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A Publication of the
Louisiana Department of Revenue
Offer in Compromise Program
P.O. Box 201
Baton Rouge, Louisiana 70821-0201

Form R-20212 (10/19)

            Louisiana Department of Revenue

            Offer in Compromise Program

This Booklet Contains:

• Offer in Compromise Policy Statement

• Basic Information Concerning Offers in Compromise

• Instructions for Completing the Offer in Compromise Application

• Offer in Compromise Application – R-20212A

• Statement of Financial Condition for Individuals – R-20223

• Statement of Financial Condition for Businesses – R-20222

• Document Checklist for Offer in Compromise – R-20211

• Power of Attorney – R-7006

Note: This booklet may be downloaded from our website at
http://www.revenue.louisiana.gov

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R-20212 (10/19)

Offer in Compromise Policy Statement
An Offer in Compromise will be considered when it is determined that the tax liability cannot be collected in full and the amount offered rea-
sonably reflects collection potential. The success of the Offer in Compromise Program will be assured only if the taxpayer makes an adequate
compromise proposal consistent with ability to pay and LDR makes a reasonable decision. The taxpayer is required to provide documentation of
financial condition. The goal of the Offer in Compromise Program is to achieve a compromise that is in the best interest of both the taxpayer and
the state. Acceptance of an offer should create for the taxpayer a fresh start regarding compliance with current and future tax filing and payment
requirements. A nonrefundable application fee of $186 payable to Louisiana Department of Revenue along with an initial payment of 20% of
the amount being offered must be submitted with each application.

Basic Information Concerning Offers in Compromise
• The Secretary of Revenue, with the written approval of two assistant secretaries under Revised Statute 47:1578(4), may compromise any judg-
ments for taxes of $500,000 or less, exclusive of interest and penalty, including assessments for such amounts that are equivalent to judgments
upon a determination that any of the following apply:
a. There is serious doubt as to the collectibility of the outstanding judgment.
b. There is serious doubt as to the taxpayer’s liability for the outstanding judgment.
c. The administration and collection costs involved would exceed the amount of the outstanding liability.

In addition, under Revised Statute 47:295, the Secretary may waive, reduce, or compromise any of the taxes, penalties, or interest or other
amounts provided by the individual income tax statutes.
• An approved Offer in Compromise is not protected by the confidentiality provisions of Revised Statute 47:1508. An Offer in Compromise,
signed by all parties and including the reason, is a public record and is open to public inspection upon request. A list of approved Offers
in Compromise is required to be published in LDR’s annual report.
• An offer will not be considered if it is determined that the offer was filed for the purpose of delaying collection or otherwise jeopardizing
LDR’s ability to collect the tax debt. Any installment payment arrangement already in effect will be continued while the offer is considered.
Interest and penalty will continue to accrue on any unpaid tax debt while the offer is being considered.
• Any payment made with the application will be applied as partial payment to the applicant’s tax liability regardless of the disposition of the offer.
• A LDR representative will evaluate the offer and make a recommendation to accept or reject. The representative may request additional
documentation to verify financial or other information concerning the offer. The financial investigation may require verification of financial
data by visual inspection of records and personal interview. The representative may determine that a larger offer amount is necessary to justify
acceptance. The applicant will have the opportunity to amend the offer if indicated. Any amendment to the offer must be in writing from the
applicant or their Power of Attorney.
• All information and statements provided by the applicant are subject to verification and are under the jurisdiction of Revised Statutes. 47:1604
and 1642, concerning the giving of false statements.
• The offer application must be submitted on Form R-20212A and must include the required financial disclosure forms. Sep arate applications
must be submitted for individual and business taxes. All business taxes can be included on one application. Depending on the legal structure
of the applicant, the following financial disclosure forms are required:
Legal Structure Form(s) Required
Individual R-20223 (Individual)
Corporate Officer R-20223 (Individual)
Proprietorship R-20222 (Business) & R-20223 (Individual)
Partnership R-20222 (Business) & R-20223 (Individual)
Corporation R-20222 (Business)
Trust/Estate R-20222 (Business)

• If a Federal Offer in Compromise application has been requested within the last three months, it may be accepted in lieu of the required financial dis-
closure forms.
• Any collection by LDR before the offer or any refund to which LDR is entitled under its offset provision cannot be considered as part of an
offer.
• Tax liens will be released only after an offer is accepted and the amount offered is paid in full.

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R-20212 (10/19)

• Compliance with all terms and conditions of the offer is required, including the timely filing and payment of all required tax returns for a
period of 10 years from the date the offer is accepted. Failure to comply may result in the offer being voided and resumption of collection on
the total balance due.
• No Offer in Compromise will be considered while a criminal investigation or prosecution is pending, or while the applicant is under bank-
ruptcy court jurisdiction.
• All documents included on the Form R-20211 checklist must be included with the application.

