PDF document

- 1 -

FORM OIC-671 Instructions

Offer in Compromise Agreement
Page 1

General Information
Please print in BLUE or BLACK ink only.

The Vermont Department of Taxes has an Offer in Compromise (OIC) Program for taxpayers with outstanding
tax debt. The OIC Program is an alternative to declaring a case as uncollectible or creating a very
long installment agreement.

Before a taxpayer may enter the OIC Program, the debt must be final.

The taxpayer must submit to the Department 1)completed Form OIC-671, 2)any supporting documents to prove
the information provided in the agreement is accurate, 3) collection of information statement if it
applies (Form OIC-672 or Form OIC-673), and 4)a good faith payment (when required). We will
base our decision to accept or deny the OIC on the information submitted and the information we
have available to us. The Department will also consider your history of filing and paying your tax
liabilities in a timely manner.

If the Department accepts an OIC Agreement, payment must be submitted within 30 days of the acceptance
notification. The terms of the agreement outlined on Form OIC-671, Section 6, must also be fulfilled.

Interest and penalty will continue to accrue on any unpaid tax debt until the terms of an accepted offer are satisfied
and the debt is paid in full.

Acceptance of an OIC by the IRS does not automatically guarantee the Vermont Department of Taxes will offer the
same terms or accept an OIC for Vermont taxes. The Department reviews and evaluates a request for
an OIC for Vermont taxes on its own merits according to our OIC procedures. Federal Form 656,
Offer in Compromise, cannot be substituted for the Vermont Form OIC-671, Offer in Compromise
Agreement. However, the taxpayer may submit to Vermont copies of other supporting documents,
such as the current financial statements included in a compromise offer submitted to the IRS.

Before you Begin, Read and Understand the OIC Program
A. Read and understand the “Offer Terms” provided on Form OIC-671, Section 6. By
submitting the OIC Agreement, you will be certifying you have read, understand, and agree
to the terms and conditions provided. If you don’t understand the terms or have questions
about the OIC Program, please call us at (802) 828-2518 during regular business hours.

B. If you are an individual taxpayer or sole proprietor, review and determine if you qualify
for the Low Income Certification provided on Form OIC-671, Section 4.

C. If you are not an individual taxpayer or sole proprietor that qualifies for the Low Income
Certification, calculate the amount of your good faith payment that must be included with
your OIC Agreement request. The good faith payment equals 5% of your current balance
due. The Department will apply your good faith payment to your outstanding balance.
We do not refund good faith payments even when we deny an OIC Agreement request.

Form OIC-671 Instructions
Page 1 of 4
Rev. 12/21

- 2 -

D. Determine the reason for an OIC that applies to your situation. When completing the
OIC Agreement, you will be required to select the ONE reason that applies to you. The
three reasons are described on Form OIC-671, Section 3. The reason that applies to your
situation will also determine the additional information you will be required to submit Page 2
with your agreement request.

Instructions for Completing Form OIC-671
Section 1 – Taxpayer Contact Information
If you are an individual submitting the request, provide the information requested in Box A and
Box C.

If you are a business entity submitting the request, provide the information requested in Box B and
Box C.

Section 2 – Tax Period(s)
Provide all the information requested in Box D.

Section 3 – Reason for Offer
Select the ONE reason that applies to your situation.

Depending on the reason selected, additional documentation will be required.

Doubt as to Collectability -If you select this reason, you must also completeONE of the following
forms:

• Form OIC-672, Collection Information Statement for Businesses

• Form OIC-673, Collection Information Statement for Wage Earners and Self-Employed
Individuals

Doubt as to Liability - If you selected this reason, you must include a detailed explanation about
why you believe you do not owe the tax. You must provide your explanation on a separate paper
and not on the form. You must also include a corrected calculation of what you believe your tax
liability to be.

