Dick Norton, EA, FATP - Offer in Compromise Questionnaire

Dick Norton Enrolled Agent

Offer in Compromise

Potential Qualification Questionnaire

An Offer in Compromise is a process available to taxpayers with significant tax liabilities that provide an opportunity to "settle" their liabilities for less than the full amount. Basically, you must be in a financial position wherein you would be unable to fully pay your liabilities (including accruing penalties and interest) within the statutory period of collection (roughtly 10 years from return filing for the IRS) through the sale of all your assets and by making monthly payments.

If you are contemplating filing an Offer in Compromise based on Doubt as to Collectability (hereinafter referred to as an "OIC") and wish me to evaluate your potential eligibility, please complete the form below as accurately as possible. If you see a next to a question, you can click on that symbol to "pop-up" a window for additional information on that question. Then click on the BACK button of that window to return to the questionnaire. The questions on income and expenses refer to average MONTHLY totals.

This is important. If you are paid weekly, multiply the weekly GROSS WAGES and the DEDUCTIONS by 4.3 to get an average per month. The same is true for any expenses paid on a weekly basis. If you are paid or you pay expenses bi-weekly (every two weeks), then multiply those bi-weekly amounts by 2.16 to get a monthly average. Unless you are frequently paid overtime, use your base wages and withholding information.

If you pay an expense (such as auto or property insurance) annually, divide that amount by 12 to arrive at a monthly total. Property taxes are usually paid twice a year. Divide one of the payments by 6 to arrive at a monthly total. Out of pocket medical expenses vary from month to month. Take a sample of no fewer that three (3) months to arrive at a monthly average. The IRS has a "standard" of allowing taxpayers under 65 an an amount of $60 per month. If 65 or older, then the standard is $120 per month. If you feel the standard is appropriate for you (and the members of your household), then you can use the standard for each taxpayers and dependent.

Please answer all questions - otherwise, I will not be able to accurately assess your potential qualification for an OIC. Please - ensure your E-mail address is accurate or I will be unable to contact you. Unfortunately, I have received questionnaires WITHOUT a valid E-mail address! Please - make sure you include this information so I can get back to you. If you submit this form and do not hear back within 24 hours, then something likely is wrong with your contact information! Call me (818-842-5927).

Print out the completed questionnaire and then either fax it to: (818-845-6031), scan/e-mail it to me, or mail it to: Richard E. Norton, EA, Tax Resolution Specialist, 513 North Florence Street, Burbank, CA 91505.

Your First Name		Last Name (Optional)	Age
Spouse First Name		Spouse Last Name (Optional)	Age
City		State / Country	County (in U.S.) Zip
Day Phone	Evening Phone	Cell Phone	Fax Number
E-mail address (required for my response to you)
Number of dependents who qualify as an exemption on your tax return. Do NOT include you or your spouse.

.

Your current occupation

Your current employer

If married, spouse's current occupation

Spouse's current employer

IRS LIABILITY

Total amount you owe per the most recent IRS notice(s)

For which tax years or periods?

Type of tax (1040, 941, Trust Fund, etc)?

Have you ever defaulted on a prior IRS OIC?
Yes    No

STATE LIABILITY

For which State (or States) do you owe?

Total amount you owe per most recent State notice(s)

For which tax years or periods?

Type of tax (income/employment)?

Have you ever defaulted on a prior State OIC?
Yes    No

Any prior levies/seizures/Withholding Orders on assets? Yes    No

     If YES, when and by which agency (IRS/STATE)

Are your wages now being levied by IRS and/or STATE? Yes    No       Agency:

Are you disputing the AMOUNT you owe? Yes    No

Do you believe you can't pay what you owe in full? Yes    No

Have you met with an IRS or STATE employee yet? Yes    No

    If YES, indicate IRS, STATE or BOTH.

When was your last contact with the IRS?

What was discussed?

When was your last contact with the STATE?

