Form OR-SOA, Oregon Settlement Offer Application, 150-101-157

OREGON

150-101-157 Form OR-SOA (Rev. 02-17)

Settlement Oer Application

General information

Introduction

Some taxpayers owe more tax than they can pay. If

you’re in this situation, we may be able to help you

settle your tax debt by paying less than you owe. This

is called a settlement offer.

The settlement offer process isn’t easy and it won’t work

for everyone; however, it may be worth applying for if

you can prove you don’t have enough money to pay it

off.

Conditions for qualifying

To qualify for a settlement offer, you must meet all of

these conditions:

• You’re not appealing any tax debts.

• You must have filed all required Oregon tax returns

for all tax years and all tax types.

• You haven’t completed another settlement offer since

October 1, 2001.

• You must show that you cannot sell assets or borrow

against them to pay your tax debt.

• You must show that you don’t have enough monthly

income or assets to pay your tax debt in full.

• You’re not in bankruptcy or in litigation.

Before you start

It will take you at least three hours to complete the appli-

cation. You must locate and copy many documents (bank

statements, pay stubs, lease agreements, deeds, etc.) to

include with your application (see page 6).

Not everyone who applies for a settlement offer will

qualify. To determine your chances, ask yourself these

questions:

1. Do you receive Social Security income, Social Security

disability, pension payments, or public assistance?

2. Are you over age 60?

3. Are your total assets worth more than $5,000?

4. Is your only asset your home?

5. Is your tax debt older than seven years?

If you answered yes to two or more questions, call

503-945-8254 for more information. Otherwise, continue

filling out the settlement offer application.

What to include in your settlement offer

It must include:

• The completed and signed application. If your offer

isn’t signed, we’ll return it without processing. You

may re-send the signed offer.

• All supporting documentation (see page 6).

• The Tax Information Authorization and Power of Attorney

for Representation form if you want someone to repre-

sent you during the settlement offer (page 16).

• Offer must follow settlement offer calculations on

page 13, or offer may be denied.

• A nonrefundable payment that is 5 percent of the

settlement offer amount. Payment must be money

order, cashier’s check, or cash.

If you don’t include payment, we’ll return your offer

without processing it. You may re-send the application

with your payment.

What to expect after you submit your application

• If your application is complete, we’ll review it and

usually accept or deny it within 30 days. We’ll notify

you in writing of our decision.

If your application is incomplete or inaccurate, we

may send it back to you or ask you to send us more

information. This will delay our review.

• We’ll continue collection action on your debt while

we review your application. Such action may include

garnishing your wages, placing property liens, and

seizing property.

Settlement offer acceptance

• If we accept your settlement offer, you must pay the

amount in full within 30 days.

• If you can’t pay the entire amount at one time, you

may ask for a payment plan to pay it off in 12 equal

monthly payments.

• We’ll accept credit or debit card, check, money order,

cashier’s check, or cash.

• You can never have another settlement offer.

Settlement offer denial

If we deny your settlement offer:

• You can’t appeal our decision.

• We’ll apply your 5-percent payment to your tax debt.

• You may file another application with a 5-percent

payment.

Frequently asked questions

Do I need an accountant or attorney to help me?

You can probably complete the form on your own. If you

need help, your assigned revenue agent or settlement

offer agent can answer your questions.

Who reviews my application?

A settlement offer agent will review your application.

If I have questions, who should I call?

You can call the revenue agent assigned to your case or

ask for a settlement offer agent, 503-945-8254.

What do I send with my application?

Please see the check list, page 6.

What if my financial condition changes after you

approve my settlement offer?

It won’t affect the terms of the offer. However, if the

change is due to information you omitted or misstated on

your application, you may be in default.

If I file all my returns on time, can I make

payments on tax I may owe?

You must pay taxes due within 90 days from the date

on the billing notice we’ll send you.

If you deny my application, may I submit another

settlement offer?

Yes. Make sure to include all supporting documentation

and another 5-percent payment.

Will you apply prior payments to my offer amount?

No. We apply any payments you make before or dur-

ing the settlement offer review process to your total tax

debt.

How long will it take you to make a decision?

If your application is complete, we’ll usually make a

decision within 30 days from the day we receive your

application.

When I pay off the offer amount, will you release

property liens?

