4905Be Form – Fill Out and Use This PDF

What you should know before preparing an Offer in Compromise

The following documentation must be submitted with your Offer in Compromise Application or your application may be returned as incomplete. Please submit copies only. We will not return any documents that you send us. Indicate if any of the items below are not applicable. Additional documentation may be required and requested as the evaluation of the Offer in Compromise proceeds.

Check List of Required Items

□Business Entity Offer in Compromise Finanical Statement, FTB form 4905 FS. (included in this booklet)

□Bank Information:

□IRS Information

If applicable, copy of IRS OIC and acceptance letter or other IRS arrangements.

□Vehicle Information:

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□Power of Attorney

Power of attorney if this offer is submitted by a designated representative.

Mail your completed and signed application to:

OFFER IN COMPROMISE GROUP

FRANCHISE TAX BOARD MS A453

PO BOX 2966

RANCHO CORDOVA CA 95741-2966

If you have questions other than those answered on the previous page of this booklet, contact the Offer in Compromise program at (916) 845-4787.

State of California — Franchise Tax Board

Offer in Compromise Application (Continued)

The undersigned submits this Offer in Compromise for payment of the California state tax liability shown below:

1.AMOUNT OWED

Tax Year(s)____________________________________________________

Amount Due __________________________________________________

Include tax, interest, and penalties.)

2.OFFER

The sum of $ ________________________________ is offered in compromise. We will instruct you when to pay the the offer amount. Do not send any funds now.

If this Offer in Compromise is denied, the Franchise Tax Board is to:

__________ Retain any amounts deposited and credit it to the undersigned’s liabilities.

__________ Return the amount deposited.

State of California — Franchise Tax Board

Offer in Compromise Application (Continued)

If yes, please provide the following information and attach a copy of the loan agreement.

Amount borrowed $ __________________________________________

Name of lender ______________________________________________

Lender’s address ____________________________________________

Lender’s telephone number ____________________________________

Amount of gift $______________________________________________

Name of donor ______________________________________________

Donor’s relationship to the entity_________________________________

c.Describe sources of offered funds other than those listed in a or b.

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

4.OWNERSHIP

List any individual or corporate owners with 25% or more interest in this entity.

Name of Owner(s)% Owned

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

(Attach a separate sheet scheduling any parent or subsidiary entity relationship.)

State of California — Franchise Tax Board

Offer in Compromise Application (Continued)

5.BASIS FOR THE OFFER

The following facts and reasons are submitted as grounds for acceptance of this offer:

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

(If more space is needed, please attach additional pages.)

6.It is understood that this offer will be considered and acted upon in due course and that it does not relieve the entity from the liability sought to be compromised unless and until the offer is accepted by the Franchise Tax Board and there has been full compliance with the terms of the agreement including any collateral agreement.

7.It is agreed that, except for any amounts deposited in connection with this offer, the Franchise Tax Board will keep all payments and other credits made to the account for the periods covered by this offer, and that the Franchise Tax Board will keep any and all amounts to which the entity may be entitled under the Revenue and Taxation Code, due through overpayments of any tax, penalty or interest, for any periods ending before the end of the calendar year in which this offer is accepted.

8.It is further agreed that upon notice to the entity of the acceptance of the offer, the entity shall have no right to contest in court or otherwise the amount of the liability sought to be compromised. No liability will be compromised until all obligations of the corporation under the compromise agreement or collateral agreement are completely performed. In the event of a default by the corporation on the collateral agreement, it is agreed that the Franchise Tax Board may disregard the amount of the offer and retain all amounts previously deposited under the offer and proceed to collect the balance of the original liability.

_________________________________________________________________________________________________

Under penalties of perjury, I declare that I have examined the information given in this statement and all other documents included with this offer and to the best of my knowledge and belief, it is (or they are) true, correct and complete.

State of California ﾱ Franchise Tax Board

Business Entity Offer in Compromise Financial Statement

Please furnish the information requested on this form along with the Offer in Compromise. It is important that all questions are answered. If a question doeｖ＃ｑｒｗ＃ｄｓｓｏ｜／＃ｓｏｈｄｖｈ＃ｈｑｗｈｕ＃ｗｋｈ＃ｚｒｕｇ＃ﾳｑｒｑｈ１ﾴ＃Ｌｉ＃｜ｒｘ＃ｕｘｑ＃ｒｘｗ＃ｒｉ＃ｖｓｄｆｈ／＃ ｓｏｈｄｖｈ＃ｄｗｗｄｆｋ＃ｄｇｇｌｗｌｒｑｄｏ＃ｓｄｊｈｖ＃＋ｚｕｌｗｈ＃｜ｒｘｕ＃ｈｑｗｌｗ｜ﾶｖ＃ｑｄｐｈ＃ｄｑｇ＃ｑｘｐｅｈｕ＃ｒｑ＃ｄｏｏ＃ｄｇｇｌｗｌｒｑｄｏ＃ｓｄｊｈｖ，１＃

1. Business Entity Information

2. List of Entity Officers/General Partners/Managing Members

3a. Bank Accounts (List all types of accounts including payroll, checking, savings, certificates of deposits, etc.) held during the past three years. Please provide copies of bank statements for the last (or final) three months for every account held.

Total ►

3b. Bank, Finance and Business Credit cards (Lines of credit)

Total ►

3c. Safe Deposit Boxes (List contents of all deposit boxes rented or accessed by your entity)

Total ►

FTB 4905FS (NEW 01-2007) PAGE 1

Assets and Liabilities

Ｓｏｈｄｖｈ＃ｉｘｕｑｌｖｋ＃｜ｒｘｕ＃ｈｑｗｌｗ｜ﾶｖ＃most recent balance sheet and profit and loss statement. Include all interests in estates, trusts, and other property rights, including contingent interests and remainders.

5. Life insurance policies

Total ►

FTB 4905FS (NEW 01-2007) PAGE 2

6. Accounts and Notes Receivable

Total ►

7. Pending Litigation and Pending Judgments

Total ►

8. Real Estate

Total ►

9. Machinery and Equipment

Total ►

FTB 4905FS (NEW 01-2007) PAGE 3

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