., average monthly cost of maintenance, repairs, insurance, fuel, registrations
   licenses, inspections, parking, tolls, etc.). A reasonable estimate of these expenses may be used .......                                               43 $
A-212 (R. 02-20)                                                    7                                                                                      Wisconsin Department of Revenue 

 Section 7       Monthly Household Income and Expense Information (Continued)

   Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative, enter "0" on that line.

44 Public transportation costs (e.g., average monthly cost of fares for mass transit such as bus, train, taxi,
   etc.) A reasonable estimate of these expenses may be used ....................................                44 $
45 Health insurance premiums ..............................................................                      45 $
46 Out-of-pocket health care costs (e.g., average monthly costs of prescription drugs, medical services, and
   medical supplies like eyeglasses, hearing aids, etc.)  ..........................................             46 $
47 Court-ordered payments (e.g., monthly cost of alimony, child support, etc.) .........................         47 $
48 Child/dependent care payments (e.g., daycare)  ..............................................                 48 $
49 Life insurance premiums   ...............................................................                     49 $
50 Current monthly taxes (e.g., monthly cost of federal, state & local tax, personal property tax, etc.) ....... 50 $
51 Secured debts (e.g., any loan where you pledged an asset as collateral not previously listed, government
 guaranteed) ..........................................................................                          51 $
52 Unsecured debts (e.g., any other loans not previously listed such as credit cards) Enter minimum monthly
   payment   ............................................................................                        52 $ 
53 Enter the amount of your monthly delinquent federal, other state agency or local tax payments .........       53 $
54 Miscellaneous (provide breakdown on a separate paper) .......................................                 54 $
   Total (add lines 38 through 54) and enter the amount=  ......................................                    $

 Section 8                                      Other Information

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

  1. If you or your business are currently in a bankruptcy proceeding, you are not eligible to apply for an offer.
   Areyouoryourspousethebeneficiaryofatrust,estate,orlifeinsurancepolicy? ....................... Yes No
   b. Are you or your spouse currently in bankruptcy? ................................................. Yes No
   Haveyouoryourspousefiledbankruptcyinthepast10years?     .................................... Yes No
    Discharge/Dismissal Date                    Location Filed
                                    (mm/dd/yyyy)

  2. We may require documentation of the complaint, orders, or judgements.
   Areyouoryourspouseorhaveyouoryourspousebeenpartytoalawsuitinthelastfiveyears?               .......... Yes No
    If yes, please provide details for each lawsuit, including county, case number, short description, your role
    (plaintiff,defendant),amountsuedfor,anddatethelawsuitwasresolved,andifnotresolved,thestatusofthe
    lawsuit:

  3. Provide either the federal Form 709 or documentation of sale, transfer, exchange or gift.
   a. In the past four years, have you or your spouse 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 either the federal Form 709 or documentation of sale, transfer, exchange or gift.
   a. In the past four years, have you or your spouse transferred any real property (land, house, etc.)?......... Yes No
    If yes, list:  Type of property                                       Date of transfer
                                                                                              (mm/dd/yyyy)

A-212 (R. 02-20)                                        8                                                        Wisconsin Department of Revenue 

Part 2:  Offer in Compromise

I/we submit this application to compromise the tax liabilities plus any interest, costs, 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:Checkeachtaxtypeincludedinyourofferandlistperiodsinrighthandcolumn.     Attachadditionalsheetsifneeded.
                 Tax Type                                                  Tax Periods

  Individual Income Tax

  Sales and Use Tax

  Withholding Tax

  Premier Resort Area Tax

  Local Exposition Area Tax

  Rental Vehicle Fee

  Other (list):

  Other (list):

  Personal or Partnership Liability
  (list company name):

  Additional page attached (please label it Liability Information)

 Section 2                                      Offer and Payment Terms

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

 Payment Terms:Checkoneofthepaymentoptionsbelowtoindicatehowyouwillpayyourofferifaccepted.
  Checkhereifyouwillsubmitfullpaymentoftheamountofferedinguaranteedfunds(cash,cashier'scheck,ormoneyorder)
  within 10 days from the date of acceptance.
  Check here if you cannot make full payment but can make installment payments. Installment payments must be made by 
  electronicfundstransfer(EFT). Thefirstpaymentwillbeduenolaterthan30daysfromthedateofacceptance.

