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Offer in Compromise Questionnaire

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 Offer Questionnaire 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 MONTHLY totals.

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.

If you pay an expense (such as auto 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.

You will have an option to SUBMIT your completed questionnaire over the Internet (NOTE: this server is NOT secure, but in our experience, the likelihood of anyone intercepting your questionnaire is very unlikely). Your responses are converted to an E-mail and transmitted to me in that format. In that regard, it is (in my opinion) as secure as any E-mail you would send to someone or some company.

If you are going to SUBMIT your questionnaire over the Internet, please print it out BEFORE you click the SUBMIT button so you have a copy of your responses. As a security measure, you will be submitting ONLY your first name (and your spouse's first name, and your city, state and zip (no street address!)). Submission of your last name is optional.

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 and telephone numbers are accurate or I will be unable to contact you. Unfortunately, I have received several questionnaires WITHOUT a valid E-mail address and telephone numbers! Please - make sure you include this information. If you submit this form and do not hear back within 24 hours, then something likely is wrong! Call me (818-842-5927).

If you are concerned about submitting this information over the Internet, do NOT click on the SUBMIT button. Instead, print the completed questionnaire and then either fax it to: (818-845-6031) 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
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 last 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 last State notice

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 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? 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:

Are you current in this year's IRS estimated tax payments (if self-employed) ? Yes    No    N/A

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

Are you current in this year's STATE estimated tax payments or withholding credits? Yes    No    N/A

GENERAL FINANCIAL INFORMATION

ASSETS-LIQUID

Bank accounts (checking/savings)

Investments (stock, bonds, mutual funds)


IRA, 401(K), KEOGH, other retirement plan

. 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

HUSBAND gross monthly wages

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


SPOUSE gross monthly wages

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


HUSBAND Net Self-employment earnings

    Less: Monthly average estimated taxes paid this year

SPOUSE Net Self-employment earnings

    Less: Monthly average estimated taxes paid this year

OTHER SOURCES OF INCOME

Interest Income

Dividend Income

Net Rental Income

Alimony Income

Child Support Income

Disability Income

Unemployment Income

Retirement Income

Other Income (explain 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

     Food (eating at home & restaurants)

     Clothing purchases and laundry/maintenance

     Entertainment (cable TV, movies)

     Health care (medical insurance premiums you pay)

     Health care (your 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

     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 $1,000 ($1,500 for both IRS and STATE offers) 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 8/1/2010

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

IRS LIABILITY
Total amount you owe per last 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 last State notice
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 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?	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:
*Are you current in this year's* IRS estimated tax payments (if self-employed) ?**	Yes No N/A

*Have you filed all required STATE* returns?**	Yes No Years Not Filed:
*Are you current in this year's* STATE estimated tax payments or withholding credits?**	Yes No N/A

GENERAL FINANCIAL INFORMATION
ASSETS-LIQUID
Bank accounts (checking/savings)
Investments (stock, bonds, mutual funds)
IRA, 401(K), KEOGH, other retirement plan

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
HUSBAND gross monthly wages
Less: husband's withholding (FICA/Federal Income taxes/Medicare/State taxes)

SPOUSE gross monthly wages
Less: SPOUSE'S withholding (FICA/Federal Income taxes/Medicare/State taxes)
HUSBAND Net Self-employment earnings
Less: Monthly average estimated taxes paid this year
SPOUSE Net Self-employment earnings
Less: Monthly average estimated taxes paid this year
OTHER SOURCES OF INCOME
Interest Income
Dividend Income
Net Rental Income
Alimony Income
Child Support Income
Disability Income
Unemployment Income
Retirement Income
*Other Income (explain 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
Food (eating at home & restaurants)
Clothing purchases and laundry/maintenance
Entertainment (cable TV, movies)

Health care (medical insurance premiums you pay)
Health care (your 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
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.