No. The lien will be released once the three year compli-

ance period has ended, at which point the settlement

fer process is complete. Contact the county in which

your property is located for a copy of the lien release. It

takes about 45 days to release the lien.

Are there any expenses that may not be allowed

in determining my disposable income?

Yes. We typically don’t allow you to claim college

tuition, voluntary retirement contributions, payments

on unsecured debts such as credit cards, and other

similar expenses.

How is my inability to pay in full determined?

We will look at property you own; past, present, and

future earning potential; your present lifestyle; your

ability to borrow; and any other factors that might be

helpful in making a decision.

Application instructions

• You must complete all sections.

• Don’t fill in shaded boxes.

• Attach additional pages if necessary.

• Print clearly.

Section 1. Personal information

Fill out completely and include all members of your

household.

Section 2. Employment information

There are two sections: one for your employment infor-

mation and one for your spouse/registered domestic

partner (RDP) employment information.

Provide the name of your employer, or the name of your

business if you’re self-employed.

Check the “paid” box that applies to how frequently

you get a pay check.

• Important—Include the number of allowances you

claim on your most recent W-4 form.

Section 3. General financial information–

personal and business

Bank accounts—List all bank accounts. For the total dol-

lar amount in your accounts, add together only those

accounts with positive balances.

• Important—For any bank accounts with negative bal-

ances, enter -0-.

Example: Bob has three bank accounts:

1. Checking account 1 $400.00

2. Checking account 2 –$100.00

3. Savings account $600.00

He lists all three accounts and enters -0- in the bal-

ance column for checking account 2. The total of his

bank accounts is $1,000; not $900.

Personal property—If you own a business, include only

personal property not used in your business.

Credit cards and unsecured lines of credit—We don’t allow

these expenses when we determine your ability to pay.

Other financial information—Include any court proceed-

ings that resulted in or may result in a financial judg-

ment in your favor.

Section 4. Assets and liability analysis

Lines 2–9, enter totals from Section 3.

Lines 18–19, don’t include everyday household items

such as clothing, furniture, appliances, etc.

Lines 21–23, include properties listed in Section 3. To

determine current property value, use the real mar-

ket value (RMV) from your most recent property tax

statement.

Line 28, include unsecured credit balance from Section

3 only if you filled it in.

Lines 30–32, explain other debts and provide supporting

documentation.

Section 5. Monthly income and expense analysis

• Important—If you work on commission or own a

business, we may ask you for more than three months

pay stubs.

Fill in gross and net amounts, except where boxes are

shaded.

Line 51–53, explain other income and provide support-

ing documentation.

Lines 55–64, provide proof of monthly payments for

each expense.

Lines 71–80, provide proof of monthly payments for

each business-related expense.

Section 6. Settlement offer calculations

Line 84, disposable income formula.

Example: Anne’s net disposable income from line 82

is $1,500. She enters $1,500 on line 83 and multiplies

it by 12.0.

$1,500 x 12.0 = $18,000

She enters $18,000 on line 84.

Line 86, assets and equity formula.

Example: Anne’s total value of all immediate assets

and real property equity from line 27 is $3,000. She

enters that on line 85 and multiplies it by 0.75.

$3,000 x 0.75 = $2,250.

She enters $2,250 on line 86.

Line 87, add lines 84 and 86 to get your settlement offer

amount.

Line 87, 5-percent nonrefundable payment to submit

with your application (whole dollar amount only).

Example: Anne adds her disposable income formula

amount of $18,000 (line 84) to her assets and equity

formula amount of $2,250 (line 86).

$18,000 + $2,250 = $20,250.

She enters $20,250 on line 87 and multiplies it by

0.05

$20,250 x 0.05 = $1,012.50

She enters $1,012.50 on line 88.

Anne gets a cashier’s check for $1,013, indicates it

is a collections payment, and includes it with her

application.

Payoff information—You must pay the offer amount in full

within 30 days from the date of our acceptance letter.

If you can’t pay it all at once, you may pay it off in 12

equal monthly payments. Write the day of the month

you want your installment payment to be due.

Tax debts included in settlement offer—Write the tax type

and years/quarters of taxes.

Section 7. Additional information

You may include information that you want us to know

regarding your settlement offer.

Terms and conditions

Read the terms and conditions carefully before you sign

the taxpayer agreement.

