The attached Form 656 is not a stand-alone form and is intended for tax professional use only. Individuals 

requesting consideration of an offer must use Form 656‐B, Offer in Compromise, which may be found under 

the Forms and Pubs tab on www.irs.gov. Completed financial statements and required application fee and 

initial payment must be included with your Form 656. Failure to include the required information will delay 

consideration of your offer.

WARNING!!!
Catalog Number 16728N www.irs.gov Form 656 (Rev. 4-2024) 

Form 656 

(April 2024) Offer in Compromise 

Department of the Treasury — Internal Revenue Service 

To: Commissioner of Internal Revenue Service 

In the following agreement, the pronoun "we" may be assumed in place of "I" when there are joint liabilities and both 

parties are signing this agreement. 

I submit this offer to compromise the tax liabilities plus any interest, penalties, additions to tax, and additional amounts 

required by law for the tax type and period(s) marked in Section 1 or Section 2 below.

IRS Received Date 

(COIC use only)

Did you use the Pre-Qualifier tool prior to filling out this form? Locate the tool on our website at IRS.gov/OICtool 

or by scanning the QR code on your smart device.

Yes No

Note: The use of the Pre-Qualifier tool is not mandatory before sending in your offer. However, it is recommended.

Attention: You must submit separate offers if either spouse has separate tax liabilities.

Include the $205 fee and initial payment with your Form 656 unless you qualify for the Low-Income Certification. Fill out 

either Section 1 or Section 2, but not both.

If you are a 1040, U.S. Individual Income Tax Return, filer, an individual with personal liability for Excise tax, individual responsible for Trust Fund 

Recovery Penalty, self-employed individual, or individual personally responsible for partnership liabilities, you should fill out Section 1.

Section 1 Individual Information (Form 1040 filers)

Your first name, middle initial, last name Social Security Number (SSN), Individual Taxpayer or Identification 

Number (ITIN) (if applicable)

- -

If a joint offer, spouse's first name, middle initial, last name Social Security Number (SSN), Individual Taxpayer or Identification 

Number (ITIN) (if applicable)

- -

Your home physical address (street, city, state, ZIP code, county of residence)

Your home mailing address (if different from above or post office box number) 

Is this a new address since your last filed tax return Yes No

If yes, would you like us to update our records to this address Yes No

Your Employer Identification Number (if applicable)

-

Individual Tax Periods (For Individual or Sole-Proprietor Tax Debt Only) List all years/periods owed

Form 1040 U.S. Individual Income Tax Return [e.g., 12-31-2018]

Trust Fund Recovery Penalty as a responsible person of (enter business name) 

for failure to pay withholding and Federal Insurance Contributions Act taxes (Social Security taxes), for period(s) ending [e.g., 03-31-2019]

Form 941 Employer's Quarterly Federal Tax Return - Quarterly period(s) 

Form 940 Employer's Annual Federal Unemployment (FUTA) Tax Return - Year(s) [e.g., 12-31-2018]

Other Federal Tax(es) [specify type(s) and period(s)] 

Note: If you need more space, use attachment and title it “Attachment to Form 656 dated .” Make sure to sign and date the 

attachment. 

Warning: The IRS will not compromise any amounts of restitution assessed by the IRS. Any liability arising from restitution is excluded from this offer. 

Also, the IRS will not compromise any liability for which an election under IRC § 965(i) is made; such liabilities are excluded from this offer. Any offer 

containing a liability for which payment is being deferred under IRC § 965(h)(1) can only be processed for investigation if an acceleration of payment 

under section 965(h)(3) and the regulations thereunder has occurred and no portion of the liability to be compromised resulted from entering into a 

transfer agreement under section 965(h)(3).
Catalog Number 16728N www.irs.gov Form 656 (Rev. 4-2024) 

Page 2 

Low-Income Certification (Individuals and Sole Proprietors Only) 

Do you qualify for Low-Income Certification? You qualify if your adjusted gross income, as determined by your most recently filed Individual Income Tax 

return (Form 1040) or your household’s gross monthly income from Form 433-A(OIC) x 12, is equal to or less than the amount shown in the chart below 

based on your family size and where you live. If you qualify, you are not required to submit any payments or the application fee upon submission or 

during the consideration of your offer. If your business is other than a sole proprietor or the offer is being filed for a deceased individual, you do not 

qualify for Low-Income Certification. The IRS will verify whether you qualify for Low-Income Certification.

