Clear form                               Print Form
                                                                 Utah State Tax Commission
                                                210 N 1950 W  •  Salt Lake City, UT 84134  •  www.tax.utah.gov 
                                                                                                                          TC-410
                                                                 Offer Request                                            Rev. 4/11

A. Taxpayer Information
 Taxpayer’s name                         Social security number  Name of personal representative / power of attorney

 Spouse’s name                           Social security number  Address

 Business/corporation name               EIN                     City                                               State ZIP Code

 Physical address                                                Telephone                    Fax

 City                                    State ZIP Code          Email

 Mailing address

 City                                    State ZIP Code

 Taxpayer’s email

B. Offer 
I submit this Offer Request for the tax liabilities of the tax types and periods (plus any interest, penalties, additions to tax, and additional 
amounts) listed below:

      Tax Type                                  Account Number             Filing Period
        Individual income tax                   _________________          ____________________
        Corporate/partnership income tax        _________________          ____________________
        Sales tax                               _________________          ____________________
        Withholding tax                         _________________          ____________________
        Non-payment penalty assessment          _________________          ____________________
        Other state tax: ______________         _________________          ____________________
                           ______________       _________________          ____________________
                           ______________       _________________          ____________________
                           ______________       _________________          ____________________

I offer to pay $ __________
I will get funds to pay this offer from the following source(s): _____________________________________
_________________________________________________________________

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C. Reason for Submitting Offer Request
I submit this Offer Request for the reason(s) listed below:
(Note: If you believe you have special circumstances affecting your ability to fully pay the amount due, explain your situation. Attach 
additional sheets if necessary.)

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D. Signatures
I agree to comply with all the terms and conditions of this Offer Request form.
Under penalty of falsification, I declare that, to the best of my knowledge, all the information in this Request and any attached 
documentation is true and complete.

___________________________________________                __________________ __________________
Taxpayer signature                                         Daytime phone number        Date (mm/dd/yyyy)

___________________________________________                __________________ __________________
Taxpayer signature                                         Daytime phone number        Date (mm/dd/yyyy)

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                                                                                                                               TC-410_i.ai
Offer Request: Information and Document Check List

  Other collection methods have been attempted to resolve this         Currently open and operating businesses submitting an Offer 
liability and were unsuccessful                                        Request for the business (Sole Proprietorship, Corporation, 
                                                                       Partnership, LLC etc) should include:
  Power of Attorney or Personal Representative State Form 
TC-737 for any personal representative                                 Documents
                                                                         Complete copies of the filed federal business income tax returns 
  Signed Offer Request form and/or letter requesting an Offer          for the three (3) filing periods prior to the date of the Offer 
in Compromise Agreement that includes:                                 Request (All tax schedules and worksheets)
  Total amount of the offer payment                                      Utah State Tax Commission Business Financial Statement 
                                                                       (Form TC-803) with justification statements for all income and/or 
  How the payment will be made                                         expenses
  Lump Sum 30 days from the date of the Offer in Compro-                 Copies of the Business Annual Financial Statements (Balance 
  mise Notice of Approval                                              Sheets and Income Statements) for the previous two (2) annual 
    Other payment arrangement (120 days or less) with                  accounting periods 
  explanation                                                            Business Bank Statement(s) from each financial institution used 
  Source of the offer payment                                          for the previous two (2) months prior to the date of the Offer 
                                                                       Request
  All offer requests funded by financing or refinancing real             Loan application(s) and denial(s) submitted in the business 
property have included:                                                name within the previous six (6) months prior to the date of the 
                                                                       Offer Request
  Sales Agreement

  Property Appraisal                                                   Closed Business or Corporation is submitted requesting the 
  Title Report                                                         offer should include:
  Proposed Loan Settlement Statement (HUD 1), if applicable            Documents
  Final Loan Settlement Statement (HUD 1)                                Verification of the closing date of the business
                                                                         Description and disposition of all the business assets
Individual taxpayer and/or Individual taxpayer with a closed             Sales agreement(s) regarding the sale of the business 
business (e.g. Sole Proprietorship, General Partnership, 
Non-Payment Penalty assessed Individual(s))

Documents                                                                       ______________________
  Federal Income tax returns for the three (3) filing periods prior to 
the date of the Offer Request  (Include all W-2’s, tax schedules 
and worksheets)
                                                                       If you need an accommodation under the Americans with 
  Utah State Tax Commission Individual Financial Statement             Disabilities Act, contact the Tax Commission at 801-297-3811 or 
(Form TC-805) with justification statements for all income and/or      TDD 801-297-2020. Please allow three working days for a 
expenses                                                               response.

  Income verification for the previous two (2) months prior to the 
date of the Offer Request (e.g. pay statements, IRS 1099 forms, 
Social Security Benefit Statement SAA-1099s, etc.)
  Bank Statement(s) from each financial institution used for the 
previous two (2) months prior to the date of the Offer Request
  Loan application(s) and denial(s) submitted within the previous 
six (6) months prior to the date of the Offer Request
  Medical documentation for claims of disabilities or medical 
conditions limiting abilities and/or employment (e.g. Annual 
Social Security Disability Statement; Signed statement from a 
Doctor or Medical Clinic verifying your condition(s) etc.)