Taxpayer agreement and authorization to use

credit reports

By signing, you confirm that the information in your

application is correct and complete to the best of your

knowledge.

Your signature also authorizes us to use credit reports

and other tools to verify any information in your appli-

cations, and for collection purposes.

Before mailing

Review your application to make sure it’s complete and

includes all supporting documentation and payment.

Have questions? Need help?

Internet

www.oregon.gov/dor

• Download forms, instructions, and publications.

• Check your refund status.

• Make payments.

• Find out how much you owe.

Email or write

General: questions.dor@state.or.us

Settlement offers: settlement.offer @oregon.gov

Oregon Department of Revenue

955 Center St NE

Salem OR 97301-2555

• Include your name and daytime phone number.

• Include the last four digits of your SSN or ITIN.

Printed forms or publications:

Forms

Oregon Department of Revenue

PO Box 14999

Salem OR 97309-0990

Español: [email protected].us

Phone

Settlement offers ......................................... 503-945-8254

Salem area or outside Oregon .................... 503-378-4988

Toll-free from an Oregon prefix ............... 1-800-356-4222

• Check your refund status.

• Order forms, instructions, and publications.

• Listen to recorded information.

• Speak with a representative:

Monday–Friday ......................................7:15 a.m.– 5 p.m.

Closed holidays. Wait times may vary.

Asistencia en español:

En Salem o fuera de Oregon ...................... 503-378-4988

Gratis de prejo de Oregon .....................1-800-356-4222

TTY (hearing or speech impaired; machine only):

Salem area or outside Oregon ................... 503-945-8617

Toll-free from an Oregon prex ..............1-800-886-7204

Americans with Disabilities Act (ADA): Call one of the help

numbers above for information in alternative formats.

In person

Find directions and hours on our website.

Settlement offer application check list

You must include the following information with your application. If you don’t, we may return it without process-

ing, or ask you for more documentation.

All tax debt you owe.

You (and your spouse/RDP, if applying jointly)must

sign the taxpayer agreement and authorization to

use credit reports (page 15); and, if needed, the Tax

Information Authorization and Power of Attorney for

Representation form (page 16).

A nonrefundable payment that is 5 percent of the

settlement offer amount. Payment must be money

order, cashier’s check, or cash.

Verification of all income sources

To verify your household income, you must include:

Complete bank statements for the last three months

for all checking and savings accounts.

Pay stubs for at least the last three months.

Documentation of other income sources for the last

three months. For example, Social Security, disabil-

ity, child support, alimony, commissions, etc.

Verification of all expenses

You must verify your household expenses. We accept:

Copies of cancelled checks (front and back).

Documents showing payments on court-ordered

debts.

Billing statements showing payments.

Receipts of payments.

Self-employed or business owners

If you’re self-employed or a business owner, you must

include:

A profit/loss statement from your business showing

all activity for the current year.

Bank statements for the last six months for all busi-

ness checking and savings accounts.

A general ledger showing business expenses actu-

ally paid for the current year.

Statements for loans you claimed as business

expenses.

Verification of Assets

You must include all property owned for personal

or business use.

Include all county value documents.

Include most current mortgage balance statement

(if currently financing).

We will continue collection action on your tax debt until your settlement offer is accepted.

Section 1. Personal information

Revenue use only

Date received

Revenue agent

Form OR-SOA

Settlement Offer Application

Other names or aliases used

Your rst name

Your Social Security number

Your date of birth

MI Last name

Spouse/RDP’s rst

name

Spouse/RDP’s Social Security number

Spouse/RDP’s date of birth

MI Last name

Spouse/RDP’s other names or aliases used

Your cell phone

State

Spouse/RDP’s cell phone

State

Dependent’s name (living with you)

Date of birth

Social Security number

Relationship

Your current physical address City State ZIP code County

Your home phone

Your mailing address (if different from above) City State ZIP code

Phone

Name of your tax representative (CPA, attorney, enrolled agent)

Fax number

Address of your tax representative

Your email

Spouse/RDP’s email

Your driver license number

Spouse/RDP’s driver license no.

