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Get and Sign Wi 212 Form 2020
Your offer is accepted, you must pay that amount within
ten (10) days from the date the offer is accepted or pay in accordance with an approved payment schedule.
1. Name of Petitioner
Social Security Number
Seller's Permit Number
Withholding Number
Business Address
Business Telephone
( )
Home Address
Home Telephone
( )
2. Record of Taxes Due
Type of Tax
Taxable Period
Unpaid Liability
3. Failure to pay the taxes listed above is due to the following...
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