Note: By checking one of the boxes below you are certifying that your adjusted gross income or your household’s gross monthly income x 12 

and size of your family qualify you for the Low-Income Certification.

I qualify for the Low-Income Certification because my adjusted gross income for my household's size is equal to or less than the amount shown in 

the table below.

I qualify for the Low-Income Certification because my household's size and gross monthly income x 12 is equal to or less than the income shown in 

the table below.

Size of family unit 48 contiguous states, D.C., and U.S. Territories Alaska Hawaii

1 $36,450 $45,525 $41,925

2 $49,300 $61,600 $56,700

3 $62,150 $77,675 $71,475

4 $75,000 $93,750 $86,250

5 $87,850 $109,825 $101,025

6 $100,700 $125,900 $115,800

7 $113,550 $141,975 $130,575

8 $126,400 $158,050 $145,350

For each additional person, add $12,850 $16,075 $14,775

Business Information (Form 1120, 1065, etc., filers)

Business Tax Periods (If Your Offer is for Business Tax Debt Only) List all years/periods owed

Form 1120 U.S. Corporate Income Tax Return - [e.g., 12-31-2019]

Form 941 Employer's Quarterly Federal Tax Return - [e.g., 03-31-2019]

Form 940 Employer's Annual Federal Unemployment (FUTA) Tax Return - [e.g., 12-31-2018]

Other Federal Tax(es) [specify type(s) and period(s)] 

Note: If you need more space, use attachment and title it “Attachment to Form 656 dated .” Make sure to sign and date the 

attachment. 

Section 2

If your business is a Corporation, Partnership, LLC, or LLP and you want to compromise those tax debts, you must complete this section. You must also 

include all required documentation including the Form 433-B (OIC), a $205 application fee, and initial payment.

Business name

Business physical address (street, city, state, ZIP code) 

Business mailing address (street, city, state, ZIP code)

Employer Identification Number 

(EIN)

-

Name and title of primary contact Telephone number

( ) -

IF YOU QUALIFY FOR THE LOW-INCOME CERTIFICATION DO NOT INCLUDE ANY PAYMENTS WITH YOUR OFFER. Generally these payments 

will not be returned and will be applied to the tax liability in the best interest of the government.
Catalog Number 16728N www.irs.gov Form 656 (Rev. 4-2024) 

Section 3 Reason for Offer

Select only ONE of the three check boxes below. 

Doubt as to Collectibility - I do not have enough in assets and income to pay my full tax liability. I have offered the minimum offer amount 

calculated on Form 433-A(OIC) and/or Form 433-B(OIC).

Note: If you have special circumstances which would prevent you from paying the minimum offer amount calculated on Form 433-A (OIC) due to 

economic hardship attach a detailed explanation.

Effective Tax Administration - Economic Hardship - I have enough in assets and income to pay my full tax liability but due to my special 

circumstances, requiring full payment would cause an economic hardship. I owe this tax liability. (Only individuals qualify for this consideration). 

Attach a detailed explanation.

Effective Tax Administration - Public Policy or Equity - I have enough in assets and income to pay my full tax liability but collection of the full 

liability could be viewed as inequitable. I owe this tax liability. The amount I am offering is based on my exceptional circumstances, not economic 

hardship. Example: A payroll service provider misappropriated taxes withheld from my employees. Attach a detailed explanation.

Section 4 Payment Terms 

Check only one of the payment options below to indicate how long it will take you to pay your offer in full. You must 

offer more than $0. The offer amount should be in whole dollars only.

Lump Sum

Check here if you will pay your offer in 5 or fewer payments within 5 or fewer months from the date of acceptance: 

Enclose a check for 20% of the offer amount (waived if you met the requirements for Low-Income Certification) and fill in the amount(s) of your 

future payment(s). 

Total offer amount - 20% initial payment = Remaining balance 

$ - $ = $ 

You may pay the remaining balance in one payment after acceptance of the offer or up to five payments, but cannot exceed 5 

months. 

Amount of payment $ payable within Month after acceptance

Amount of payment $ payable within Months after acceptance

Amount of payment $ payable within Months after acceptance

Amount of payment $ payable within Months after acceptance

Amount of payment $ payable within Months after acceptance

You must continue to make these monthly payments while the IRS is considering the offer (waived if you met the requirements for LowIncome Certification). Failure to make regular monthly payments until you have received a final decision letter will cause your offer to be 

returned with no appeal rights. If you qualified under the Low-Income Certification and are not required to submit payments while the 

offer is under consideration, your first payment will be due 30 calendar days after acceptance of the offer, unless another date is agreed 

to in an amended offer. 

