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     Missouri Department of Revenue

     Exceptional  

  Circumstances or  

  Low Income Offer in 

     Compromise 

  This book includes the following:

    Offer in Compromise documentation checklist.  

     Offer in Compromise Application: 

    t  Form MO-656A use for Exceptional Circumstances or if you are   
     considered low income by federal standards. Please see the   
     instructions to see if you qualify for either option.

     Terms and Conditions for the Offer in Compromise.

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Offer in Compromise Checklist

r Form MO-656A, Offer In Compromise (enclosed), is completed to the best of your

knowledge.

r Third Party Affirmation - Power of Attorney, Form 2827 (if applicable)

r Supporting Documentation

r Included a written statement to explain your exceptional circumstance.

r Attached any and all documents to support reasoning.

If applying for the low income:

r Proof of monthly gross earnings, pension, social security, and other income.

This includes: paystubs or earning statements that show all deductions

(including health insurance and taxes) for the past three (3) months.

r Copies of ALL bank statements for all checking and savings accounts

as well as itemized statements for all credit cards for the past three (3) months.

Federal Poverty Level (Annual)
125% of Federal 200% of Federal
Household/
Poverty Level Poverty Level
Family Size
(Annual Income) (Annual Income)
1 15,950 25,520
Circle the income level that
your family falls under. 2 21,550 34,480
3 27,150 43,440
4 32,750 52,400
5 38,350 61,360

The Department may ask for additional records to verify your offer. For example, we may

ask for records supporting your income, expenses, assets, or other debts. You will be given

a reasonable amount of time to comply with the request.

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                                                                                                                                                                             Reset Form                  Print Form

                                                                           Missouri Department of Revenue                                                Department Use OnlyDepartment Use Only
                                                                  Form     Short Form for Exceptional Circumstances                                      (MM/DD/YY)(MM/DD/YY)
MO-656A                                                                    and Low Income Taxpayers

                                                                  Taxpayer                                                                    Social Security
                                                                  Name                                                                        Number
                                                                                                                                              Spouse’s Social 
                                                                  Spouse’s                                                                    Security  
                                                                  Name                                                                        Number

                                                                  Business
                                                                  Name

                                                                  Missouri Tax I.D.                                                           Federal Employer
                                                                  Number                                                                      I.D. Number

                                                                  Provide information for all other persons in the household and claimed as a dependent.  Attach additional pages as needed.  
                                                                                    Name                         Age                          Relationship                   Claimed as a Dependent           Contributes to  
                                                                                                                                                                             on your Form 1040?          Household Income?
                                 Section 1 - Personal Information                                                                                                            r Yes    r No                    r Yes    r No

                                                                                                                                                                             r Yes    r No                    r Yes    r No
                                                                                                                                                                             r Yes    r No                    r Yes    r No
                                                                  Your Current Street Address                    City                                                        State             ZIP Code  County

                                                                  E-Mail Address                                                              Phone Number                                      Secondary Phone Number
                                                                                                                                              (__ __ __)__ __ __-__ __ __ __                    (__ __ __)__ __ __-__ __ __ __
                                                                  Your Mailing Address (If Different From Above)                              City                                                      State ZIP Code 

                                                                  Name of your Tax Representative (CPA, Attorney, Etc.)  Attach POA Form 2827 Phone Number                                     Fax Number
                                                                                                                                              (__ __ __)__ __ __-__ __ __ __                   (__ __ __)__ __ __-__ __ __ __
                                                                  Tax Representative’s Address                                                City                                                      State ZIP Code

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Tax Type Tax Periods

r Personal Income Tax     r Business Tax

I offer to pay $ ____________________ .  (Must be more than zero.) Comments

Select one of the following:

r One-Time Payment in Full

$ ____________________ within 30 days.

r Short-Term Deferred Payment Plan

$ ____________________ on the ___________ day of each month  
starting the first month after written notice of acceptance of the offer 
for a total of __________ months.

Explain why you are requesting an offer in compromise. Include any extraordinary circumstances you think we should know about. Attach a 
written statement and any supporting documents you believe support your claim.

Section 2 - Your Offer Information

Employment
Name of Employer (Taxpayer) Phone Number How Long Employed
 (__ __ __)__ __ __-__ __ __ __ _______ Years    _______ Months
Address City State ZIP Code 

Occupation   Paid     r Weekly   r Every 2 Weeks    r Monthly   r Twice Monthly  
 (e.g., 1st & 15th)
Spouse’s Employment
Name of Employer (Spouse) Phone Number How Long Employed
 (__ __ __)__ __ __-__ __ __ __ _______ Years    _______ Months
Address City State ZIP Code 

Occupation   Paid     r Weekly   r Every 2 Weeks    r Monthly   r Twice Monthly  
 (e.g., 1st & 15th)
Additional Employment
Section 3 - Employment Information Name of Employer  Phone Number How Long Employed
 r Taxpayer  r Spouse (__ __ __)__ __ __-__ __ __ __ _______ Years    _______ Months
Address City State ZIP Code 