City State ZIP code

Section 2. Employment information (personal and business)

Your employer or business name

Address

Business phone

Date hired:____________________ Occupation: _______________________________ Wage earner Sole proprietor Partner Owner ofcer

Paid: Weekly Every other week Monthly Twice a month Number of allowances claimed on Form W-4:____________________

City State ZIP code

Payroll fax

– –

( )

( )( )

( )

– –

( )( )

( )

Spouse/RDP’s employer or business name

Address

Date hired:____________________ Occupation: _______________________________ Wage earner Sole proprietor Partner Owner ofcer

Paid: Weekly Every other week Monthly Twice a month Number of allowances claimed on Form W-4:____________________

City State ZIP code

Business phone

Payroll fax

( )

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Section 2. (continued) Employment information (personal and business)

If self-employed: List all responsible owner(s), partner(s), ofcer(s), major shareholder(s), etc.

Identify the major responsibilities of each by circling the codes that apply: 1 = Files returns; 2 = Pays taxes; 3 = Prefers creditors; 4 = Hires and res

Name and title Effective date Home address Home phone SSN Code

1 2 3 4

Section 3. General ﬁnancial information (personal and business)

Bank accounts. Include IRA and retirement plans certicates of deposit, etc. For all accounts, attach copies of your last three bank statements.

Attach additional pages as needed.

Name of institution Address Type Date opened Account number Balance

Total. Enter this amount on line 2, Section 4 (asset and liability analysis) ........................

Vehicles. Attach supporting documentation of current payoff. Attach additional pages as needed, and vehicles paid in full.

Available equity

(cannot be less than -0-)

Current market valueYear, make, model, license number Lender/lien holder Current payoff

Total. Enter this amount on line 4, section 4 (asset and liability analysis) ........................

Safe deposit boxes (rented or accessed). Include location, box number, and contents. Attach additional pages as needed.

Name of institution Address Box identication Current value of assets

Total. Enter this amount on line 3, Section 4 (asset and liability analysis) ........................

Current market value

Personal property. Include water craft, RVs, air craft, business equipment, and/or machinery. Attach additional pages as needed.

Year, make, model, license number Lender/lien holder Current payoff

Available equity

(cannot be less than -0-)

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Section 3. (continued) General ﬁnancial information (personal and business)

Real property. Include a copy of the deed and a copy of homeowners/rental insurance policy with riders and supporting documentation of loan balance.

Attach additional pages as needed.

Policy number

Life insurance. Attach additional pages as needed.

Name of insurance company Agent’s name and phone Type

Face amount

Loan/cash

surrender value

Owner of record

Total. Enter this amount on line 7, section 4 (asset and liability analysis) ........................

Securities. Include stocks, bonds, mutual funds, money market funds, securities, 401(k), etc. Attach additional pages as needed.

Type Where located

Quantity or denomination Current value

Total. Enter this amount on line 8, section 4 (asset and liability analysis) ........................

Current market value

Personal property. (continued) Include water craft, RVs, air craft, business equipment, and/or machinery. Attach additional pages as needed.

Year, make, model, license number Lender/lien holder Current payoff

Total. Enter this amount on line 6, section 4 (asset and liability analysis) ........................

Available equity

(cannot be less than -0-)

A. Physical address

Type

(single- or multi-family dwelling,

lot, rental, etc.)

Mortgage lender’s name and address

Parcel number:_______________

How is title held:______________________________________ Purchase price: _________________ Purchase date: __________________

Current market value: _______________________Mortgage balance: ___________________________ Equity: ___________________________

B. Physical address

Type

(single- or multi-family dwelling,

lot, rental, etc.)

Mortgage lender’s name and address

Parcel number:_______________

How is title held:______________________________________ Purchase price: _________________ Purchase date: __________________

Current market value: _______________________Mortgage balance: ___________________________ Equity: ___________________________

C. Physical address

Type

(single- or multi-family dwelling,

lot, rental, etc.)

Mortgage lender’s name and address

Parcel number:_______________

How is title held:______________________________________ Purchase price: _________________ Purchase date: __________________

Current market value: _______________________Mortgage balance: ___________________________ Equity: ___________________________

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Section 3. (continued) General ﬁnancial information (personal and business)

Credit cards and lines of credit. Credit cards and unsecured lines of credit may only be allowed with three months of statements showing they are used

for living expenses.

Type of account Name and address of creditor Monthly payment Credit limit Credit available

Amount owed

Total. Enter this amount on line 28, Section 4 (asset and liability analysis) . . . . . . . . .

