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Santa Clarita, CA 91355

Offer in Compromise

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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 interestwithin 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)
Spouse First Name
Spouse Last Name (Optional)
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 
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



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 
 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 
  Total of all judgments against you 
  Back child support  
  Total of credit card balances 
  Total of personal loan balances 
  Total of other liabilites 
  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 


 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!) 


     Mortgage payment or rent   
     Utilities (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