If the Offer Is Accepted
LDR will notify the applicant by mail if the offer is accepted. Payment of the accepted offer must be made by the payment due date indicated on
the acceptance letter. Failure to pay by this date may cause the accepted offer to become null and void. Payment of the offer by electronic means
or payment by cashier’s check or money order will assure faster satisfaction of the lien. If payment is made by personal check and the check later
becomes NSF, the accepted offer will be null and void and the entire liability will immediately become due. In addition, NSF check penalties
will apply.
An applicant is limited to having only one offer in compromise approved in a 10-year period. If an offer in compromise is approved, LDR will
not consider or accept any other application for an offer in compromise from the applicant until the expiration of the 10-year period.

If the Offer Is Declined
The applicant will be notified by mail if the offer is declined. The applicant should immediately contact LDR to arrange for payment of the entire
liability. If immediate payment is not possible, the applicant may request payment through a LDR-approved installment payment agreement.
Louisiana law makes no provision for appeal of a declined offer.

Returning the Offer
LDR may reject the application for any of the following reasons:
1. The applicant is not adequately identified (name, address, Louisiana Account Number, etc.) or required signatures are not provided.
2. An offer of “zero” or “none” will not be considered.
3. The offer includes an amount already collected or subject to refund offset.
4. The tax liability is not adequately identified.
5. The offer does not show a reason (“Doubt as to Collectibility” and/or “Doubt as to Liability”) or the summary statement supporting the
reason for the offer has not been provided.
6. Financial statements have not been included or are incomplete.
7. LDR’s records indicate noncompliance with filing of required returns.
8. The applicant is currently under bankruptcy court jurisdiction.
9. Power of Attorney Form (if indicated) has not been included.
10. Criminal investigation or prosecution is pending.
11. The mandatory 20 percent down payment was not included with the offer.

Instructions for Completing the Offer in Compromise Application (Form R-20212A)
Item 1 Enter the applicant’s full name, street address, Social Security Number, Louisiana Account Number (if applicable), and daytime tele-
phone number. If the tax liability is owed by more than one person, identify each person or business for which the offer is made.
Item 2 Enter the mailing address, if different from the street address.
Item 3 Place an “X” in the box next to the term or terms that identify the applicant’s legal structure.
Item 4 Enter the offer amount. An application fee of $186 and a nonrefundable payment of at least 20 percent of the offered amount is required and
must accompany an Offer in Compromise. In the event the Offer in Compromise is rejected, the deposit shall be applied to the taxpayer’s
outstanding tax liability.
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R-20212 (10/19)

Item 5 Place an “X” in the box next to the method of payment. All payments made with the application will be applied as partial payment
toward the applicant’s tax liability and will not be returned, regardless of the disposition of the offer. The acceptance of this payment
constitutes neither a waiver of LDR’s rights nor an acceptance of the offer.
Item 6 Place an “X” to identify the involved tax types. Specify the account number, the period, the amount due, and the amount offered for
which the offer is made. Please contact LDR if you need to confirm any periods of liability.
Item 7 LDR may compromise a tax liability for one or both of the following reasons:
• “Doubt as to Collectibility” – The applicant doubts his ability to ever pay the full amount of tax owed.
• “Doubt as to Liability” – The applicant believes that the tax liability is not correct or he is not liable.

Note: LDR will not accept a compromise based on doubt as to collectibility when there is no doubt that the full amount can be collected.
LDR will not accept a compromise based on doubt as to liability if the amount owed has already been determined to be legally correct
by a court or the Board of Tax Appeals. Provide a detailed statement explaining the reason for the offer. You may attach any documents
that support the statement.

Item 8 Provide name of offer funding source.
Item 9 Attach completed and signed Power of Attorney Form R-7006 if an attorney, accountant, or any other agent represents you.
Item 10 It is important that the Terms and Conditions listed in this section are understood. Also, the applicant authorizes LDR to
obtain bank and financial information, as well as a credit history from any consumer reporting agency, for the purpose of
verifying the financial information provided by the Offer in Compromise applicant. All persons submitting the offer must sign and date
the application.
Item 11 The applicant may at his discretion allow LDR to exchange information regarding a pending or completed offer with the IRS. All
information in this section must be provided including applicant(s) signature(s) and date.

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R-20212A (10/15)
                                                                                                    Louisiana Department of Revenue
                                                                                                    Offer in Compromise Program
                                                    Offer in Compromise Application                 P.O. Box 201
                                                                                                    Baton Rouge, Louisiana 70821-0201

Please read instructions before completing this form and include the $186 non-refundable Application Fee.
Tax Type to be included in this offer
 Individual                     Business
1. Applicant’s Name (Individual)                                              Social Security Number

Street Address

City, State, ZIP                                                              Daytime Telephone Number

1. Applicant’s Name (Individual)                                              Social Security Number

Street Address

City, State, ZIP                                                              Daytime Telephone Number

1. Applicant’s Name (Business)                                                LA Account Number

Street Address                                                                Parish

City, State, ZIP                                                              Daytime Telephone Number

1. Applicant’s Name (Business)                                                LA Account Number

Street Address                                                                Parish

City, State, ZIP                                                              Daytime Telephone Number

2. Applicant(s) Mailing Address  (If different from above)                    3. Applicant(s) Legal Structure
                                                                              	   Individual                	Proprietorship 
Street Address                                                                   	Partnership               	Corporation 
                                                                                 	Trust/Estate              	Corporate Officer(s) 
City, State, ZIP
                                                                                  LLC

4. Offer Amount

I/We offer to pay the amount of $__________________ to compromise and settle the tax liabilities listed in Section 6 below and will 
pay this amount in the following manner: (Place an “X” in the appropriate box.)

