Click mouse on line below and enter name of petitioner. Tab throughout rest of form. Save Print Clear 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 To Page 2 |
To Previous Page To Page 3 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. To Page 3 |
To Previous Page To Page 4 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) To Page 4 |
To Previous Page Return to Page 1 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 |