Economic Hardship -If you selected this reason, you must submit a written narrative explaining
your exceptional circumstance. You must provide your explanation on a separate paper and not on
the form. You must also complete ONE of the following forms:

• Form OIC-672, Collection Information Statement for Businesses

• Form OIC-673, Collection Information Statement for Wage Earners and Self-Employed
Individuals

Exceptional Circumstances - The Department recognizes there are unplanned events or special
circumstances, such as serious illness, where paying the full amount might impair your ability to
provide for yourself and your family. If this is the case, describe your situation and attach documents
that support your claim to your OIC Agreement request. When reviewing your OIC, the Department
will consider your claim of exceptional circumstance in relation to your financial profile.

Form OIC-671 Instructions
Page 2 of 4
Rev. 12/21

- 3 -

Section 4 - Low Income Certification (Individuals only)
If you are an individual or sole proprietor, place an “X” in the appropriate spot indicating if you do
or do not qualify for the Low Income Certification.

NOTE: If your gross monthly household income is less than or equal to the amount shown in the Page 3
chart provided on Form OIC-671, considering your family size and where you live, you qualify
for the Low Income Certification. If you qualify for the Low Income Certification, you are not
required to submit the 5% good faith payment.

Section 5 – Payment Terms
This section of the agreement request requires you to:

1. Provide how much you currently owe, the amount of your offer, good faith payment, and
the balance to be paid if your offer is accepted.

• If you qualify for the Low Income Certification, indicate zero as the amount of your
good faith payment.

• The amount of your offer must be more than zero.

2. Indicate which payment option you want to pay the balance due if your offer is accepted.

3. Provide additional information related to the payment option you selected.

NOTE: If you select payment option #2, you also are agreeing to have your payments made
electronically through ACH debit following the acceptance of your agreement.

With either option, you must pay within 30 days of being notified the Department has accepted
your agreement.

Section 6 – Offer Terms
Before you submit your OIC Agreement request, it is very important that you understand the terms
of your agreement.

Read this section thoroughly.

Section 7 – Mandatory Signatures
You must complete this section, providing the requested information and your signature.

If you do not provide the requested information, the Department will either 1)return your agreement
request to you and apply your good faith payment to your balance due, or 2) deny your agreement
request.

Section 8 – Submission Information
You must include a check, payable to the Vermont Department of Taxes, as a good faith payment
with your agreement request. If you qualified for the Low Income Certification, you do not need
to send payment.

Your check, along with your payment and other required documents, must be mailed to:
Offer in Compromise Program
Vermont Department of Taxes
PO Box 429
Montpelier, VT 05601-0429

Form OIC-671 Instructions
Page 3 of 4
Rev. 12/21

- 4 -

Final check to ensure you have provided all the necessary information
If you are an individual, did you:
F  Provide your name and Social Security Number on the top of pages 2 through 6?
                                                                                                             Page 4
F  Provide all the required information in Section 1 (Boxes A and C) and Section 2?
F  Indicate only ONE reason for your offer in Section 3?
F  Complete the appropriate Collection of Information Statement and/or provide a detailed explanation 
 as required by the type of reason you selected?  See Section 3 Instructions for additional detail.
F  Indicate whether you qualified for the Low Income Certification in Section 4?
F  Indicate amounts on Lines 1 through 4 in Section 5?
F  Select Payment Option #1 or #2 AND provide the additional information related to your payment 
 option in Section 5?
F  Thoroughly read the “Offer Terms” provided in Section 6?
F  Provide all the information required in Section 7, Mandatory Signature, and sign the form?
F  Make your check payable to the Vermont Department of Taxes, in the amount equal to the good faith 
 payment (if you do not qualify for Low Income Certification)? 