     Paid in full with this offer.  (Make check payable to the “Louisiana Department of Revenue.”)
     A payment of $ ________________ , which is at least 20% of the offer is required; the balance is to be paid within 30 
      days from acceptance.

Note: An application fee of $186 and a nonrefundable initial payment of at least 20 percent of the amount offered must be submitted 
with the Offer in Compromise Application. In the event the Offer in Compromise is rejected, the deposit shall be applied to the tax-
payer’s outstanding tax liability.

5. Method of Payment

 Bank Draft                     Cash                     	Credit Card   Money Order                      	Check
Note: It is understood that this offer will be considered and acted upon in due course and that it does not relieve the taxpayer(s) from 
the liability sought to be settled until the offer is accepted in writing by the Secretary of the Louisiana Department of Revenue, two 
assistant secretaries, and the Louisiana Board of Tax Appeals, and there has been full compliance with the terms of the offer.

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R-20212A (7/15)
6. Description of Tax Liabilities to be Compromised (Mark and complete all that apply.)
                       Tax Type                              Period(s)                 Amount Due                   Amount Offered
 Individual Income Tax
  SSN ________________________________________
 Employer Withholding Tax
  LA Account Number ____________________________
 Sales & Use Tax
  LA Account Number ____________________________
 Corporate Income Tax
  LA Account Number ____________________________
 Corporate Franchise Tax
  LA Account Number ____________________________
 Other (Specify.)______________________
  LA Account Number ____________________________
7. Reason for Offer: (Mark either or both and provide supporting statements. Attach additional sheets if necessary.)

 Doubt as to Collectibility (“I am unable to pay this tax.”)

 Doubt as to Liability (“I do not believe I owe this tax and/or the tax liability is not correct.”)

8. Provide name of offer funding source.

9. If you are represented by an attorney, accountant or agent, please provide the following information.
Name                                    Firm

Mailing Address

City, State, ZIP

Telephone Number 

If you are represented by an attorney, accountant, or agent, attach Power of Attorney – Use Form R-7006 only.

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R-20212A (7/15)
10. Terms and Conditions
By submitting this offer and signing below, I/we understand and agree to LDR’s Offer in Compromise Terms and Conditions as follows:
(a) I/We will submit a non refundable application fee of $186 and a payment of at least 20 percent of the offer that I/We understand will be
applied as a partial payment toward my/our tax liability and will not be returned, regardless of the disposition of the offer.
(b) I/We will remain in compliance with all tax return filing provisions of the Revised Statutes during the existence of this offer.
(c) The offer remains pending until an authorized LDR representative issues written notification of acceptance or rejection, or until the offer 
is withdrawn by me/us.
(d) I/We understand that collection enforcement activity will not be suspended while an offer is pending.
(e)LDR will retain and apply any payment toward the liability for which this offer is made, if the payment was received before official accep-
tance of the offer. LDR will retain any credits received before full payment of an accepted offer.
(f) I/We understand that the 20 percent down payment is nonrefundable and will be credited to the liability.
(g) I/We understand that the tax I/we owe is, and will remain, a tax liability until I/we meet all the terms and conditions of this
offer. If I/we file bankruptcy before the terms and conditions of this offer are completed, any claim LDR files in a bankruptcy
proceeding will be a tax claim.
(h) I/We understand that LDR will only consider one Offer in Compromise application in a 10-year period.
(i) I/We authorize LDR to obtain bank and financial information, as well as a credit history, from any consumer reporting agency for the
purpose of verifying the financial information provided by the Offer in Compromise applicant.
(j) If I/we fail to meet the terms and conditions of an accepted offer, the offer will be considered null and void. LDR will continue to add
applicable interest and penalty on the total unpaid balance until paid in full. In addition, LDR may:
(1)Immediately issue and record any tax lien necessary to protect the state’s legal interest;
(2)Proceed with enforced collection of the total outstanding liability;
(3)Apply amounts already paid under the offer to the total liability.
(k) It is also agreed that on notice to the taxpayer of the acceptance of this offer, the taxpayer shall have no right to contest, in court or other-
wise, the liability sought to be settled. If full payment is not received within 30 days after notification of the acceptance of this offer, the
Secretary of the Louisiana Department of Revenue or a designee may disregard the amount of the offer and, without notice of any kind,
assess and collect by seizure or any other legal means, the balance of the original liability.
(l) I/We waive prescription applicable to the assessment and collection of the liability sought to be settled and agree to the suspension of pre-
scription on assessment and collection for the period during which the offer is pending. The offer shall be deemed pending from the date of 
acceptance of the waiver of prescription until the date the offer is formally accepted, rejected, or withdrawn in writing.

I/We have examined this offer, including accompanying schedules, returns, and statements, and hereby affirm that to the best of my/our knowledge 
and belief it is true, correct, and complete.