Total

Other ﬁnancial information. Please provide the following information relating to your nancial conditions. If you check “Yes” in any box, provide dates,

an explanation, and documentation. Attach additional pages as needed.

Court proceedings ............................................. No Yes _______________________________________________________________________________

Repossessions .................................................. No Yes _______________________________________________________________________________

Anticipated increase in income ......................... No Yes _______________________________________________________________________________

Bankruptcies/receiverships ............................... No Yes _______________________________________________________________________________

Recent transfer of assets .................................. No Yes _______________________________________________________________________________

Beneciary to trust, estate, prot sharing, etc. ... No Yes _______________________________________________________________________________

Last Oregon income tax return led .................. Year:_______ _______________________________________________________________________________

Total number of exemptions claimed ................ ___________ ________________________________________________________________________________

Adjusted gross income from return ................... $__________ ________________________________________________________________________________

List any vehicles, equipment, or property sold, given away, or repossessed during the past three years. Attach additional pages as needed.

Year, make, model of vehicle, or property address Who took possession Value

D. Physical address

Type

(single- or multi-family dwelling,

lot, rental, etc.)

Mortgage lender’s name and address

Parcel number:_______________

How is title held:______________________________________ Purchase price: _________________ Purchase date: __________________

Current market value: _______________________Mortgage balance: ___________________________ Equity: ___________________________

Total Equity. Enter this amount on line 9, Section 4 (asset and liability analysis) . . . . . . . . .

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1. Cash

2. Bank accounts / balance (from section 3)

3. Safe deposit box value of contents (from section 3)

4. Enter vehicles / available equity (from section 3) here:_______________________________________________________________.

5. Vehicle equity formula (line 4 - $3000, if less than -0-, enter -0-)

6. Personal property (from section 3)

7. Loan / cash surrender value for life insurance (from section 3)

8. Securities (from section 3)

9. Current real estate equity (from section 3)

10. Notes

11. Accounts receivable

12. Judgements / settlements received or pending

13. Interest in trusts

14. Interest in estates

15. Partnership interests

16. Major machinery / equipment, etc.

17. Business inventory

18. Other assets: (specify): (Example: $1,000 guns / $200 jewelry / $800 gold)

19. Other assets (specify):

20. Total assests ....................................................................................................................................................................................

Immediate assets. Totals

Section 4. Assets and liability analysis

21. Property 1:

22. Property 2:

23. Property 3:

24. Total equity from properties listed on additional sheet (if applicable)

25. Total of all real property equity (add the Equity column from lines 21 thru 24)

26. Enter dollar amount from line 20

27. Total value of all immediate assets and real property equity (line 25 plus line 26) .............................

Real property equity. From Section 3. Liens or cost of sale don’t reduce equity (can’t be less than -0-).

Address or location

Mortgage payoff amount

Equity

RMV from property tax statement

28. Amount owed to credit cards and lines of credit (from Section 3)

29. Taxes owed to IRS (provide a copy of recent notices)

30. Other liabilities (specify):

31. Other liabilities (specify):

32. Other liabilities (specify):

33. Total liabilities .................................................................................................................................................................................

Current liabilities. Include judgements, notes, and other charge accounts. Do not include vehicle or home loans.

Totals

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34. Wages / salaries / tips (yours)

35. Social Security income (yours)

36. Pension / annuities (yours)

pension

annuities

both

37. Disability (yours)

38. Wages / salaries / tips (spouse/RDP’s)

39. Social Security income (spouse/RDP’s)

40. Pension / annuities (spouse/RDP’s)

pension

annuities

both

41. Disability (spouse/RDP’s)

42. Interest / dividends / royalties (average monthly)

Income. Attach copies of all income sources that contribute to household expenses (minimum three months).

Section 5. Monthly income and expense analysis

Totals

List Net Income

43. Payments from trust / partnerships / entities

44. Unemployment

45. Other income (specify)

46. Other income (specify)

47. Other income (specify)

List Gross Income

48. Business income (yours)

49. Business income (spouse/RDP’s)

50. Rental income

51. Child support

52. Alimony

53. Seller carried contracts / sales

54. Total income ...........................................................................................................................................................................