If you are filing on behalf of a business, did you:
F  Provide the name of your business and Social Security Number or Federal Identification Number on 
 the top of pages 2 through 6?
F  Provide all the required information in Section 1 (Boxes B and C) and Section 2?
F  Indicate only ONE reason for your offer in Section 3?
F  Complete the appropriate Collection of Information Statement and/or provide a detailed explanation 
 as required by the type of reason you selected?  See Section 3 Instructions for additional detail.
F  Indicate amounts on Lines 1 through 4 in Section 5?
F  Select Payment Option #1 or #2 AND provide the additional information related to your payment 
 option in Section 5?
F  Thoroughly read the “Offer Terms” provided in Section 6?
F  Provide all the information required in Section 7, Mandatory Signature, and sign the form?
F  Make your check payable to the Vermont Department of Taxes in the amount equal to the good faith 
 payment? 

 Consideration of your OIC Agreement request
Once the Department receives your OIC Agreement request, we will review it to make sure it is complete.  
 We will confirm you have provided all the required information on Form OIC-671, including 
 supporting documents (depending on the reason of your request noted in Section 3) and that your 
 good faith payment (when required) has been honored by the bank.  When we have confirmed all 
 requirements have been met, we will send you an acknowledgment letter saying your agreement 
 is being considered.

The Department will accept or deny your OIC Agreement within 60 days of the acknowledgment letter.

If you have any questions about the OIC program or your balance due the Vermont Department of Taxes, please 
 contact us during regular business hours at (802) 828-2518.
                                                               Form OIC-671 Instructions
                                                                                                  Page 4 of 4
                                                                                                  Rev. 12/21

- 5 -

Vermont Department of Taxes     PO Box 429     Montpelier, VT  05601-0429
Phone:  (802) 828-2518
                                                                                                              *216711100*
     VT Form
                            OFFER IN COMPROMISE 
                                                                                                              *216711100*
OIC-671                               AGREEMENT                                                                                                          Page 5

Before completing this agreement request, the Vermont Department of Taxes strongly encourages you to review 
the Offer in Compromise Agreement Program Instructions.  

Additional  information  about  the  Offer  in  Compromise  Program  is  also  provided  at                   www.tax.vermont.gov.  
Incomplete or improperly completed Offer in Compromise (OIC) documents will delay the processing of your 
request and may be grounds to deny it.
NOTE:  In the following agreement, the pronoun “we” may be assumed in place of “I” when there are joint 
liabilities and both parties are signing this agreement.

SECTION 1        Taxpayer Contact Information
BOX A                                                      For Individual(s) only
Taxpayer’s Last Name                            First Name                                Initial             Taxpayer’s Social Security Number

Cell Phone (anytime)                            Daytime Telephone                                             Evening Telephone

Spouse/CU Partner Last Name                     First Name                                Initial             Spouse/CU Partner Social Security Number

Cell Phone (anytime)                            Daytime Telephone                                             Evening Telephone

OR
BOX B                                           For Business Entity only
Business Name (use if business is making offer)                                                               Federal ID Number

Authorized Agent                                                              Title                           Telephone Number

AND
BOX C                                           For Both Individual(s) and Business Entity
Mailing Address                                                                                               For Department Use Only

City                                                                    State ZIP Code

Foreign Country (if not United States)

SECTION 2        Tax Period(s)

                 I submit this offer to compromise the tax liabilities plus any interest, penalties, additions to tax, and 
                 additional amounts required by law for the tax type(s) and period(s) noted below.
BOX D
Individual Income Tax - Tax Period(s) Sales and Use Tax - Tax Period(s)       Withholding Tax - Tax Period(s) Meals and Rooms Tax - Tax Period(s)

Other Tax Type #1 (specify)           Other Tax Type #1 - Tax Period(s)       Other Tax Type #2 (specify)     Other Tax Type #2 - Tax Period(s)

                                                (continued on next page)                                                       Form OIC-671
                                                                                                                               Page 1 of 7
5454                                                                                                                                           Rev. 12/21

