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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 to dick@dicknorton.com, 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

 

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Updated 7/1/14