  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 - 31st days 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-212 (R. 02-20)                                              9                                    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 only includes those taxes, costs, interest, penalty and taxable periods specifically identified on any Order
that may be entered.
This offer does not provide relief from liability until the offer is accepted in writing by the department and paid within ten days from
the date of such acceptance, or by installment schedule approved by the department.
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 costs, penalties and interest, and that any claim filed in the bankruptcy proceeding will be a tax
claim.
The department may offset any overpayments, federal refunds and payments, refunds from other states, vendor payments, lottery
prize winnings, and unclaimed property until all the terms and conditions of an order are complete.
Itismutuallyagreedthatifwithinthreeyearsfromthedatethisofferisaccepted,thepetitionerhasincomeorpropertysufficientto
enable him/her to pay the remainder of the tax including penalties, costs, and interest, the department may reopen this matter and 
order payment in full, or in part, of such tax, penalty and interest.
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.
IfIfailtomeetanyofthetermsofanacceptedoffer,theofferwillbewithdrawnandthedepartmentwillpursuecollectionofthefull
amount due.

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

Collection Actions
CollectionactionsinitiatedpriortoreceiptofthisOfferinCompromisewillnotbeceaseduntiltheofferisacceptedinwriting,theoffer
ispaidinfull,andIhavemetallthetermsandconditionsoftheoffer.
The department will offset any overpayments, federal refunds and payments, refunds from other states, vendor payments, lottery
prizewinnings,andunclaimedpropertywhileconsideringthisapplicationanduntiltheofferisacceptedinwriting,theofferispaidin
full,andIhavemetallthetermsandconditionsoftheoffer.

Tax Warrants
Thedepartmentmayfileataxwarrantwhileconsideringmyofferorafteracceptanceduringanyinstallmentperiod.
The department will satisfy outstanding tax warrants within 45 days of full satisfaction of all requirements of the compromise agreement.

Internet Posting
Thedebtor'snamewillbetemporarilyremovedfromtheDelinquentTaxpayersInternetPostingwithinfivedaysofreceiptofthisOffer
in Compromise.

 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.
Your Signature                                                       Phone Number                   Date (mm/dd/yyyy)

Spouse's Signature                                                   Spouse's 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-212 (R. 02-20)                                           10                                       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 my Offer in Compromise (check each line as attached or indicate n/a).
FailuretoattachrequireddocumentationmayresultinrejectionofyourOfferinCompromise.

Verification of Income
 Copies of my and my spouse's three most recent pay stubs, earnings statement, etc., from each employer
 Copies of the most recent statement from all other sources of income such as pensions, Social Security, rental income, interest 
 and dividends (including any received from a related partnership, corporation, LLC, LLP, etc.), court order for child support, 
 alimony, and rent subsidies
 Ifself-employed,acurrent36-monthprofitandloss(P &L)statement.Ifnotprovided,section6iscomplete.

Verification of Assets
 Complete copies of bank statements for the three most recent months (six most recent months if I am self-employed)
 Copies of the most recent statement of each investment and retirement account
 Copies of the most recent statement of each cash value life insurance policy
 Copies of a recent appraisal or property tax bill to verify the fair market value for each property owned
 Copies of current rental agreements where I or my spouse is the lessor or lessee
 Copiesofrecentappraisalorotherverificationofthevalueofothervaluableitems
 List of notes receivable, if applicable (see Part 1, Section 5)
 List of accounts receivable, if applicable (see Part 1, Section 5)

Verification of Expenses
 If self-employed, copies of the most recent statements for expenses claimed
 Complete copies of the most recent statement from lenders on loans such as mortgages, vehicles, student loans, and credit 
 cardsshowingmonthlypayments,loanpayoffs,balances,andrecentactivity
 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 (home, vehicle, life, health, etc.)
 Statement from child or dependent care provider showing amount paid monthly for ongoing care (e.g., daycare)
 Verificationofdelinquent federal,otherstateagencyorlocaltaxliability

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 
 haveoneonfile
 CertifiedcopiesofLettersofGuardianshipandDomiciliaryLetters
 Copies of any transfers of assets valued over $1,000, including real property within the past four years
 Documentation to support any special circumstances or medical conditions, if applicable
 Proofoffundsforyourproposedoffer,ifapplicable
 Documentation as described in Part 1, Section 8 regarding any lawsuit(s) 
 
A-212 (R. 02-20)                                 11                                                       Wisconsin Department of Revenue