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PETITION	FOR	COMPROMISE	OF	TAXES	BASED	ON	INABILITY	TO	PAY
This	form	should	only	be	used	to	petition	the	Wisconsin	Department	of	Revenue	for	the	compromise	of	taxes	based	on	an	in-
ability	to	pay	in	full	in	accordance	with	secs.	71.92(3),	73.13	and	77.62(5)	Wis.	Stats.	The	completed	form	and	all	supporting	
documentation should be submitted to the office listed on your Statement of Account.  Corporations must also complete and 
submit Form A-213 Corporation Schedule A with this petition.  NOTE:		If	your	offer	is	accepted,	you	must	pay	that	amount	within	
ten	(10)	days	from	the	date	the	offer	is	accepted	or	pay	in	accordance	with	an	approved	payment	schedule.
	 1.	 Name	of	Petitioner	                      Social	Security	Number	                     Seller's	Permit	Number	       Withholding	Number

	 Business	Address                                                                                                       Business	Telephone
	       	       	                                                                                                        (	 	 	 )
	 Home	Address                                                                                                           Home	Telephone
                                                                                                                         (	 	 	 )
  2.  Record of Taxes Due
	                  Type	of	Tax	                Taxable	Period	                                                    Unpaid	Liability

	 3.	 Failure	to	pay	the	taxes	listed	above	is	due	to	the	following	causes:

	 4.	 Source	of	funds	for	offer	(list):

	 5.	 If	the	outstanding	taxes	were	incurred	in	the	operation	of	a	business,	has	the	business	been	discontinued?	 Yes	   No	
	 	 If	discontinued,	when?
	 	 What	disposition	was	made	of	the	assets?

	 6.	 Family	Information
	 Name	of	spouse                                                                           Petitioner,	Date	of	Birth     Spouse,	Date	of	Birth

	 Name(s)	of	dependent(s)	-	list                                                           Relationship                           Date	of	Birth

	 7.	 Employment	Information	                                              Petitioner	                                 	 Spouse

	 	 Present	employer
	 	 Gross	salary	per	week
	 	 Take	home	pay	per	week
	 	 If	unemployed,	give	date	last	employed	and                                  Type date, then tab to                            Type date, then tab to 
	 	 gross	salary	per	week                                                       enter salary in same box.                      enter salary in same box.
  8.  List names of banks and other financial institutions you have done business with any time during the past 3 years.
	                         Name	and	Address	                                                            Name	and	Address

Do	you	rent	a	safety	deposit	box	in	your	name	or	in	any	other	name?	       Yes	        No	 If	yes,	give	name	and	address	of	bank	where	the	box	is	
located.
A-212	(R.7-09)	                                                                                                          Wisconsin	Department	of	Revenue	
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9.	 Statement	of	Assets	and	Liabilities
    The following is a true and complete statement of petitioner's financial condition as of                           ,                                         . If this statement is 
    not sufficient for your purpose, please attach a schedule. If explanatory comments are necessary, please attach a letter to the petition.
    	                 Assets (show at fair market value)                                                      Liabilities
Cash on hand and in banks                                                       *Bonds or mortgage indebtedness (see below)
Cash surrender value of life insurance                                          *Bills and accounts payable (see below)
(Total	from	section	10	below)	                                                  Taxes	payable
Real	estate	(Total	from	section	11	below)	                                      	 Property
Assets	listed	in	section	12	below	                                              	 Income	(U.S.)
	   Bills	and	accounts	receivable	                                              Other	liabilities
	   Inventories
	   Machinery
	   Other	equipment	(autos,	etc.)
    Furniture and fixtures
	   Securities,	stocks,	bonds,	etc.
All	other	assets	(specify)

	   	                                                                           	 Total	liabilities                                                                          0.00
	   Total	assets	                                                  $0.00        	 Net worth (total assets less total liabilities)                                            $0.00
*If	these	liabilities (other than mortgages) exceed $2,000, attach schedule listing each creditor and amount owed.
NOTE:	no	depreciation	reserve	should	be	shown	above	since	the	assets	are	listed	at	fair	market	value.
10.  Life Insurance Policies
                                                                                                                                                                 Have	Premiums
                                                                                                     Cash              Balance                                   Been	Paid	to	Date?
                      Company                       Beneficiary                   Amount         Surrender	Value       on	Loan                                   (Yes	or	No)

                      Is	this	insurance	pledged	with	banks	or	other	creditors?	     Yes	            No

11.  Real Estate (include personal residence)
                                                                                Fair	Market      Balance	Due       Date	Mortgage                                 Unpaid	Interest
                      Description                           Cost                  Value          on Mortgage*          Recorded                                  and Taxes*

 *Proof by documentation must accompany this petition. Copy of property tax bills to verify value and lender's statement to verify mortgage balance are required.
  Back Property tax must also be verified.
12.  Receivables, inventories, machinery and equipment, trucks and automobiles (for personal or business use), stocks and bonds, etc.
                                                                                Fair	Market      Amount	of	indebtedness
                      Description                           Cost                  Value               if Pledged**                                               Date	Pledged

                                                   ** Submit written verification of the amount due.
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 13.  Have you any other assets or interest in assets, either actual or contingent other than those listed herein? Yes            No
     (If yes, provide an explanation. Include any interest in a trust.)

 14.  Are you a party in a lawsuit?     Yes   No                       If so, please explain including the amount of the suit.