What was discussed?

Have you filed all required IRS returns? Yes    No    Years Unfiled:

If you are SELF EMPLOYED, have you made estimated tax payments during this current year? Yes    No    N/A

Have you filed all required STATE tax returns? Yes    No Years Not Filed:

If you are SELF EMPLOYED, have you made estimated tax payments during this current year? Yes    No    N/A

GENERAL FINANCIAL INFORMATION

ASSETS-LIQUID

Total for all bank accounts (checking/savings)

Total for all investments (stocks, bonds, mutual funds)


Total for IRA, 401(K), KEOGH, other retirement plans

. ASSETS-OTHER

Personal Residence (Fair market value)


Less: amount of secured loan(s) on your residence


Total fair market value of all other rental and vacation property


Less: total of secured loans on rental and vacation properties


Total fair market value of all cars you own


Less: total of loans against all cars

Total fair market value boats, RVs and planes

   Less: total of loans against above

Total fair market value of other personal property

LIABILITIES

  Total of all judgments against you

  Back child support

  Total of credit card balances

  Total of personal loan balances

  Total of other liabilites

MONTHLY INCOME/EXPENSES

TAXPAYER'S gross monthly wages

     Less: withholding    (FICA/Federal Income taxes/Medicare/State taxes)


SPOUSE'S gross monthly wages

     Less: SPOUSE'S withholding    (FICA/Federal Income taxes/Medicare/State taxes)


TAXPAYER'S Net Monthly Self-employment earnings
Gross average monthly receipts MINUS business expenses

SPOUSE'S Net Monthly Self-employment earnings
Gross average monthly receipts MINUS business expenses

OTHER SOURCES OF AVERAGE MONTHLY INCOME

Interest Income

Dividend Income

Net Rental Income Gross average monthly rents MINUS rental expenses

Alimony Income

Child Support Income

Disability Income

Unemployment Income

Retirement Income (Social Security/Pensions)

Other Income (explain sources in an E-mail to me!)

MONTHLY EXPENSES

     Mortgage payment or rent

     Utilities (electricity)

                    (gas)

                    (water)

                    (electricity)

     Association Dues

     Property taxes (1/12 of annual amt)

     Property/homeowner's/renter insurance

     Auto loan payments

     Auto lease payments

     Auto gas expense

     Auto insurance expense (annual premium divided by 12)

     Food (eating at home & restaurants)

     Clothing purchases and laundry/maintenance

     Entertainment (cable TV, movies, Internet)

     Health care (monthly avg medical insurance premiums)

     Health care (monthly avg co-pay and out-of-pocket exp.)

     Child care expenses

     Court-ordered alimony

     Court-ordered child support

     Other court-ordered expenses (Explain in an E-mail)

     Credit card payments ( minimum required amount only)

     List other monthly expenses









Comments regarding your monthly income or expenses

Your offer to the IRS must be more than the IRS can get through seizure and quick-sale of your assets, in addition to payments you could make over a period of months spanning the statute of limitations (usually 10 years from filing your returns). Offers to certain STATES are different.

What will be the source and the proposed amount of your offer? Include sources that the IRS and/or STATE could not get through collection efforts such as loans from your family or friends.

.

Have you ever filed bankruptcy? Yes    No

   If YES, in what month and year were you discharged?

Are you able to pay an estimated retainer of $1,350 ($1,800 for both IRS and a STATE offer) to start the process?

