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. |
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| 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
