Ohio Offer in Compromise

Claim of Exemption and Financial Declaration

Case Number:

Name of State Tax Agency:

Tax Agency Number:

Attorney or Party Without Attorney:

Telephone No.:    Fax No.:

Attorney for State Taxpayer/Respondent

Name of Court:

Street Address:

Mailing Address:

City and ZIP Code:

Branch Name:

Application of (Name):

Taxpayer/Respondent

1. I need the following earnings to support myself or my family:

All earnings    $ each pay period

2. Please send all papers to:

me    my attorney    at the address shown above    following (specify):

3. In addition to the 25 percent minimum withholding, I am willing for the following amount to be withheld from my earnings during the withholding period:

None    Withhold: $ each pay period

4.

a. I am paid daily weekly every two weeks twice a month monthly

b. My gross pay is: $ per pay period

c. My take-home pay is: $ per pay period

d. My payroll deductions are (item and amount):

5. The following persons depend, in whole or in part, on me for support:

Name    Age    Relationship to me    Monthly income and its source

a. Myself

b.   Age:   Relationship:   Income/source:

c.   Age:   Relationship:   Income/source:

d.   Age:   Relationship:   Income/source:

e.   Age:   Relationship:   Income/source:

6. The earnings of others listed in item 5 are now subject to wage assignments and Earnings Withholding Orders as follows:

7. My monthly expenses are as follows:

a. Rent or house payment and maintenance $

b. Food and household supplies $

c. Utilities and telephone $

d. Clothing $

e. Laundry and cleaning $

f. Medical and dental payments $

g. Insurance (life, health, accident, etc.) $

h. School, child care $

i. Child, spousal support (prior marriage) $

j. Entertainment and incidentals $

k. Transportation and auto expenses (insurance, gas, repair) $

l. Installment payments (insert total and list below in item 8) $

m. Other (specify): $

Total Monthly Expenses (add a through m): $

8. List payments on installment and other debts. Continued on Attachment 8.

9. What do you own? (State value.)

a. Cash $

b. Checking, savings and credit union accounts, etc. (list institutions):

c. Cars, other vehicles, and boat equity (list make, year of each):

d. Real estate equity (addresses):

e. Other personal property jewelry, furniture, furs, stocks and bonds, etc. (list separately): Total for item e - $

10. An Order Assigning Salary and Wages (for support) is now in effect as to my earnings. The amount payable under that order is: $ monthly.

11. Other facts that support this Claim of Exemption are: Continued on Attachment 11.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

File this form with the clerk of the court and mail a copy to the tax agency as soon as possible. Keep a copy and take it with you to the court hearing. If you wish to obtain the advice of an attorney, you should do so at once.