Catalog Number 68987G www.irs.gov
Form
14773-A (Rev. 12-2017)
Form 14773-A
(December 2017)
Department of the Treasury - Internal Revenue Service
Offer in Compromise Withdrawal - Joint
Offer number Taxpayer Identification Number (last 4 digits) Taxpayer Identification Number (last 4 digits)
To whom it may concern:
We hereby withdraw our Offer in Compromise (OIC) dated
. We understand that by withdrawing this OIC,
we waive our appeal rights.
Signature
Name (printed)
Date
Signature
Name (printed)
Date
Please complete this section if you submitted a deposit with the OIC. (This does not include the non-refundable
application fee you paid.) (If you need additional space, attach a separate sheet.)
Amount of Deposit $
Check one
We wish to have our OIC deposit refunded to us.
We consent to the application against our outstanding tax liability, as shown below, of the above amount deposited on
my OIC.
Taxpayer ID Number (last 4 digits) Type of Tax Period Amount to be Applied
Sign here to acknowledge application of deposit
Signature
Date Signature Date
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signature
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signature
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dd mmm yyyy
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signature
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dd mmm yyyy
click to sign
signature
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dd mmm yyyy
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