- 6 -

 Taxpayer’s Last Name OR Business Name

 Social Security Number OR Federal ID Number                              *216711200*
                                                                          *216711200*
                                                                                                                  Page 6
SECTION 3 Reason for Offer.  Select ONE reason by placing an “X” in the appropriate box.
F  Doubt as to Collectability, meaning “I have insufficient assets and income to pay the full amount.”
          When you choose this reason, you must also complete ONE of the following forms:
                  •  Form OIC-672, Collection Information Statement for Business
                  •  Form OIC-673, Collection Information Statement for Wage Earners and Self-Employed 
                  Individuals
F  Doubt as to Liability, meaning “I do not believe I owe this amount.”
          When you choose this reason, you must include a detailed explanation of the reason(s) about 
          why you believe you do not owe the tax.  You must submit this on a separate paper and not on 
          the form.  You must also include a corrected calculation of what you believe your tax liability 
          to be.  Please note:  You cannot submit an Offer in Compromise claiming both that you do not 
          believe the liability is correct (Doubt as to Liability) and that you are unable to pay it (Doubt as to 
          Collectability).
F  Economic Hardship, meaning “I owe this amount and have sufficient assets to pay the full amount, but due 
          to my exceptional circumstances, requiring full payment would cause an economic hardship.”
          When you choose this reason, you must also complete ONE of the following forms AND submit 
          a written narrative explaining your exceptional circumstances:
                  •  Form OIC-672, Collection Information State for Business
                  •  Form OIC-673, Collection Information Statement for Wage Earners and Self-Employed 
                  Individuals
          Exceptional Circumstances          (attach additional pages, if necessary):  The Vermont Department 
          of Taxes recognizes there are unplanned events or special circumstances, such as serious illness, 
          where paying the full amount might impair your ability to provide for yourself and your family.  If 
          this is the case, describe your situation below and attach documents that support your claim to 
          your request.  When reviewing your OIC, the Department will consider your claim of exceptional 
          circumstance in relation to your financial profile.
          ______________________________________________________________________________
          ______________________________________________________________________________
          ______________________________________________________________________________
          ______________________________________________________________________________

SECTION 4 Low Income Certification (Individuals and Sole Proprietors Only)
          Do you qualify for Low Income Certification?  You qualify if your adjusted gross income, as 
          determined by your most recently filed Individual Income Tax Return (federal Form 1040) or your 
          household’s gross monthly income from VT Form OIC-673, Box 3 x 12, is equal to or less than the 
          amount shown in the chart below based on your family size and where you live.  If you qualify, you 
          are not required to submit a good faith payment.  If your business is other than a sole proprietor, 
          you cannot qualify for Low Income Certification.  The Department will verify whether you qualify 
          for Low Income Certification.
          After review of the chart below, please check the ONE statement that applies to you.  If you do not 
          select one, a good faith payment of 5% of the current balance will be required.

                                                                                         Form OIC-671
                                             (continued on next page)                                 Page 2 of 7
5454                                                                                                  Rev. 12/21

- 7 -

Taxpayer’s Last Name OR Business Name

Social Security Number OR Federal ID Number                                        *216711300*
                                                                                   *216711300*
                                                                                                             Page 7
SECTION 4    Low Income Certification (Individuals and Sole Proprietors Only) (continued)
     F  I do not qualify for the low income certification.
     F  I qualify for the low income certification because my adjusted gross income for my household’s size 
          is equal to or less than the amount shown in the table below.
     F  I qualify for the low income certification because my household’s size and gross monthly income x 12 
          is equal to or less than the income shown in the table below.