________________________________________________________________________________   ________________________
                                             Applicant’s Signature                                                        Date
____________________________________________________________________________________________________   ______________________________
                                             Applicant’s Signature                                                        Date
____________________________________________________________________________________________________   ______________________________
                               Power of Attorney Signature                                                                Date
____________________________________________________________________________________________________   ______________________________
                                             Notary Signature                                                             Date

Note: LDR Forms R-20223 (Statement of Financial Condition for Individuals) or R-20222 (Statement of Financial Condition for 
Businesses) must be completed, signed, and attached for this to be a complete offer. For individuals filing joint returns, both spouses must 
sign. If the business is a corporation, this must be signed by an officer or board member; if a partnership or LLC, this must be signed by one 
of the partners. LDR personnel may request verification of the financial information provided on these forms and may request additional 
information.

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R-20212A (7/15)
11. Disclosure Agreement (Complete this section if an Offer in Compromise is currently pending or has been completed with the IRS.)

 Completed  Date ____________________________________      Accepted (Amount $ ____________ )   or    Declined
                                                           IRS Agent Assigned
 Pending      Date filed ________________________________
                                                           Telephone Number           
 To be filed  Date ____________________________________
Tax Period(s) Covered        Amount Owed                   Federal Taxpayer Identification Number
___________________________– $___________________________
By my/our signature(s) below, I/we authorize the Louisiana Department of Revenue and the Internal Revenue Service to exchange 
information from their respective files regarding my/our pending or completed Offer in Compromise. 

  __________________________________________________________                 ________________________
                             Applicant’s Signature                                                 Date
  __________________________________________________________                 ________________________
                             Applicant’s Signature                                                 Date

                             Revenue Offices – Hours 8:00 A.M. – 4:30 P.M.
                                                   Headquarters
                             617 North Third Street, Baton Rouge, LA 70802
                             P.O. Box 201, Baton Rouge, LA 70821-0201
                                                   (855) 307-3893

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R-20223 (6/13)
Louisiana Department of Revenue
Statement of Financial Condition Formal Installment Agreement for Individuals
for Individuals P.O. Box 66658
Baton Rouge, LA 70896-6658

The information provided in this statement must include all household employment, assets, liabilities, income and expenses.
Spouse and dependent information are required even though only one person is liable for the tax.
Section I – Personal Information
1. Taxpayer(s) Name(s) and Residence Address 2. Daytime Telephone Number 3. Marital Status (Mark One.)
 Single  Married
 Separated  Divorced
4. Social Security Number 5. Date of Birth
Taxpayer Taxpayer
Spouse Spouse
How long at this address? ___Years ___Months Do you own  or rent  ?
6. Previous Address if at Current Address Less than Two Years 7. Income Tax Return Information

A. Year of Last Filed Federal Income Tax Return
B. Federal Adjusted Gross Income from Last Return $
C. Year of Last Filed Louisiana Income Tax Return

Section II – Employment Information
8. Taxpayer(s) Employer or Business – Name and Address 9.Employer Telephone Number 10. Occupation

11. Length of Employment 12. Work Relationship
 Employee  Proprietor
Years______ Months______  Partner  Officer
13. Spouse’s Employer or Business – Name and Address 14. Employer Telephone Number 15. Occupation

16. Length of Employment 17. Work Relationship
Years______ Months______  Employee  Proprietor
 Partner  Officer
18. Taxpayer(s) Part-time or Previous Employment in Last Three Years 19. Spouse’s Part-time or Previous Employment in Last Three Years
Employer Name Employment Date Employer Name Employment Date
to to
to to
to to
20. Have your wages or salary been garnished within the last three years? Taxpayer  Yes  No Spouse  Yes  No
Section III – Dependent Information
21. Dependent Name (Other than Spouse) Date of Birth Relationship Monthly Income
$

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R-20223 (6/13)

                                         Section IV – Assets as of          _____-_____-______MM DD  YY
22. Cash                                                                                           Total (Enter also on Line 30-A.) $
23. Bank or Credit Union Accounts (Checking, Savings, Certificate of Deposit, etc.)*
         Name of Institution                        Account Number                                 Type of Account                   Balance
                                                                                                                                    $

                                                                                                   Total (Enter also on Line 30-B.) $
24. Bank Credit Cards (Visa, MasterCard, Discover, American Express, etc.)*
               Name of Issuer                       Account Number                                 Credit Limit   Amount Owed       Credit Available
                                                                                      $                           $                 $

                                                                                                   Total (Enter also on Line 30-C.) $
25. Securities (Stocks, Bonds, Mutual Funds, IRA, Government Securities, Money Market Funds, etc.)*
         Type                                            Issuer                                                     Quantity or      Current Value
                                                                                                                  Denomination
                                                                                                                                    $

                                                                                                   Total (Enter also on Line 30-D.) $
26. Real Property (Personal Residence, Vacation or Second Home, Investment Property, Unimproved Land, etc.)*
  Description                                    Address                                           Current Market Amount Owed       Equity in Property
                                                                                                   Value
                                                                                      $                           $                 $

                                                                                                   Total (Enter also on Line 30-E.) $
27. Vehicles – Excluding Leased Vehicles (Including Motor Homes, Campers, Motorcycles, Boats, Trailers, etc.)*
  Description                     Make     Purchase   Year                 Tag Number              Current Market Amount Owed       Equity in Vehicle
                                           Date                                                    Value
                                                                                      $                           $                 $

