Missouri Department of Revenue

  Missouri Business 

      Tax Offer in 

     Compromise 

    Offer in Compromise documentation checklist.  

     Offer in Compromise Application: 

    t  Form MO-656B for Missouri Business Tax.

      w If you owe Individual Income Tax and Business Tax, this form  
      should be used to submit an offer on your entire balance.

     w Must complete all sections on this form.

    Please refer to the instructions for qualifications.

     Terms and Conditions for the Offer in Compromise.

        *20000000001*
        20000000001

   Offer in Compromise Checklist

r Form MO-656B (enclosed)

r Power of Attorney, Form 2827 (if applicable)

r Three Months of Supporting Documentation

  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 Profit and Loss statements of the business 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. (If the debt is over $50,000.00,  
    will need past six (6) months for all checking and savings 
    accounts and itemized statements for all credit cards.)

  r A list of all accounts receivable, showing the payer, amount  
    due, age, and status of each business account.

r Complete  all  sections  of  Form  MO-656B  to  the  best  of  your  
  knowledge.

The Department may ask for additional records to verify your offer. 
For  example, we may  ask for  records documenting your income, 
expenses, assets, or other debts. You will be given a reasonable 
amount of time to comply with the request.

                 *20000000001*
                         20000000001
                         2

                                                                                                                                                         Department Use Only
                                                                           Missouri Department of Revenue
                                                                                                                                                         (MM/DD/YY)
                                                                  Form     Offer in Compromise Application 
MO-656B                                                                    for Individual and Business Tax

                                                                  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

                                                                  Charter
                                                                  Number

                                                                  If additional businesses, please list below.

                                                                  Taxpayer Date of Birth(MM/DD/YYYY)  Spouse’s Date of Birth(MM/DD/YYYY)                Marital Status
                                                                  ___ ___ / ___ ___ / ___ ___ ___ ___ ___ ___ / ___ ___ / ___ ___ ___ ___                r Married    r Unmarried (Single, Divorced, or Widowed)
                                 Section 1 - Personal Information Other Names or Aliases Used                                       Spouses Other Names or Aliases Used

                                                                  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?
                                                                                                                                                                        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

                                                                                                                 *20709010001*
                                                                                                                                    20709010001
                                                                                                                                    3

Include an explaination of why you are requesting an offer in compromise.

r “I do not have the means to pay the entire debt  r “I will suffer severe economic hardship if the    
 (Doubt as to Collectability).” entire debt is collected.”

Tax Type Tax Periods

r Personal Income Tax     r Business Tax
Section 2 - Payment Information
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.

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)

*20709020001*
20709020001
4

If you select “yes”, provide dates, and an explanation. Attach additional pages as needed.

Are you a party to any court proceedings? (litigation, probate, etc.) ......... . . r No r Yes  _____________________________________
Do you anticipate a change in your income?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . r No r Yes  _____________________________________
Are you a party to any bankruptcies or receiverships? ................... . . r No r Yes  _____________________________________
Are you a beneficiary to a trust, estate, profit sharing, etc?  ............... . . r No r Yes  _____________________________________
Do you owe taxes to the IRS? How much is your debt? .................. . . r No r Yes  _____________________________________
Do you owe taxes to other states, counties, districts, agencies, etc? ........ . . r No r Yes  _____________________________________
Do you owe other debt? Explain.  ................................... . . r No r Yes  _____________________________________
Have you made any major purchases over $2,000 in the last 12 months? .... . . r No r Yes  _____________________________________

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 Type Date Opened Account Number Balance

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.
Section 4 - Personal Financial Information
Available Equity
Year Make Model License Number Lender or Lienholder Current Market Value Current Payoff (cannot be less than 0)

Total equity of all personal property  ........................................................
Personal credit cards and unsecured lines of credit.
Type Name of Creditor Record Owner Balance Owed Available Credit

Total unsecured credit balance amount  .......................................................

*20709030001*
20709030001
5

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
Net Monthly Household Disposable Income (“Combined Monthly Income” minus “Total Monthly Living Expenses”)

*20709040001*
20709040001
6

Business Name Missouri Tax Identification Number Average Gross Monthly Income Total Employees

Business Address Business Telephone Number Business Website
 (__ __ __)__ __ __–__ __ __ __
City State  ZIP Do you or your spouse have any other business interests? 
Type of Business (Select One)  r Yes r No
r Sole Ownership     r Partnership      r LLC     r Corporation   r Other If Yes, complete additional attachment for each 
business interest. 
Description of Business

 List all owners or responsible parties of the business.

Section 6 - Business Information

An offer will not be approved unless the Department has received a separate OIC form for all owners or responsible parties of the business or 
an explanation of why it can’t be obtained.
Bank Accounts: Include certificates of deposit, etc. Attach all pages of the most recent three months bank statements for all accounts. 
Attach additional pages as needed. If you owe more than $50,000, six months bank statements are required
Name of Institution Address Type Date Opened Account Number Balance

Total of all bank accounts with positive balance .....................................................
Business Property: Include automobiles, boats, ATV’s, recreational vehicles, airplanes, machinery, etc., used in your business. Attach addi-
tional pages as needed.
Available Equity
Year Make Model License Number Lender or Lienholder Current Market Value Current Payoff (cannot be less than 0)

Total equity of all personal property  ........................................................

Section 7 - Business Financial Information List of equipment used for business and current value. Attach additional pages as needed.
Type Location Record Owner Quantity or  Current Value
Denomination

Total value of all equipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

*20709050001*
20709050001
7

Other Valuable Items: Include cash, accounts receivable, and any other valuable items. Attach additional pages as needed. 
Type Location Record Owner Quantity or  Current Value
Denomination

Total value of all valuable items  .............................................................
Property 1
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)
__ __ /__ __ /__ __ __ __
Property 2
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)

__ __ /__ __ /__ __ __ __
Business credit cards and unsecured lines of credit.
Type Name of Creditor Record Owner Balance Owed Available Credit

Section 7 - Business Financial Information Continued

Total unsecured credit balance amount  .......................................................

If you select “yes”, provide dates, and an explanation. Attach additional pages as needed.

Are you a party to any court proceedings? (litigation, probate, etc.) ......... . . r No r Yes  _____________________________________

Do you anticipate a change in your income?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . r No r Yes  _____________________________________
Are you a party to any bankruptcies or receiverships? ................... . . r No r Yes  _____________________________________
Are you a beneficiary to a trust, estate, profit sharing, etc?  ............... . . r No r Yes  _____________________________________
Do you owe taxes to the IRS? How much is your debt? .................. . . r No r Yes  _____________________________________
Do you owe taxes to other states, counties, districts, agencies, etc? ........ . . r No r Yes  _____________________________________
Do you owe other debt? Explain.  ................................... . . r No r Yes  _____________________________________
Have you made any major purchases over $2,000 in the last 12 months? .... . . r No r Yes  _____________________________________

*20709060001*
20709060001
8

Total Monthly Business Revenue Total Monthly Business Expenses
Source Gross Monthly Source Amount
Gross Receipts from Sales and Services Materials Purchased
Gross Rental Income Inventory Purchased
Interest Income Gross Wages and Salaries
Dividends Rent
Cash Supplies
Other Income (Specify below) Utilities and Telephone
Vehicle Gasoline and Oil
Repairs and Maintenance
Insurance
Current Taxes
Other Expenses (Specify)
Section 8 - Business Income and Expense Analysis
Total Income     Total Expenses

*20709070001*
20709070001
9

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

                                                                                                      *20709080001*
                                                                                                                         20709080001
                                                                                                                           10