Occupation   Paid     r Weekly   r Every 2 Weeks    r Monthly   r Twice Monthly     
 (e.g., 1st & 15th)

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Bank Accounts: Include IRA’s, other retirement plans, certificates of deposit, etc. Attach all pages of the most recent three months bank
statements for all accounts of each person in the household. Attach additional pages as needed. If you owe more than $50,000, six months
bank statements are required.
Provide information for all persons in the household or claimed as a dependent.
Name of Institution Address

Total of all bank accounts with positive balance .....................................................
Personal Property: Include automobiles, boats, ATV’s, motorcycles, recreational vehicles, airplanes, machinery, etc., not used in your
business. Attach additional pages as needed. Be sure to include anything with a value over $1,000.
Year Make Model License Number

Total equity of all personal property ........................................................
Real Property: For each property, include most recent property tax statement. If you rent your home, include rental or lease contract.
Do you rent a home or apartment? r Yes r No If yes, skip the property section below.
Property
Physical Address and Description County Parcel Number
(Single Family Home, Multi-Family Home, Bare Lot, Acreage, etc.)

Mortgage Lender’s Name and Address Current Loan Value Available
Market Value Balance Equity

Name(s) of Owners on Deed Purchase Price Purchase Date (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __
If you have additional property, please list below.
Section 4 - Personal Financial Information

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Monthly Household Disposal Income
Gross Monthly Income Monthly Living Expenses
Source Taxpayer Spouse Source Amount
Salary, Wages, Commissions, Tips House or Rent Payment
Self-Employment Income Groceries
Pensions, Disability & Social Security Medical Expenses & Prescriptions - Out of Pocket
Dividends & Interest Utilities:
Gift or Loan Proceeds Electric  $ ____________ + Gas $ ____________ +
Rental Income Water $ ____________ + Phone  $ ____________ =
Estate, Trust & Royalty Income Insurance:
Workers’ Compensation Life $ ____________ + Health  $ ____________ +
Unemployment Auto $ ____________ + Home  $ ____________ =
Food Stamps/Taniff
Alimony Child Care
Child Support Clothing & Personal Grooming
Seller Carried Contracts Vehicle Loan or Lease Payment 
Sales Installment & Credit Card Payments
Court Ordered Settlement Tuition Payment 
Restitution Personal Loan Payment
Other (Specify) Income Taxes (Federal, State, FICA)
Property Taxes
Estimated Tax (If Applicable)
Legal Fees
Court Ordered Payment
Transportation Expense
Other (Specify)

Section 5 - Personal Income and Expense Analysis Information

Subtotal    
Combined Monthly Income Total Monthly Living Expenses

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1. I will remain in compliance with all tax types for three years after acceptance of the offer.
2. The offer remains pending until an authorized Department official issues notification of acceptance
or rejection, or until the offer is withdrawn by me.
3. I understand that I voluntarily submit any payment made with this offer.
4. If the Department rejects the offer or if the offer is withdrawn, the Department will treat any paid
amount with the offer as payment toward the outstanding tax liability.
5. The Department will retain any payment(s) toward the liability from enforced collections, offsets, or
other payment(s) sent to the Department prior to the submission of this offer.
6. I understand that collection activity may continue if it is determined to be in the state’s best interest,
or if it is otherwise determined that the filing of the offer has not been made in good faith. In addition
the Department may:
a. Immediately issue and record any tax liens necessary to protect the state’s legal interest;
b. Proceed with enforced collection of the total outstanding liability;
c. Apply amounts already paid under the offer to the total liability.
7. I understand that the tax I owe is, and will remain, a tax liability until I meet all the terms and conditions
of the offer. If I file bankruptcy before the terms and conditions of the offer are completed, any claim
Terms and Conditions
the Department filed will be for the full amount, less any payments.
8. Once the Department accepts the offer in writing, I have no right to contest, in court or otherwise, the
amount of the tax liability.
9. I, the taxpayer, shall bear all of my own costs, including attorney fees.
10. If I fail to meet the terms and conditions of an accepted offer, the compromise will be considered null
and void. Updated interest and penalties will be added to the total balance due until paid in full.

I agree to be bound by all the terms and conditions set forth in this offer. Under penalties of perjury, I declare that I have
examined this offer, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true,
correct, and complete. I also declare under penalties or perjury that I employ no illegal or unauthorized aliens as defined under
federal law and that I am not eligible for any tax exemption, credit, or abatement if I employ such aliens.

Taxpayer Signature Date (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
Signature of Taxpayer Spouse or Partner Date (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
On behalf of the Missouri Department of Revenue, I accept the offer to pay for the reasons listed in Section 2.

Signature of Authorized Department Official Title Date (MM/DD/YYYY)
Office Use Only __ __ /__ __ /__ __ __ __

Form MO- 656A (Revised 09-2020)
Mail to: Taxation Division Phone: (573) 751-7200
P.O. Box 1646 Fax: (573) 522-3218 Visit http://dor.mo.gov/
Jefferson City, MO 65105-1646 TTY: (800) 735-2966 for additional information.
E-mail: collectionsliaison@dor.mo.gov

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