Periodic Payment 

Check here if you will pay your offer in full in 6 to 24 months

Enter the amount of your offer $ 

Note: The total months may not exceed a total of 24. For example, if you are requesting your payments extend for 24 months then your 

first payment is considered to be month 1 and your last payment is considered month 24. There will be 22 payments between the first 

and last month. 

Enclose a check for the first month's payment (waived if you met the requirements for Low-Income Certification).

The first monthly payment of $ is included with this offer then $ will be paid on the (pick number 1-28)

day of each month thereafter for months with a final payment of $ to be paid on the day of the

 month.

Page 3 
Catalog Number 16728N www.irs.gov Form 656 (Rev. 4-2024) 

Page 4 

Section 5 Designation of Payment and Electronic Federal Tax Payment System (EFTPS)

Designation of Payment

If you want your payment to be applied to a specific tax year and a specific tax debt, such as employment taxes or a Trust Fund Recovery Penalty, 

tell us the tax period/quarter . If you are not specific with your designation we will apply any money you send to the government's 

best interest. If you want to designate any future payments not included with this Form 656 while the offer is pending [see section 7(j) below] with 

the IRS, you must include the specific tax year and type of tax at the time each payment is made. However, you cannot designate the application 

fee or any payment after the IRS accepts the offer.

Note: Payments submitted with your offer cannot be designated as estimated tax payments for a current or past tax year. 

Electronic Federal Tax Payment System (EFTPS)

List offer payments made through Electronic Federal Tax Payment System (EFTPS) below.

Note: Any Offer Application Fee or initial payment made electronically must be made the same date your offer is mailed.

Section 6 Source of Funds, Making Your Payment, Filing Requirements, and Tax Payment Requirements

Source of Funds

Tell us where you will obtain the funds to pay your offer

Making Your Payment

Include separate checks for the payment and application fee. 

Make checks payable to the “United States Treasury” and attach to the front of your Form 656, Offer in Compromise. All payments must be in U.S. 

dollars. Do not send cash. Send a separate application fee with each offer; do not combine it with any other tax payments, as this may delay 

processing of your offer. You may also make payments electronically through Electronic Federal Tax Payment System (EFTPS). Your offer will be 

returned to you if the application fee and the required payment are not included, or if your check is returned for insufficient funds. 

Filing Requirements

I have filed all required tax returns and have included a complete copy of any tax return filed within 12 weeks of this offer submission

I was not required to file a tax return for the following years

Note: Do not include original tax returns with your offer. You must either electronically file your tax return or mail it to the appropriate 

IRS processing office before sending in your offer. 

Tax Payment Requirements (check all that apply)

I have made all required estimated tax payments for the current tax year

I am not required to make any estimated tax payments for the current tax year

I have made all required federal tax deposits for the current quarter and two preceding quarters

I am not required to make any federal tax deposits for the current quarter and two preceding quarters

Offer application fee

Offer payment Date Electronic funds transfer number (15 digits)

Date Electronic funds transfer number (15 digits)

Section 7 Offer Terms 

By submitting this offer, I have read, understand and agree to the following terms and conditions: 

Terms, Conditions, and Legal 

Agreement 

a) I request that the IRS accept the offer amount listed in this offer application as payment of my outstanding tax 

debt arising under Title 26 (including interest, penalties, and any additional amounts required by law) as of the 

date listed on this form. I authorize the IRS to amend Section 1 or Section 2 if I failed to list any of my assessed 

tax debt or tax debt assessed before acceptance of my offer. By submitting a joint offer, both signers grant 

approval to the Internal Revenue Service to disclose the existence of any separate liabilities owed.

b) I also authorize the IRS to amend Section 1 or Section 2 by removing any tax years on which there is currently 

no outstanding liability. I understand that my offer will be accepted, by law, unless the IRS notifies me otherwise, 

in writing, within 24 months of the date my offer was received by our IRS centralized offer in compromise unit, 

located in Memphis/Brookhaven. See mailing instructions on page 29 of Form 656-B. The 24-month period for a 

deemed acceptance will not begin to run until the correct site receives the offer. I also understand that if any tax 

debt that is included in the offer is in dispute in any judicial proceeding that tax debt will not be included in 

determining the expiration of the 24-month period. I instruct the IRS to disregard any period on my Form 656 for 

court ordered restitution or under the jurisdiction of the Department of Justice. 
Catalog Number 16728N www.irs.gov Form 656 (Rev. 4-2024) 

Page 5 

Section 7 (Continued) Offer Terms 

c) I voluntarily submit the payments made on this offer and understand that they will not be returned even if I 

withdraw the offer or the IRS rejects or returns the offer. Unless I designate how to apply each required payment 

in Section 5, the IRS will apply my payment in the best interest of the government, choosing which tax years and 

tax debts to pay off. The IRS will also keep my application fee unless the offer is not accepted for processing. 