                                                                                                   Total (Enter also on Line 30-F.) $
28. Other Assets*
                                         Current or Appraised Value                                                           Current or Appraised Value

Notes Receivable                         $                          Timber, Mineral, or Drilling Rights                       $
Cash Surrender Value of Life Insurance                              Patents or Copyrights
Judgments or Settlements Receivable                                 Other (Specify.)
Vested Retirement Account
Collectibles, Antiques, or Artwork
                                                                                    Total          (Enter also on Line 30-G.) $

	*If additional lines are needed, check this box and attach additional pages, noting line number and description.
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R-20223 (6/13)

Section V – Liabilities as of _____-_____-______MM DD YY
29. Liabilities (Do Not Include Any Mortgages or Vehicle Loans)
Total Amount Owed Total Amount Owed
Notes Payable $ Past Due Other Taxes $
Installment or Personal Loans Vehicle Lease: Make__________ Year______
Education or Student Loans Vehicle Lease: Make__________ Year______
Bank Revolving Credit Other Liabilities:
Judgments Payable
Past Due Federal Taxes
Past Due State Taxes
Total (Enter also on Line 31.) $
Section VI – Net Worth Calculation
30. Assets (Section IV)
A. Cash (Section IV, Line 22) $
B. Bank or Credit Union Accounts (Section IV, Line 23)
C. Bank Credit Cards (Section IV, Line 24)
D. Securities (Section IV, Line 25)
E. Real Property (Section IV, Line 26)
F. Vehicles (Section IV, Line 27)
G. Other Assets (Section IV, Line 28)
Total Assets (Add Lines 30A – 30G.) $
31. Liabilities (Total of Section V, Line 29) $
32. Net Worth (Total Assets from Line 30 minus Total Liabilities from Line 31) $
Section VII – Other Information

33. Are you currently in filing compliance with all Louisiana taxes?
 Yes No If “No”, identify tax type and period. ___________________________________________________________________________
34. If the tax liability was incurred in the operation of a business, has the business been discontinued?
 Yes  No N/A  If “Yes”, date discontinued. ____________________________________________________________________________
35. 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”, identify. _________________________________________________________________________________________
36. Is a foreclosure proceeding pending on any real estate that you own or have an interest in?
 Yes No
37. Is anyone holding any assets on your behalf?
 Yes No If “Yes”, identify. ______________________________________ Relationship ________________________________________
38. Are you a party to any lawsuit now pending?
 Yes No
39. Do you anticipate any significant change in your current income levels or financial situation within the next four years?
 Yes No If “Yes”, explain. __________________________________________________________________________________________
40. Have you previously petitioned the Louisiana Department of Revenue for an Offer in Compromise for any tax liability within the last ten years?
 Yes No If “Yes”, date the offer was approved or declined. ________________________________________________________________
41. Are you or any business that you own currently under bankruptcy court jurisdiction?
 Yes No Bankruptcy Case Number __________________________________________________________________________________

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R-20223 (6/13)
                                            Section VIII – Income and Expense Analysis
42. Monthly Household Disposable Income
                       GROSS MONTHLY INCOME                                          MONTHLY LIVING EXPENSES
                 Source                     Taxpayer      Spouse                     Source                         Amount
Salary, Wages, Commissions, Tips          $             $        House or Rent Payment                             $
Self-Employment Income                                           Income Taxes (Federal, State, FICA)
Pensions, Disability, and Social Security                        Estimated Tax (If Applicable)
Dividends and Interest                                           Groceries
Gift or Loan Proceeds                                            Medical Expenses and Prescriptions
Rental Income                                                    Utilities
                                                                   Electric $_______  + Gas $__________
Estate, Trust, and Royalty Income                                + Water $________  + Phone $________ =
Workers’ Compensation and                                        Insurance:
Unemployment                                                       Life $_________   + Health $________
Alimony and Child Support                                        + Auto $________   + Home $________ =
Other (Specify.)                                                 Court Ordered Payment
                                                                 Personal Loan Payment
                                                                 Religious and Charitable Donations
                                                                 Clothing and Personal Grooming
                                                                 Entertainment and Recreation
                                                                 Legal Fees
                                                                 Transportation Expense
                                                                 Vehicle Loan Payment
                                                                 Vehicle Lease Payment
                                                                 Property and Ad Valorem Taxes
                                                                 Child Care
                                                                 Installment & Credit Card Payments
                                                                 Tuition Payment
                                                                 Other (Specify.)

                          Subtotal        $             $
      Combined Monthly Income             $                                 Total Monthly Living Expenses          $
(Add Taxpayer and Spouse Monthly Income.)
43. Net Monthly Household Disposable Income (Subtract Total Monthly Living Expenses from Combined Monthly Income.) $

I/We have examined this Statement of Financial Condition for Individuals and hereby affirm that to the best of my/our knowledge and belief, it is true, 
correct and complete. 