NOTE: The amount of your retainer depends upon the complexity of your personal finances. The estimates above are the minimum retainer amounts for wage earners and small service-oriented businesses.
Yes    No

End of Questionnaire

Updated 5/24/21

Your current occupation
Your current employer
If married, spouse's current occupation
Spouse's current employer

IRS LIABILITY
Total amount you owe per the most recent IRS notice(s)
For which tax years or periods?
Type of tax (1040, 941, Trust Fund, etc)?
Have you ever defaulted on a prior IRS OIC?	Yes No


STATE LIABILITY
For which State (or States) do you owe?
Total amount you owe per most recent State notice(s)
For which tax years or periods?
Type of tax (income/employment)?
Have you ever defaulted on a prior State OIC?	Yes No

Any prior levies/seizures/Withholding Orders on assets?	Yes No
If YES, when and by which agency (IRS/STATE)
Are your wages now being levied by IRS and/or STATE?	Yes No Agency:
Are you disputing the AMOUNT you owe?	Yes No
Do you believe you can't pay what you owe in full?	Yes No

Have you met with an IRS or STATE employee yet?	Yes No
If YES, indicate IRS, STATE or BOTH.
When was your last contact with the IRS?
What was discussed?
When was your last contact with the STATE?
What was discussed?
*Have you filed all required IRS* returns?**	Yes No Years Unfiled:
If you are SELF EMPLOYED, have you made estimated tax payments during this current year?	Yes No N/A

*Have you filed all required STATE* tax returns?**	Yes No Years Not Filed:
If you are SELF EMPLOYED, have you made estimated tax payments during this current year?	Yes No N/A

GENERAL FINANCIAL INFORMATION
ASSETS-LIQUID
Total for all bank accounts (checking/savings)
Total for all investments (stocks, bonds, mutual funds)
Total for IRA, 401(K), KEOGH, other retirement plans

Personal Residence (Fair market value)
Less: amount of secured loan(s) on your residence
Total fair market value of all other rental and vacation property
*Less: total of secured loans* on rental and vacation properties**
Total fair market value of all cars you own
Less: total of loans against all cars
Total fair market value boats, RVs and planes
Less: total of loans against above
Total fair market value of other personal property
LIABILITIES
Total of all judgments against you
Back child support
Total of credit card balances
Total of personal loan balances
Total of other liabilites

MONTHLY INCOME/EXPENSES
TAXPAYER'S gross monthly wages
Less: withholding (FICA/Federal Income taxes/Medicare/State taxes)

SPOUSE'S gross monthly wages
Less: SPOUSE'S withholding (FICA/Federal Income taxes/Medicare/State taxes)
TAXPAYER'S Net Monthly Self-employment earnings	Gross average monthly receipts MINUS business expenses

SPOUSE'S Net Monthly Self-employment earnings	Gross average monthly receipts MINUS business expenses

OTHER SOURCES OF AVERAGE MONTHLY INCOME
Interest Income
Dividend Income
Net Rental Income	Gross average monthly rents MINUS rental expenses
Alimony Income
Child Support Income
Disability Income
Unemployment Income
Retirement Income (Social Security/Pensions)
*Other Income (explain sources in an E-mail to me!)*
MONTHLY EXPENSES
Mortgage payment or rent
Utilities (electricity)
(gas)
(water)
(electricity)
Association Dues
Property taxes (1/12 of annual amt)
Property/homeowner's/renter insurance
Auto loan payments
Auto lease payments
Auto gas expense
*Auto insurance expense (annual premium divided by 12)*
Food (eating at home & restaurants)
Clothing purchases and laundry/maintenance
Entertainment (cable TV, movies, Internet)

*Health care (monthly avg medical insurance premiums)*
*Health care (monthly avg co-pay and out-of-pocket exp.)*
Child care expenses
Court-ordered alimony
Court-ordered child support
*Other court-ordered expenses (Explain in an E-mail)*
Credit card payments ( minimum required amount only)
List other monthly expenses




Comments regarding your monthly income or expenses
Your offer to the IRS must be more than the IRS can get through seizure and quick-sale of your assets, in addition to payments you could make over a period of months spanning the statute of limitations (usually 10 years from filing your returns). Offers to certain STATES are different. What will be the source and the proposed amount of your offer? Include sources that the IRS and/or STATE could not get through collection efforts such as loans from your family or friends.