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Missouri Department of Revenue
Missouri Individual
Income Tax Offer in
Compromise
Offer in Compromise documentation checklist.
Offer in Compromise Application:
t Form MO-656 use for Missouri Individual Income Tax
w Doubt as to Collectability
w Severe Economic Hardship
Please refer to the instructions for qualifications.
Terms and Conditions for the Offer in Compromise.
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Offer in Compromise Checklist
r Form MO-656, Offer In Compromise (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 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.
r Complete all parts of Form MO-656 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.
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| Reset Form Print Form Department Use Only Missouri Department of Revenue (MM/DD/YY) Form Offer in Compromise Application MO-656 for Individual Income Tax Taxpayer Social Security Name Number Spouse’s Social Spouse’s Security Name Number 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) Other Names or Aliases Used Spouse’s Other Names or Aliases Used Provide information for all other persons in the household and claimed as a dependent. Attach additional pages as needed. (This information is optional if offer is based on doubt as to liability or exceptional circumstances). Name Age Relationship Claimed as a Dependent Contributes to on your Form 1040? Household Income? r Yes r No r Yes r No Section 1 - Personal Information 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 Tax Type Tax Periods r Personal Income 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 Section 2 - Your Offer Information $ ____________________ on the ___________ day of each month starting the first month after written notice of acceptance of the offer for a total of __________ months. *17400010001* 17400010001 3 |
| 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 - Continued 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.” 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) Section 3 - Income Information Additional Employment 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) If you select “yes”, provide dates, 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 _____________________________________ Section 4 - Financial Information 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 _____________________________________ *17400020001* 17400020001 4 |
| 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) __ __ /__ __ /__ __ __ __ 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 ..................................................... Section 4 - Financial Information Continued 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. 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 ....................................................... *17400030001* 17400030001 5 |
| Life Insurance: Attach additional pages as needed. Name of Agent’s Name and Policy Number Type Face Amount Loan or Cash Insurance Company Telephone Number Surrender Value Total value of all life insurance policies ........................................................ Securities: Include stocks, bonds, mutual funds, money market funds, 401(k), etc. Attach additional pages as needed. Type Location Record Owner Quantity or Current Value Denomination Section 4 - Continued Total value of all securities ................................................................. 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 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 Section 5 - Personal Income and Expense Analysis Information Court Ordered Payment Transportation Expense Other (Specify) Subtotal Combined Monthly Income Total Monthly Living Expenses Net Monthly Household Disposable Income (“Combined Monthly Income” minus “Total Monthly Living Expenses”) *17400040001* 17400040001 6 |
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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 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
Terms, Conditions & Signature
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-656 (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
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