Taxpayer Signature _______________________________________________________  Date ________________________________________
Spouse Signature ________________________________________________________  Date ________________________________________
Power of Attorney Signature ________________________________________________  Date ________________________________________

                                            (Attach Power of Attorney – Form R-7006.)

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R-20222 (6/13)

                                                                                                                   Louisiana Department of Revenue
                                             Statement of Financial                                                Formal Installment Agreement for Business
                                             Condition for Businesses                                              P.O. Box 201
                                                                                                                   Baton Rouge, LA 70821-0201

                                             Section I – Business Identification
1. Business Name and Address                                                          2. Mailing Address (If Different from Street Address)

3. Parish or County                                                                   4. Daytime Telephone Number            5. Number of Employees
                                                                                       
6. Type of Ownership                                                                  7. Louisiana Tax ID
 Proprietorship    	Partnership 	LLC
 Corporation       	Other (Specify.)____________________________                    8. Federal Tax ID

9. Beginning Date of Business                                                         10. Ending Date of Business (If Closed)

11. Latest Filed Louisiana Income Tax Return Revenue Form Number Tax Year Ended                                              Net Income
                                                                                                                             $
12. Information About Owner, Partners, Officers, Major Shareholder, etc.
                     Name                                      Social Security             Title         Effective Date        Monthly        Total Shares  
                                                               Number                                                        Salary or Wages  or Interest
                                                                                                                             $

                                             Section II        – Assets as of           _____-_____-______MM DD  YY
13. Cash On Hand                                                                                         Total (Enter also on Line 25-A.)    $
14. Bank Accounts (General Operating, Payroll, Savings, Certificate of Deposit, etc.)*
              Name of Institution                                Account Number                                    Type of Account            Balance
                                                                                                                                             $

                                                                                                           Total (Enter also on Line 25-B.) $
15. Bank Credit Available (Line of Credit, Credit Cards, etc.)*
                 Name of Issuer                                  Account Number                            Credit Limit      Amount Owed     Credit Available
                                                                                                         $                   $               $

                                                                                                           Total (Enter also on Line 25-C.) $

		*If additional lines are needed, check this box and attach additional pages, noting line number and description.

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R-20222 (6/13)

                                         Section II  – Assets as of       _____-_____-______MM DD YY (continued)
16. Real Property (Including Investment Property, Unimproved Land, etc.)*
  Description                                          Address                                 Current Market          Amount Owed               Equity in 
                                                                                                     Value                                       Property
                                                                                             $                       $                          $

                                                                                                      Total (Enter also on Line 25-D.) $
17. Vehicles (Excluding Leased Vehicles)*
  Description               Make                 Model                   Year   Tag Number     Current Market        Amount Owed                Equity in Vehicle
                                                                                                     Value
                                                                                             $                       $                          $

                                                                                                      Total          (Enter also on Line 25-E.) $
18. Accounts Receivable*
                                         Name                                                     Date Due             Status                    Amount Due
                                                                                                                                                $

                                                                                                      Total          (Enter also on Line 25-F.) $
19. Loans from Business to Proprietor, Partners, Officers, Shareholders, or Others*
                            Name                                                Relationship   Payoff Date             Status                    Amount Due
                                                                                                                                                $

                                                                                                      Total          (Enter also on Line 25-G.) $
20. Machinery and Equipment (Including Furniture, Fixtures, Business Machines, etc.)*
                                                                                                                                                 Equity in 
                                         Description                                           Current Market        Amount Owed                 Machinery and 
                                                                                                     Value                                       Equipment
                                                                                             $                       $                          $

                                                                                                      Total (Enter also on Line 25-H.) $
21. Merchandise Inventory (Goods Held for Sale and/or Raw Materials Used in Manufacture, Fabrication, or Production)*
                                         Description                                           Current Market        Amount Owed                 Equity in  
                                                                                                     Value                                       Merchandise

                                                                                                      Total (Enter also on Line 25-I.) $

	*If additional lines are needed, check this box and attach additional pages, noting line number and description.
                                                                              13

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R-20222 (6/13)

                                       Section II   – Assets as of              _____-_____-______MM DD  YY (continued)
22. Securities (Stocks, Bonds, Mutual Funds, Government Securities, Money Market Funds, etc.)*
                   Type                                                        Issuer                        Quantity or                 Current Value
                                                                                                             Denomination
                                                                                                                                        $