              Low Income Certification (Individuals and Sole Proprietors Only)
                                     Size of  48 Contiguous States, D.C., Alaska   Hawaii
              Family Unit                     and U.S. Territories
                                     1        $31,900                     $39,875  $36,700
                                     2        $43,100                     $53,875  $49,575
                                     3        $54,300                     $67,875  $62,450
                                     4        $65,500                     $81,875  $75,325
                                     5        $76,700                     $95,875  $88,200
                                     6        $87,900                     $109,875 $101,075
                                     7        $99,100                     $123,875 $113,950
                                     8        $110,300                    $137,875 $126,825
              For each additional  
              person, add                     $11,200                     $14,000  $12,875
             Source:  IRS Form 656, Section 1

SECTION 5    Payment Terms

Enter the applicable dollar amounts on Lines 1 through 4.
          1. Total amount due (as shown on the last Statement of Account) .... 1.   $_______________ .____
          2. Amount of my offer*  
             (For Doubt to Liability OIC, enter amount of tax due based on  
             documentation provided; for all other OICs, enter amount from  
             Form OIC-672, Box 7 or Form OIC-673, Box 8) ............... 2.  $_______________ .____
          3. Amount of good faith payment submitted with this  
             OIC Agreement request (Form OIC-671) ..................... 3.  $_______________ .____
          4. Balance to be paid (Line 2 minus Line 3) ..................... 4.  $_______________ .____
     *NOTE:  If amount of offer is less than “Minimum Offer Amount” on Collection Information 
     Statement (Form OIC-672 or OIC-673), provide a detailed explanation on a separate paper.

                                                                                             Form OIC-671
                                              (continued on next page)                       Page 3 of 7
5454                                                                                         Rev. 12/21

- 8 -

Taxpayer’s Last Name OR Business Name

Social Security Number OR Federal ID Number *216711400*
*216711400*
Page 8
SECTION 5 Payment Terms (continued)
Indicate your payment option.
F Payment Option #1 – I will pay the offer in full within 30 days from written acceptance of the offer.
Tell us where you will obtain the funds to pay your offer. You may consider borrowing from
friends and/or family, taking out a loan, or selling assets.
______________________________________________________________________________
______________________________________________________________________________
F Payment Option #2 – I will need more than 30 days from written acceptance of the offer to pay the
amount indicated on Line 4 in full. In selecting this payment option, I also understand my payments
will be made electronically through ACH debit, which I agree to set up following the acceptance of my
agreement.

5. Number of months, generally not to exceed 36 months ...................... 5. _________
6. Amount of payment due each month (Divide Line 4 by Line 5) ... 6. ________________ .____
7. Day of the month payment will be made on ............................... 7. _________

SECTION 6 Offer Terms
By submitting this offer, I/we have read, understand, and agree to the following terms and conditions:
Terms, Conditions, and Legal Agreement
a) I request that the Vermont Department of Taxes (Department) accept the offer amount listed in
this offer application as payment of my outstanding tax debt (including interest, penalties, and any
additional amounts required by law) as of the date listed on this form. I authorize the Department
to amend Section 2 on page 1 in the event I failed to list any of my assessed tax debt.
The Department will keep my deposit, payments, vendor offsets, and refunds
b) I voluntarily submit the good faith payment (entered in Section 5) made on this offer and understand
it is not refundable even if I withdraw the offer or the Department rejects or returns the offer. If the
offer is accepted, I understand the Department will apply the good faith payment to my assessed
tax debt and the Department will apply payments made after acceptance in the best interest of the
government.
c) The Department will keep any federal offset, State of Vermont vendor offset payment or refund,
including interest, that might be due to me until the agreed amount has been paid. The Department
will apply them to reduce the balance and term of the offer. I cannot designate that a refund be
applied to estimated tax payments for the following year. If I receive a refund after I submit this
offer, I will return the refund as soon as possible.
d) The Department will keep any monies it has collected prior to this offer and any payments I
make relating to this offer. The Department may continue collection activities up to the time a
Department official sends a letter acknowledging receipt of my offer. I understand that after an