IRS will keep my payments, 

fees, and some refunds. 

d) I understand that if I checked the Low-Income Certification in Section 1, then no payments are required. If I 

qualify for the Low-Income Certification and voluntarily submit payments, all money will be applied to my tax debt 

and will not be returned to me.

e) Treas. Reg. section 301.7122(e)(5) states, in part, that acceptance of an offer in compromise will conclusively 

settle the liability for the tax periods specified in the offer. To enforce the regulation as a contract term, I agree 

that I cannot file an amended return for the tax years listed on Form 656 after the offer is accepted. Further, I 

agree that I will not file an amended return for the tax years listed on Form 656 after I have submitted my offer 

and while my offer remains pending [see section 7(j) below] with the Service. The filing of the amended return 

could be considered grounds for termination. In addition, any refunds related to an amended return filed for a tax 

year which has an ending date prior to offer acceptance will be offset to the tax liability. If I receive a refund prior 

to offer acceptance, or based on an amended return for any tax periods extending to the date my offer is 

accepted, I will return the refund within 30 days of receiving the refund. The IRS will keep any refund, including 

interest, that I might be due for tax returns filed through the date the IRS accepts my offer. Systemic offset of 

overpayments will continue in accordance with IRC 6402(a) prior to the offer acceptance date. I understand that 

my tax refund may be offset to the tax liability while the offer is pending, but that assistance could be available for 

taxpayers (other than businesses) facing an economic hardship.

f) I understand that the amount I am offering may not include part or all of an expected or current tax refund, 

money already paid, funds attached by any collection action, or anticipated benefits from a capital or net operating 

loss.

g) The IRS will keep any monies it has collected prior to this offer. Under section 6331(k), the IRS may levy on my 

property and rights to property up to the time that the IRS official signs and acknowledges my offer as pending. 

The IRS may keep any proceeds arising from such a levy. No levy will be issued on individual shared 

responsibility payments. However, if the IRS served a continuous levy on wages, salary, or certain federal 

payments under sections 6331(e) or (h), then the IRS could choose to either retain or release the levy.

h) The IRS will keep any payments that I make related to this offer. I agree that any funds submitted with this offer 

will be treated as a payment. I also agree that any funds submitted with periodic payments made after the 

submission of this offer and prior to the acceptance, rejection, or return of this offer will be treated as payments.

i) If my offer is accepted and my final payment is more than the agreed amount, the IRS will not return the 

difference, but will apply the entire payment to my tax debt. 

j) Once an authorized IRS official signs this form, my offer is considered pending as of that signature date and it 

remains pending until the IRS accepts, rejects, or returns my offer, or I withdraw my offer. An offer is also 

considered pending for 30 days after any rejection of my offer by the IRS, and during the time that any rejection of 

my offer is being considered by the Appeals Office. An offer will be considered withdrawn when the IRS receives 

my written notification of withdrawal by personal delivery or certified mail or when I inform the IRS of my 

withdrawal by other means and the IRS acknowledges in writing my intent to withdraw the offer.

Pending status of an offer and 

right to appeal 

k) I waive the right to an Appeals hearing if I do not request a hearing in writing within 30 days of the date the IRS 

notifies me of the decision to reject the offer.

l) As both an express condition and as a contractual promise, I will strictly comply with all provisions of the internal 

revenue laws, including requirements to timely file tax returns and timely pay taxes for the five year period 

beginning with the date of acceptance of this offer and ending through the fifth year. I agree to promptly pay any 

liabilities assessed after acceptance of this offer for tax years ending prior to acceptance of this offer that were not 

otherwise identified in Section 1 or Section 2 of this agreement. I also understand that during the five year period I 

cannot request an installment agreement for unpaid taxes incurred before or after the accepted offer. I understand 

that I cannot request an offer for a tax liability during the five year period. If this is an offer being submitted for joint 

tax debt, and one of us does not comply with future obligations, only the non-compliant taxpayer will be in default 

of this agreement. An accepted offer will not be defaulted solely due to the assessment of an individual shared 

responsibility payment. I understand failure to pay any restitution-based assessments will provide basis for the 

default of my offer acceptance for administrative tax periods included on this Form 656.