                                                                                                   Total     (Enter also on Line 25-J.) $
23. Other Assets*
                                                      Current or                                                                         Current or  
                                                    Appraised Value                                                                      Appraised Value
Notes Receivable                                 $                               Patents or Copyrights
Timber, Mineral, or Drilling Rights                                              Others:
Collectibles, Antiques, or Artwork
Judgments or Settlements Receivable
                                                                                                   Total     (Enter also on Line 25-K.) $
                                        Section III – Liabilities as of _____ - _____ - ______
                                                                                 MM DD  YY
24. Liabilities (Do not include any mortgages or vehicle loans.)
                                                    Total Amount Owed                                                                    Total Amount Owed
Accounts Payable                                 $                               Past Due Federal Taxes                                 $
Notes Payable                                                                    Past Due State Taxes
Vehicle Lease: Make__________  Year________                                      Past Due Other Taxes
Vehicle Lease: Make__________  Year________                                      Equipment Leases
Bank Revolving Credit                                                            Other Liabilities:
Judgments Payable
                                                                                                   Total (Enter also on Line 26.)       $
                                                    Section IV – Net Worth Calculation
25. Assets (from Section II, Lines 16 through 23)
  A. Cash on Hand (Section II, Line 13)                                                                                                 $
  B. Bank Accounts (Section II, Line 14)
  C. Bank Credit Available (Section II, Line 15)
  D. Real Property (Section II, Line 16)
  E. Vehicles (Section II, Line 17)
  F. Accounts Receivable (Section II, Line 18)
  G. Loans from Business to Proprietor, Partners, Officers, Shareholders, or Others (Section II, Line 19)
  H. Machinery and Equipment (Section II, Line 20)
  I. Merchandise Inventory (Section II, Line 21)
  J. Securities (Section II, Line 22)
  K. Other Assets (Section II, Line 23)
  Total Assets (Add Lines 25A through 25K.)                                                                                             $
26. Liabilities (Section III, Line 24)                                                                                                  $
27. Net Worth (Total Assets from Line 25 minus Total Liabilities from Line 26)                                                          $

	*If additional lines are needed, check this box and attach additional pages, noting line number and description.
                                                                               14

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R-20222 (6/13)
Section V – Income and Expense Analysis
28. Business Income and Expenses for: (Mark One.)  Fiscal Year Ending __________ OR  Period __________ to __________.
Accounting Method: (Mark One.)  Cash  Accrual  Other ______________________________________
Income Amount Expenses Amount
Gross Receipts from Sales, Services, etc. $ Materials Purchased $
Gross Rental Income Net Wages and Salaries
Interest Income Rent or Mortgage Expenses
Dividends and Capital Gain Distribution Installment and Lease Payments
Royalty Income Supplies and Office Expenses
Commissions Utilities
Other Income (Specify.) Transportation Expenses
Repairs and Maintenance
Insurance
Current Taxes
Bad Debts
Travel and Entertainment
Advertising
Other Expenses (Specify.)

Total Income $ Total Expenses $
29. Net Income (Subtract Total Expenses from Total Income.) $
Section VI – Other Information

30. Is this business currently in filing compliance with all Louisiana taxes?
 Yes No If “No”, identify tax type(s) and period(s). ____________________________________________________________________
___________________________________________________________________________________________________________________
31. Has this business 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”, identify receiving party. ______________________________________________________________________________
32. Is a foreclosure proceeding pending on any real estate, equipment or other property that this business owns or has an interest in?
 Yes No
33. Is another party holding any assets on behalf of this business?
 Yes No If “Yes”, identify party. _____________________________________________________________________________________
34. Is this business a party to any lawsuit now pending?
 Yes No
35. Is this business currently under bankruptcy court jurisdiction?
 Yes No If “Yes”, Print Bankruptcy Case Number. _______________________________________________________________________

I/we have examined this Statement of Financial Condition for Businesses and hereby affirm that to the best of my/our knowledge and belief it is true, cor-
rect, and complete. If the business is a corporation, an officer or board member of the corporation must sign; if a partnership or LLC, a partner must sign.

Applicant Name Printed* ____________________________________ Title ______________________________ Date ____________________
Applicant Signature* ____________________________________________________________________________ Date ____________________
Power of Attorney Signature ______________________________________________________________________ Date ____________________

(Attach Power of Attorney – Form R-7006)

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R-20211 (7/15)

Document Checklist for Offer in Compromise Based
on Serious Doubt as to Collectibility

Consideration for an Offer in Compromise based on serious doubt as to collectibility will require an in-depth financial
analysis. To expedite this process, it is necessary that the following information and documents be provided along with the
initial application.

 Copies of federal income tax returns for the two most current years.

 Copies of bank statements for all checking and savings accounts, personal and/or business, for the most current six months.

 Copies of current statements showing the value of all retirement accounts, pensions, and profit-sharing plans for the
most current six months.

 A list of all stocks, bonds, and/or other securities owned, along with the current market value of each.

 A statement from the insurance company for each life insurance policy showing the current cash loan value, accumulated
dividends and interest, dates and amounts of policy loans.

 A list of all real estate owned, wholly or in part, with appraisals, if available, and a statement of payoff on each mortgage.

 A statement from lending institutions and other creditors that clearly indicates current balances owed and payment
schedule on all notes payable and/or revolving accounts.

 A complete inventory of asset-bearing items contained in all safe deposit boxes, including fair market value of each
item, copies of documents, etc.

 Copies of any judgments or legal decrees, excluding bankruptcy, for the past six years.

 A list of all business equipment, office furniture, and other business assets, including the current fair market value of each.

 A list of all accounts receivable (business), showing the payor, amount due, age, and status of each account.

 If personal liability applies, then proof of employment, income, commissions, fees, pensions, etc., must be provided
for both applicant and spouse. Even though the spouse may not be liable, this is needed for equitable distribution of
cost-of-living expenses.

 Denials of loan requests by two or more financial institutions.

 Down payment of at least 20 percent of the offer.

 Copy of your Federal Offer in Compromise application, if applicable.