(continued on next page)
Form OIC-671
Page 4 of 7
5454 Rev. 12/21

- 9 -

  Taxpayer’s Last Name OR Business Name

  Social Security Number OR Federal ID Number                            *216711500*
                                                                         *216711500*
                                                                                                                         Page 9
SECTION 6    Offer Terms (continued)
             offer is determined to be complete and submitted for processing, the Department will not act to 
             collect the tax liability while it considers and evaluates my offer.  However, I also understand the 
             Department will not suspend collection if the Department determines that I submitted my offer to 
             delay collection or cause a delay that will jeopardize the Department’s ability to collect the tax.
Pending status of an offer
          e)  Once an authorized Department official sends a letter acknowledging receipt of my offer, my 
             offer is considered pending as of that letter date.  It remains pending until the Department accepts, 
             rejects,  returns,  or  terminates  my  offer,  or I  withdraw  my  offer.   An offer  will  be  considered 
             withdrawn when the Department receives my written notification of withdrawal or when I inform 
             the Department of my withdrawal by other means, and the Department acknowledges in writing 
             my intent to withdraw the offer.
I must comply with my future tax obligations  and understand I remain liable for the full amount of my tax 
             debt until all terms and conditions of this offer have been met.
          f)  I will file tax returns and pay required taxes until my offer is paid in full.  If this is an offer being 
             submitted for joint tax debt, and one of us does not comply with future obligations, only the 
             non-compliant taxpayer will be in default of this agreement.
          g) The Department will not remove the original amount of my tax debt from its records until I have 
             met all the terms and conditions of this offer.  Penalty and interest will continue to accrue on all 
             tax liabilities until all payment terms of the offer have been met.  If I file for bankruptcy before 
             the terms are fully met, any claim the Department files in the bankruptcy proceedings will be a tax 
             claim.
          h) Once the Department accepts my offer in writing, I have no right to contest, in court or otherwise, 
             the amount of the tax debt.
I understand what will happen if I fail to meet the terms of my offer (e.g., default).
          i) If I fail to meet any of the terms of this offer, this agreement becomes null and void.  The Department 
             may initiate enforced collection activities, including levy or garnishment, to collect any amount 
             ranging from the unpaid balance of the offer to the original amount of the tax debt without further 
             notice of any kind.
I agree to waive time limits provided by law.
          j)  To have my offer considered, I agree to extend the time limit provided by law to assess my tax debt 
             (statutory period of assessment).  I agree the date by which the Department must assess my tax 
             debt will now be the date by which my debt must currently be assessed plus the period of time my 
             offer is pending plus one additional year if the Department rejects, returns, or terminates my offer 
             or I withdraw it.  (Paragraph e of this section defines pending and withdrawal.)  I understand I have 
             the right not to extend or to limit the extension to a certain length or certain periods or issues.  I 
             understand, however, the Department may not consider my offer if I refuse to extend the statutory 
             period of assessment or if I limit the extension.  (32 V.S.A. § 5882 (b)(4))  I also understand the 
             statutory period for collecting my tax debt will be suspended during the time my offer is pending 

                                                                                          Form OIC-671
                                              (continued on next page)                           Page 5 of 7
5454                                                                                             Rev. 12/21