55. Rent / mortgage / real estate secured line(s) of credit

56. Real estate taxes (Is this included in your mortgage payment? No Yes)

57. Personal home owners / renters insurance: ( ) Assoc. fees: ( )

58. Personal utilities: Electric: ( )

Natural gas / oil: ( ) Phone, internet, & cable: ( )

Garbage: ( ) Water / sewer: ( )

59. Food / clothing / other Items: No. of people: ( ) Their ages: ( )

60. Auto payments / lease

61. Auto insurance

62. Auto maintenance / fuel / other transportation

63. Medical payments (not covered by insurance) (provide proof)

64. Estimated tax payments (provide proof)

65. Court ordered payments (alimony, child support, restitution, not deducted from your paycheck)

Personal expenses (actually paid). (May be limited by federal standards.)

Amount

If renting—name, address, and phone number of landlord

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66. Garnishments (specify)

67. Delinquent tax payments (other than Oregon state taxes, IRS, etc.)

68. Work related child care expenses

69. Other expenses (do not include unsecured debt) (specify)

70. Total personal expenses .......................................................................................................................................................

Personal expenses (actually paid). (continued) (May be limited by federal standards.)

Amount

Business expenses (actually paid). Provide current general ledger and prot / loss.

71. Materials purchased (specify)

72. Supplies (specify)

Amount

73. Installment payments (specify)

74. Monthly payments (specify)

75. Rent / mortgage

76. Insurance

77. Business utilities: Electric: ( )

Natural gas / oil: ( ) Phone, internet, & cable: ( )

Garbage: ( ) Water / sewer: ( )

78. Net wages and salaries paid to employees

79. Current taxes (payroll / business)

80. Other: Specify: (do not include unsecured debt)

81. Total business expenses .....................................................................................................................................................

82. Net disposable income (line 54 minus lines 70 and 81)........................................................................................................

If renting—name, address, and phone number of landlord

Section 6. Settlement offer calculations

83. Net disposable income from line 82 (If less than -0-, enter -0-)

84. Disposable income formula (line 83 x 12.0)

85. Total value of all immediate assets and real property equity from line 27 (If less than -0-, enter -0-)

86. Assets and equity formula (line 85 x 0.75)

87. Total settlement offer amount (add lines 84 and 86) .................................................................................

88. 5-percent nonrefundable payment submitted with this application (line 87 x 0.05)

Payoff information

When will you pay the remainder of this settlement offer? (check one)

Within 30 days from the date of Department of Revenue’s acceptance letter.

In 12 equal monthly installments. Day of month you want your installment payments due: _____________________________

Will you borrow the settlement offer amount (line 87)?

Yes No

Section 5. (continued) Monthly income and expense analysis

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Please provide any additional information not already included. Attach additional pages as needed. All household income must be included.

Section 7. Additional information

Tax type

Social Security number or

business identification number

Years/quarters

Personal income tax

Business tax

Other (explain)_________________________________________________

Tax debts included in settlement offer. Check all that apply.

Lender information

Name

Mailing address City State ZIP code

Phone

Is lender a member of your household or immediate family?

Collateral

If yes, provide lender’s name, address, phone; list all collateral, if any, pledged to secure the loan.

Yes No

( )

Section 6. (continued) Settlement offer calculations

Payoff information (Continued)

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Terms and conditions

By making this offer, I understand and agree to these

terms and conditions:

1. If I don’t meet all of the terms and conditions of this

offer, the Department of Revenue will cancel the

settlement offer and collect the full amount of my

debt, including interest and penalties.

2. I will voluntarily submit all settlement offer

payments.

3. The Department of Revenue will apply all payments,

refunds, or credits it receives before my settlement

offer is approved to my debt and not to the settle-

ment offer amount.

4. If I have a current payment plan for this debt, I will

continue making payments, as agreed, while this

offer is pending.

Return your completed application, documentation,

and 5-percent payment to: Oregon Department of Revenue

PO Box 14725

Salem OR 97309-5018

5. I forfeit my right to appeal [Oregon Revised Statute

(ORS) 305.280(3)].

6. For three years from the date I pay the settlement

offer amount in full, I will file all returns and pay all

taxes due. I will pay any tax debt in full within 90

days from the date of the notice I receive from the

department. If I don’t, I violate this settlement offer

agreement and the Department of Revenue will col-

lect the full debt amount.

7. I authorize the Department of Revenue to contact

third parties (IRS, Department of Employment, credit

reporting firms, etc.) to verify information I provided

in the settlement offer application.