 Application Fee of $186.

I have reviewed and attached a copy of all necessary documents. I have checked each item that is applicable.

Name Daytime Telephone Number

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R-7006 (1/11)

Power of Attorney and Declaration of Representative

PART I. POWER OF ATTORNEY
Taxpayer(s) must sign and date this form on page 2. PLEASE TYPE OR PRINT.
Your Name or Name of Entity Spouse’s Name, if a joint return (or corporate officer, partner or fiduciary, if a business)

Street Address City State ZIP

Social Security/Louisiana or Federal ID Number Spouse’s Social Security Number (if a joint return)

I/we appoint the following representative as my/our true and lawful agent and attorney-in-fact to represent me/us before the Louisiana Department of
Revenue. The representative is authorized to receive and inspect confidential information concerning my/our tax matters, and to perform any and all acts
that I/we can perform with respect to my/our tax matters, unless noted below. Modes of communication for requesting and receiving information
may include telephone, e-mail, or fax. The authority does not include the power to receive refund checks, the power to substitute another rep-
resentative, the power to add additional representatives, or the power to execute a request for disclosure of tax returns or return information
to a third party.
Representative must sign and date this form on page 2, Part II.
Name

Firm

Street Address

City State ZIP

Telephone Number

Fax number

E-mail Address

Acts Authorized. Mark only the boxes that apply. By marking the boxes, you authorize the representative to perform any and all acts on your behalf,
including the authority to sign tax returns, with respect only to the indicated tax matters:

Tax Type Year(s) or Period(s) Tax Type Year(s) or Period(s)
■ Individual income tax ■ Sales and use tax
■ Corporate income/franchise tax ■ Withholding tax
■ Special Fuels tax ■ Gasoline tax
■ Tobacco tax ■ Other (Please specify.)

DELETIONS. Mark or list any specific deletions to the acts otherwise authorized in this power of attorney.
■ Sign the return(s) for the above tax matters.
■ Execute an agreement to suspend prescription of tax.
■ File a protest to a proposed assessment.
■ Execute offers in compromise or settlements of tax liability.
■ Represent the taxpayer before the department in any proceeding, including protest hearings.
■ Obtain a private letter ruling on behalf of the taxpayer.
■ Other prohibited acts. (List prohibited acts.) _____________________________________________________________________________________________________________
17

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R-7006 (1/11) Page 2

NOTICES AND COMMUNICATIONS. Original notices and other written communications will be sent only to you, the taxpayer. Your representative may request
and receive information by telephone, e-mail or fax. Upon request, the representative may be provided with a copy of a notice or communication sent to you. If
you want the representative to request and receive a copy of notices and communications sent to you, check this box. ■

REVOCATION OF PRIOR POWER(S) OF ATTORNEY. Except for Power(s) of Attorney and Declaration of Representative(s) filed on Form R-7006 (1/11), the
filing of this Power of Attorney automatically revokes all earlier Power(s) of Attorney on file with the Louisiana Department of Revenue for the same tax matters
and years or periods covered by this document.

Signature of Taxpayer(s). If a tax matter concerns a joint return, both husband and wife must sign if joint representation is requested. If signed by a
corporate officer, partner, guardian, tax matters partner, executor, receiver, administrator, or trustee on behalf of the taxpayer, I certify that I have the
authority to execute this form on behalf of the taxpayer.

IF THIS POWER OF ATTORNEY IS NOT SIGNED AND DATED, IT WILL BE RETURNED.
_______________________________________________________________________________________________________________________________________ ______________________________
Taxpayer signature Date (mm/dd/yyyy)

_________________________________________________________________________________ _______________________________________________________ _________________________________
Signature of duly authorized representative, if the taxpayer Title Date (mm/dd/yyyy)
is a corporation, partnership, executor or administrator

Part II. DECLARATION OF REPRESENTATIVE
Under penalties of perjury, I declare that:
• I am not currently under suspension or disbarment from practice before the Internal Revenue Service.
• I am authorized to represent the taxpayer(s) identified in Part I for the tax matters specified there; and
• I am one of the following: (insert applicable letter in table below)
a. Attorney—a member in good standing of the highest court of the jurisdiction shown below.
b. Certified Public Accountant—duly qualified to practice as a certified public accountant in the jurisdiction shown below.
c. Enrolled Agent—a person enrolled to practice before the Internal Revenue Service.
d. Officer—a bona fide officer of the taxpayer organization.
e. Employee—an employee of the taxpayer.
f. Family Member—a member of the taxpayer’s immediate family (state the relationship, i.e., spouse, parent, child, brother, or sister).

g.Other (state the relationship, i.e., bookkeeper or friend)
h.Former Louisiana Department of Revenue Employee. As a representative, I cannot accept representation in a matter with which I had
direct involvement while I was a public employee.

IF THIS DECLARATION OF REPRESENTATIVE IS NOT SIGNED AND DATED, THE POWER OF ATTORNEY WILL BE RETURNED.

Designation-Insert State Issuing State License Number Signature Date
Above Letter (a-h) License (mm/dd/yyyy)

PDF file checksum: 210067209

(Plugin #1/8.13/12.0)