I must comply with my future 

tax obligations and understand 

I remain liable for the full 

amount of my tax debt until all 

terms and conditions of this 

offer have been met. 

m) I agree that I will remain liable for the full amount of the tax liability, accrued penalties and interest, until I have 

met all of the terms and conditions of this offer. Penalties and interest will continue to accrue until all payment 

terms of the offer have been met. If I file for bankruptcy before the terms and conditions of the offer are met, I 

agree that the IRS may file a claim for the full amount of the tax liability, accrued penalties and interest, and that 

any claim the IRS files in the bankruptcy proceeding will be a tax claim.

n) Once the IRS accepts my offer in writing, I have no right to challenge the tax debt(s) in court or by filing a 

refund claim or refund suit for any liability or period listed in Section 1 or Section 2, even if the IRS defaults or 

rescinds the offer.
Catalog Number 16728N www.irs.gov Form 656 (Rev. 4-2024) 

Page 6 

Section 7 (Continued) Offer Terms 

o) If I fail to meet any of the terms of this offer, the IRS may revoke the certificate of release of federal tax lien and 

file a new notice of federal tax lien; levy or sue me to collect any amount ranging from one or more missed 

payments to the original amount of the tax debt (less payments made) plus penalties and interest that have 

accrued from the time the underlying tax liability arose. The IRS will continue to add interest, as required by 

section 6601 of the Internal Revenue Code, on the amount the IRS determines is due after default. I agree that if I 

provide false information or documents in conjunction with this offer or conceal my assets or my ability to pay, 

then the IRS may reopen my offer and exercise its discretion in the further treatment of the offer, including a 

termination of the offer contract. If the IRS terminates my offer contract, I will be liable for the full amount of the 

tax liability, accrued penalties and interest.

I understand what will happen if 

I fail to meet the terms of my 

offer (e.g., default). 

p) To have my offer considered, I agree to the extension of the time limit provided by law to assess my tax debt 

(statutory period of assessment). I agree that the date by which the IRS must assess my tax debt will now be the 

date by which my debt must currently be assessed plus the period of time my offer is pending plus one additional 

year if the IRS rejects, returns, or terminates my offer or I withdraw it. (Paragraph (j) of this section defines 

pending and withdrawal.) I understand that I have the right not to waive the statutory period of assessment or to 

limit the waiver to a certain length or certain periods or issues. I understand, however, that the IRS may not 

consider my offer if I refuse to waive the statutory period of assessment or if I provide only a limited waiver. I also 

understand that the statutory period for collecting my tax debt will be suspended during the time my offer is 

pending with the IRS, for 30 days after any rejection of my offer by the IRS, and during the time that any rejection 

of my offer is being considered by the Independent Office of Appeals. By submitting this offer I immediately 

withdraw any pending installment agreement that is on file for all tax periods and I understand a pending 

installment agreement (an installment agreement that has been accepted for processing but the IRS has not 

accepted its terms) will not be automatically reinstated after the offer is closed.

I agree to waive time limits 

provided by law. 

q) The IRS may file a Notice of Federal Tax Lien during consideration of the offer or for offers that will be paid 

over time. If the offer is accepted, the tax lien(s) for the periods and taxes listed in Section 1 will generally be 

released within 45 days after the final payment has been received and verified. The time it takes to transfer funds 

to the IRS from commercial institutions varies based on the form of payment. If I have not finished paying my offer 

amount, then the IRS may be entitled to any proceeds from the sale of my property. The IRS will not file a Notice 

of Federal Tax Lien on any individual shared responsibility debt.

I understand the IRS may file a 

Notice of Federal Tax Lien on 

my property. 

r) I authorize the IRS, to correct any typographical or clerical errors or make minor modifications to my Form 656 

that I signed in connection to this offer.

Correction Agreement 

s) By authorizing the IRS to contact third parties, I understand that I will not be notified of which third parties the 

IRS contacts as part of the offer application process, including tax periods that have not been assessed, as stated 

in §7602 (c ) of the Internal Revenue Code. In addition, I authorize the IRS to request a consumer report on me 

from a credit bureau. 