8. The Department of Revenue will release any tax liens

on my property after a three year compliance period

is complete.

Taxpayer agreement and authorization to use credit reports

I read and agree to the above terms and conditions. Under penalties of perjury, I declare that I examined this

offer, including all attached documentation, and to the best of my knowledge and belief, it is true, correct, and

complete. I (we) authorize the Oregon Department of Revenue to use credit reports and other tools to verify

any information in this settlement offer application and for collection purposes.

Your signature

Date

Spouse/RDP signature (if applying jointly, BOTH must sign even if only one had income)

SIGN

HERE

Date

➨

Did you include everything?

Before mailing, please review your application to make sure it’s complete and includes all supporting

documentation. We’ll return your application if you don’t sign it or include payment; are appealing your

tax debt; or haven’t filed all required tax returns (see page 2).

Did you...

1. Include a 5-percent payment with this application?

2. Sign the taxpayer agreement and authorization to use credit reports (above)? If applying jointly, did your

spouse/RDP sign it?

3. Complete the Tax Information Authorization and Power of Attorney for Representation form, if needed?

4. Make a copy of this application for your records?

If you answered yes to each question, included all supporting documentation, meet all the conditions for

qualifying (page 2), you’re ready to submit your application. We’ll contact you within 10 business days to let

you know we received it.

If you need to contact us, see page 5.

150-800-005 (Rev. 12-15)

Tax Information Authorization

and

Power of Attorney for Representation

For office use only

Date received

Complete the following, if known (for routing purposes only):

Revenue employee: __________________________________________________

Division/Section: ____________________________________________________

Phone/Fax: _________________________________________________________

Send to: Oregon Department of Rev e nue

955 Center St NE

Salem OR 97301-2555

• Please print. • Use only blue or black ink. • See additional information on the back.

Address City State ZIP code

Taxpayer name Identifying number (SSN, BIN, FEIN, etc.)

Spouse’s name, if joint return

Spouse’s identifying number (SSN, etc.)

Check only one:

Tax Information Authorization: Checking this box allows the department to disclose your confidential tax information to your

des ig nee. You may designate a person, agency, firm, or or ga ni za tion.

Power of Attorney for Representation: Check this box if you want a person to “rep re sent” you. This means the person may

receive confidential information and may make decisions on your behalf. The per son you des ig nate must meet the qual i fi ca tions

listed on the back of this form.

For All tax years, or Specific tax years: __________________________________________________________________ ,

I hereby appoint the following person as designee or authorized representative:

Mailing address

City

State ZIP code

Name

Phone

Fax

( ) ( )

Signature of taxpayer(s)

• I acknowledge the following provision: Actions taken by an authorized representative are binding, even if the representative is

not an attorney. Proceedings cannot later be declared legally defective because the representative was not an attorney.

• Corporate officers, partners, fiduciaries, or other qualified persons signing on behalf of the taxpayer(s): By signing, I also certify

that I have the authority to execute this form.

•

If a tax matter concerns a joint return, both spouses must sign if joint representation is requested. Taxpayers filing jointly may

authorize separate representatives.

The above named is authorized to receive my confidential tax information and/or represent me before the Oregon Department of Rev e nue for:

All tax matters, or

Specific tax matters.

Enter tax program name(s): ________________________________________________________________________

Visit www.oregon.gov/dor to complete this form using Revenue Online.

If this tax in for ma tion au tho ri za tion or pow er of at tor ney form is not signed, it will be returned.

Power of attorney forms submitted with Revenue Online will be signed electronically.

Daytime phone

Note: This authorization form automatically revokes and replaces all earlier tax authorizations and/or all earlier powers of attorney

on file with the Oregon De part ment of Rev e nue for the same tax mat ters and years or periods covered by this form. If you do not

want to revoke a prior authorization, initial here ______.

Attach a copy of any other tax information authorization or power of attorney you want to remain in effect.

( )

Print name Date

Signature

Title (if applicable)

Spouse (if joint rep re sen ta tion)

Representative’s title and Oregon license number or relationship to taxpayer

If out-of-state CPA, sign here attesting you meet the requirements to practice in Oregon (see instructions)

Clear This Page

150-800-005 (Rev. 12-15)

Additional information

This form is used for two purposes:

• Tax information disclosure authorization. You authorize

the department to disclose your confidential tax infor-

mation to another person. This person will not receive

original notices we send to you.