- 10 -

 Taxpayer’s Last Name OR Business Name

 Social Security Number OR Federal ID Number                          *216711600*
                                                                      *216711600*
                                                                                                                        Page 10
SECTION 6   Offer Terms (continued)
            with the Department, for 30 days after any rejection of my offer by the Department, and during 
            the time any rejection of my offer is being considered by the Department.  I also agree to stipulate 
            to a civil judgment to extend the statute of limitations for collections, if needed, to complete an 
            installment payment agreement.
I understand the Department may file a Tax Lien on my property.
          k)  The Department may sue me to obtain a civil judgment or may file a tax lien during the offer 
            investigation and to protect the Government’s interest on offers with deferred payments.  This 
            judgment (if recorded) and tax lien will be released when the payment terms of the offer agreement 
            have been satisfied.
I authorize the Department to contact relevant third parties in order to process my offer.
          l)  By authorizing the Department to contact third parties including credit bureaus, I understand that 
            I will not be notified which third parties the Department contacts as part of the offer application 
            process.
I am submitting an offer as an individual for a joint liability.
     m)  I understand if the liability sought to be compromised is the joint and individual liability of myself 
            and my co-obligor(s) and I am submitting this offer to compromise my individual liability only, 
            then if this offer is accepted, it does not release or discharge my co-obligor(s) from liability.  The 
            Department still reserves all rights of collection against the co-obligor(s).
I authorize the Department to withdraw money from my bank account if I choose a monthly payment 
            option.
          n)  If Payment Option #2 is selected under Section 5 of this application, I will initiate a recurring monthly 
            payment from my bank account to pay this obligation. If necessary, I authorize the Department and 
            its designated financial agent to initiate a monthly ACH electronic funds withdrawal entry to the 
            financial institution account indicated in Section 5 for payments of my state taxes included in this 
            offer and the financial institution to debit the entry to this account.  I also authorize the financial 
            institutions involved in the processing of electronic payments of state taxes to receive confidential 
            tax information necessary to answer inquiries and resolve issues related to those payments.  This 
            authorization is to remain in full force and effect until I notify the Department to terminate the 
            authorization.   Offers paid  using Payment  Option  #2 will  continue  to  accrue  at  the  statutory 
            interest rate.

                                                                                          Form OIC-671
                                             (continued on next page)                     Page 6 of 7
5454                                                                                      Rev. 12/21

- 11 -

 Taxpayer’s Last Name OR Business Name

 Social Security Number OR Federal ID Number                                                                   *216711700*
                                                                                                               *216711700*
                                                                                                                                                                         Page 11

SECTION 7  Mandatory Signatures

I declare under the penalties of perjury, this application is true, correct, and complete to the best of my knowledge.  If prepared by a person other than the taxpayer, 
his/her declaration further provides under 32 V.S.A. §§ 5901-5903 this information has not been and will not be used for any other purpose or made available to any 
other person other than for the preparation of this application unless a separate valid consent form is signed by the taxpayer and retained by the preparer.
                                                                                                                                    May the Dept. of Taxes discuss 
     Signature of Taxpayer (Individual) or Authorized Agent (Business)                Date   Daytime telephone                      this application with the preparer 
                                                                                             number                                 shown?
                                                                                             (               )                      F  Yes           * F  No
     Signature of Spouse or CU Partner (Individual only)                              Date   Email address

           Preparer’s                                                                        Date                                   Check if self-employed   F
           signature
Paid       Preparer’s                                                                        Preparer’s Social 
           printed name                                                                      Security No. or PTIN
Preparer’s Firm’s name (or yours if self-employed) and address
Use Only
           EIN                                           Preparer’s telephone number         Preparer’s email address (optional)
                                                         (                )

SECTION 8  Submission Information
Make the check for your good faith payment payable to                                 Vermont Department of Taxes and attach it to the front 
of your Form OIC-671, Offer in Compromise.  Do not send cash.  Send a separate good faith payment with each 
offer; do not combine it with any other tax payments as this may delay processing of your offer.  Your offer will 
be returned to you if the good faith payment and the required forms are not properly submitted or if your check is 
returned for insufficient funds.

Mail this agreement request and all attachments to:
     Offer in Compromise Program
     Vermont Department of Taxes
     PO Box 429
     Montpelier, VT  05601-0429
*NOTE:  You must submit Form PA-1, Power of Attorney, if you want to authorize someone else to make decisions 
and act on your behalf regarding this offer.

SECTION 9  Acceptance or Denial of Offer in Compromise (completed by the Department after review of request)

Your request has been   ..... F Accepted                                             F Denied

Signature of Authorized Representative                                                                                          Date

                                                                                                                                          Form OIC-671
                                                                                                                                          Page 7 of 7
5454                                                                                                                                                   Rev. 12/21

PDF file checksum: 2248255600

(Plugin #1/9.12/13.0)