I authorize the IRS to contact 

relevant third parties in order to 

process my offer. 

t) I understand if the liability sought to be compromised is the joint and individual liability of myself and my coobligor(s) and I am submitting this offer to compromise my individual liability only, then if this offer is accepted, it 

does not release or discharge my co-obligor(s) from liability. The United States still reserves all rights of collection 

against the co-obligor(s).

I am submitting an offer as an 

individual for a joint liability.

u) If your offer includes any shared responsibility payment (SRP) amount that you owe for not having minimum 

essential health coverage for you and, if applicable, your dependents per Internal Revenue Code Section 5000A 

- Individual shared responsibility payment, it is not subject to penalties (except applicable bad check penalty) or to 

lien and levy enforcement actions. However, interest will continue to accrue until you pay the total SRP balance 

due. We may apply your federal tax refunds to the SRP amount that you owe until it is paid in full. 

I understand the IRS Shared 

Responsibility Payment (SRP).

v) The IRS is required to make certain information, such as taxpayer name, city/state/zip, liability amount, and 

offer terms, available for public inspection and review for one year after the date of offer acceptance.

I understand the IRS is required 

to make certain information 

public.

w) By sending and receiving encrypted messages through the IRS Secure Messaging platform, I agree to accept 

offer final determination letters on this platform.

Secure Messaging
Catalog Number 16728N www.irs.gov Form 656 (Rev. 4-2024) 

Page 7 

Section 8 Signatures 

Under penalties of perjury, I declare that I have examined this offer, including accompanying schedules and statements, and to the best of my 

knowledge and belief, it is true, correct and complete. 

Signature of Taxpayer/Corporation Name Phone number Today's date (mm/dd/yyyy) 

By checking this box you are authorizing the IRS to contact you at the telephone number listed above and leave detailed messages concerning 

this offer on your voice mail or answering machine.

Signature of Spouse/Authorized Corporate Officer Phone number Today's date (mm/dd/yyyy) 

By checking this box you are authorizing the IRS to contact you at the telephone number listed above and leave detailed messages concerning 

this offer on your voice mail or answering machine.

Section 9 Paid Preparer Use Only 

Signature of Preparer Phone number Today's date (mm/dd/yyyy) 

By checking this box you are authorizing the IRS to contact you at the telephone number listed above and leave detailed messages concerning 

this offer on your voice mail or answering machine. 

Name of Paid Preparer Preparer's CAF no. or PTIN 

Firm's name (or yours if self-employed), address, and ZIP code 

If you would like to have someone represent you during the offer investigation, attach a valid, signed Form 2848 with this application or a 

copy of a previously filed form. Form 2848 allows for representation and receipt of confidential information. You should also include the 

current tax year on the form, in the list of applicable years or periods. 

We ask for the information on this form to carry out the internal revenue laws of the United States. Our authority to request this information is section § 

7801 of the Internal Revenue Code. 

Our purpose for requesting the information is to determine if it is in the best interests of the IRS to accept an offer. You are not required to make an offer; 

however, if you choose to do so, you must provide all of the taxpayer information requested. Failure to provide all of the information may prevent us from 

processing your request. 

If you are a paid preparer and you prepared the Form 656 for the taxpayer submitting an offer, we request that you complete and sign Section 9 on Form 

656, and provide identifying information. Providing this information is voluntary. This information will be used to administer and enforce the internal 

revenue laws of the United States and may be used to regulate practice before the Internal Revenue Service for those persons subject to Treasury 

Department Circular No. 230, Regulations Governing the Practice of Attorneys, Certified Public Accountants, Enrolled Agents, Enrolled Actuaries, and 

Appraisers before the Internal Revenue Service. Information on this form may be disclosed to the Department of Justice for civil and criminal litigation. 

We may also disclose this information to cities, states and the District of Columbia for use in administering their tax laws and to combat terrorism. 

Providing false or fraudulent information on this form may subject you to criminal prosecution and penalties. 

Privacy Act Statement

Form 8821 allows a third party to receive confidential information but they cannot represent you before the IRS in a Collection matter. If you 

would like a third party to receive confidential information on your behalf attach a copy if previously filed and include the current tax year on 

the form.

IRS Use Only. I accept the waiver of the statutory period of limitations on assessment for the Internal Revenue Service, as described in Section 7(p). 

Signature of Authorized Internal Revenue Service Official Title Date (mm/dd/yyyy)