• Power of attorney for representation. You authorize

another person to represent you and act on your behalf.

The person must meet the qualifications below. Unless

you specify differently, this person will have full power to

do all things you might do, with as much binding effect,

including, but not limited to: providing information; pre-

paring, signing, executing, filing, and inspecting returns

and reports; and executing statute of limitation extensions

and closing agreements.

This form is effective on the date signed. Authorization termi-

nates when the department receives written revocation notice

or a new form is executed (unless the space provided on the

front is initialed indicating that prior forms are still valid).

Unless the appointed representative has a fiduciary relation-

ship to the taxpayer (such as personal representative, trustee,

guardian, conservator), original Notices of Deficiency or

Assessment will be mailed to the taxpayer as required by

law. A copy will be provided to the appointed representative

when requested.

For corporations, “taxpayer” as used on this form, must be

the corporation that is subject to Oregon tax. List fiscal years

by year end date.

Qualifications to represent taxpayer(s) before

Department of Revenue

Under Oregon Revised Statute (ORS) 305.230 and Oregon

Administrative Rule (OAR) 150-305.230, a person must meet

one of the following qualifications in order to represent you

before the Department of Revenue.

1. For all tax programs:

a. An adult immediate family member (spouse, parent,

child, or sibling).

b. An attorney qualified to practice law in Oregon.

c. A certified public accountant (CPA) or public accoun-

tant (PA) qualified to practice public accountancy in

Oregon, and their employees.

d. An IRS enrolled agent (EA) qualified to prepare tax

returns in Oregon.

e. A designated employee of the taxpayer.

f. An officer or full-time employee of a corporation (includ-

ing a parent, subsidiary, or other affiliated corporation),

association, or organized group for that entity.

g. A full-time employee of a trust, receivership, guardian-

ship, or estate for that entity.

h. An individual outside the United States if representa-

tion takes place outside the United States.

2. For income tax issues:

a. All those listed in (1); plus

b. A licensed tax consultant (LTC) or licensed tax pre-

parer (LTP) licensed by the Oregon State Board of Tax

Practitioners.

3. For ad valorem property tax issues:

a. All those listed in (1); plus

b. An Oregon licensed real estate broker or a principal real

estate broker; or

c. An Oregon certified, licensed, or registered appraiser; or

d. An authorized agent for designated utilities and com-

panies assessed by the department under ORS 308.505

through 308.665 and ORS 308.805 through 308.820.

4. For forestland and timber tax issues:

a. All those listed in (1), (2), and (3)(b) and (c); plus

b. A consulting forester.

An individual who prepares and either signs your tax return

or who is not required to sign your tax return (by the instruc-

tions or by rule), may represent you during an audit of that

return. That individual may not represent you for any

other purpose unless they meet one of the qualifications

listed above.

Generally, declarations for representation in cases appealed

beyond the Department of Revenue must be in writing to the

Tax Court Magistrate. A person recognized by a Tax Court

Magistrate will be recognized as your representative by the

department.

Tax matters partners and S corporation shareholders. See

OARs 150-305.242(2) and (5) and 150-305.230 for additional

information. Include the partnership or S corporation name

in the taxpayer name area.

Out-of-state attorneys and CPAs

Attorneys may contact the Oregon State Bar for information

on practicing in Oregon. If your out-of-state representative

receives authorization to practice in Oregon, attach proof to

this form.

CPAs may practice in Oregon if they meet the following

substantial equivalency requirements of ORS 673.010:

1. Licensed in another state;

2. Have an accredited baccalaureate degree with at least 150

semester hours of college education;

3. Passed the Uniform CPA exam; and

4. Have a minimum of one year experience.

Have questions? Need help?

General tax information ...................... www.oregon.gov/dor

Salem ............................................................... (503) 378-4988

Toll-free from an Oregon prefix ................1 (800) 356-4222

Asistencia en español:

En Salem o fuera de Oregon ........................(503) 378-4988

Gratis de prefijo de Oregon ......................1 (800) 356-4222

TTY (hearing or speech impaired; machine only):

Salem area or outside Oregon .....................(503) 945-8617

Toll-free from an Oregon prefix ................1 (800) 886-7204

Americans with Disabilities Act (ADA): Call one of the help

numbers above for information in alternative formats.