 15.  Disposal of assets – Have you disposed of any assets or property by sale, transfer, exchange, gift or in any other manner during the past 
     18 months?    Yes              No  (If yes, complete the schedule appearing below. Attach separate statement if necessary.)
                Description of                Date of                     Fair Market Value       Consideration                   Relationship of
	                  Asset	                     Transfer	                   When	Transferred	       Received	                   	Transferee	To	Taxpayer

 16.  If individual, give an analysis of income and expenses as follows:

   	               Income                     Monthly                                          Expenses                           Monthly
 Wages	(gross)	                                                           Food,	clothing	and	misc.
 Spouse	wages	(gross)	                                                    Housing	and	utilities
 Interest	and	dividends	                                                  Transportation
 Net	income	from	business	                                                Healthcare
 Net rental income                                                        Taxes (income & FICA)
 Pension / social security (yourself)                                     Court ordered payments
 Pension / social security (spouse)                                       Child / dependent care
 Child support                                                            Life insurance
 Alimony	                                                                 Other	secured	debt
 Other	income	(specify)	                                                  Unsecured	debt
 	 	                                                                      Other	(list	and	specify)

 	                                    Total		           0.00                                                       Total	                    0.00
 17.  Prospect of increase in value of assets or in present income (describe and explain)

 18.  Are foreclosure, bankruptcy, receivership or assignment proceedings pending for the benefit of creditors?               Yes No
 19.  Judgments
	                          	                                            	                         Date	Recorded	                  Recorded	in
                   Name of Creditor              Amount of Judgment                               or Docketed      (District, County or State)

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 20.                                                PETITIONER'S OFFER IN COMPROMISE

	    In	accordance	with	secs.	71.92(3),	73.13	and	77.62(5)	of	the	Wisconsin	Statutes,	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	his/her	knowledge.	The	sum	of	$	                  is	being	offered	to	compromise	the	tax	liability	set	forth	in	this	petition.
     It is understood that this offer in compromise only includes those taxes and taxable periods specifically identified on the petition.  
	    It	is	understood	that	this	offer	does	not	provide	relief	from	said	liability	until	the	offer	is	accepted	in	writing	by	the	Department	of	
Revenue	and	paid	within	ten	days	from	the	date	of	such	acceptance,	or	by	installment	schedule	approved	by	the	department.
     It is mutually agreed that if within three years from the date this offer is accepted, the petitioner has income or property sufficient to 
enable	him/her	to	pay	the	remainder	of	the	tax	including	penalty	and	interest,	the	department	may	reopen	this	matter	and	order	payment	in	
full,	or	in	part,	of	such	tax,	penalty	and	interest.
	    As	a	part	of	the	consideration	for	this	offer,	the	petitioner	waives	any	claims	to	overpayments	of	taxes	to	which	he/she	may	be	entitled	
for	any	of	the	years	prior	to	and	including	those	involved	in	this	compromise	settlement	when	the	overpayments	are	not	in	excess	of	the	
difference	between	the	liability	sought	to	be	compromised	and	the	amount	offered.	This	waiver	is	withdrawn	if	the	total	amount	of	tax	set	forth	
in	this	petition	is	paid	in	full	within	three	years	from	the	date	the	offer	is	accepted.
	    The	petitioner	also	agrees	that,	as	part	of	the	consideration	for	this	offer,	they	will	withdraw	or	stipulate	to	dismiss	any	pending	
administrative	or	other	appeals	against	the	department	within	15	days	of	acceptance	of	this	offer	by	the	department.	This	includes,	but	is	not	
limited to, petitions for redetermination, appeals to the Tax Appeals Commission, and appeals to any state or federal court which relate to the 
tax	liability	set	forth	in	this	petition.	Petitioner	further	agrees	to	waive	and	release	all	claims	against	the	department	which	relate	to	the	tax	
liability	set	forth	in	this	petition.

                                                         Signature of petitioner (or corporate officer) Title               Date

 21.                                                     COMPROMISE	ORDER

	    On	the	basis	of	the	sworn	statement	of	the	above-named	petitioner,	the	Wisconsin	Department	of	Revenue	by	its	duly	authorized	
     undersigned	hereby	determines:

	    That	the	petition	for	compromise	is	rejected.

	    That	the	petition	for	compromise	offering	the	sum	of	$		         in	compromise	of	the	petitioner's	liablity	which	amounts	to
	    $	               is	accepted.	Therefore,	the	petitioner's	liability	as	set	forth	in	this	petition	is	reduced	to	$
     provided this sum is paid in the form of certified funds (cashiers check or money order) and received by the Department of Revenue 
     within	10	days	from	the	date	this	offer	was	accepted.

	    That	the	department	proposes	a	counter	offer	in	the	amount	of	$	                   in	compromise	of	the	petitioner's	liability	which	
     amounts	to	$	                     .	Therefore,	the	petitioner's	liability	as	set	forth	in	this	petition	is	reduced	to	$
     provided this sum is paid in the form of certified funds (cashiers check or money order) and received by the Department of Revenue 
     within	20	days	from	the	date	this	counter	offer	was	made.

     Correspondence dated                           and enclosed with this petition contains additional conditions of your compromise. No 
     compromise	adjustment	to	your	account,	including	the	satisfaction	of	tax	warrants,	will	be	made	until	all	conditions	have	been	met	
     unless	the	enclosed	correspondence	so	states.

                                                         Signature	                                                         Date

 22.                                                LOCATIONS	OF	DISTRICT	OFFICES

  Appleton                             Eau Claire                     Madison                                               Milwaukee

265 W. Northland Ave.                718 Clairemont Ave.              PO Box 8901                             819 N. Sixth St.
54911	  	                            54701	                           2135	Rimrock	Rd.	                       Rm.	408
(920)	832-2727	                      (715)	836-2811	                  53708	                                  53203
	       	                            	                                (608)	266-7879	                         (414)	227-4000






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