Catalog Number 68986V www.irs.gov
Form
14773 (Rev. 12-2017)
Form 14773
(December 2017)
Department of the Treasury - Internal Revenue Service
Offer in Compromise Withdrawal
Offer number Taxpayer Identification Number (last 4 digits)
To whom it may concern:
I hereby withdraw my Offer in Compromise (OIC) dated
. I understand that by withdrawing this OIC, I waive
my appeal rights.
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
I wish to have my OIC deposit refunded to me.
I consent to the application against my 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
Date
click to sign
signature
click to edit
dd mmm yyyy
click to sign
signature
click to edit
dd mmm yyyy
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