Form 2000 - 4 
 
                   Arkansas Department of Finance and Administration 
                          Settlement or Compromise of Tax Liability 
                                                                                                   
        Submit this Form and other items listed in the checklist on page 6 via postal mail to the 
                         following address. Please do not submit via fax or email. 
  
             An application without the required attachments will be returned for completion. 
                                                                                                   
                              Department of Finance and Administration 
                                           OIC Program 
                                           P.O. Box 2717 
                                   Little Rock, AR 72203-2717 
                                   Telephone  –(501) 682-7751 
 
  Item 1- Name of Individual Taxpayer or Primary Business Owner, Home Address & Telephone 
  
  Name: 
  
  Street Address: 
  
  City, State, ZIP Code: 
                          
  Telephone Number: (     ) 
                          
  Fax Number:      (      ) 
                          
  E-mail Address:                          @ 
 
  Item 2  –Business Name, Address and Telephone Number 
  
  Business Name: 
  
  Street Address: 
  
  City, State, ZIP Code: 
  
  Telephone Number:   (     ) 
  
  Fax Number:          (  ) 
 
  Item 3 - Social Security Numbers  - Individual Taxpayer’s or Business Owner’s 
                                                  
  (a) Primary:                                     (b) Secondary:                                  
 
  Item 4  –Sales Tax Permit Number 

  Item 5  –Federal Employer Identification Numbers or other Permit Numbers 
 
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  Rev 1/2019 

  Item 6  –To:  Assistant Commissioner of Revenue 
 
  I/We submit this  offer to compromise the tax liabilities plus any interest, penalties, additions to tax,  and additional 
  amounts required by law for the tax type and period marked below. Mark an “X” in the box by the correct type of tax 
  and list the period(s) included in your offer. 
 
       Individual Income Tax   – List Year(s) 
 
       Withholding Tax   – List Months and Years 
 
       Sales/Use Tax   – List Months and Years 
 
       Other Tax(es) 
 
  Type(s)                                                Months/Years 
                                                          
  Note:  If you need more space, attach a separate page. 
 
  Item 7  –Bankruptcy 
 
  List all prior bankruptcies. Attach separate sheet if needed. Please list NA, if not applicable. 
 
  Date Filed              Docket Number                               Date of Discharge or Dismissal 
                                                            
                                                         2 
  Rev 1/2019 

 Item 8  –Why is a payment plan (equal monthly payments over specified period of time) not an 
 option to settle this liability? 
 
 Item 9 - I/We submit this offer for the reason(s) checked below: 
 
      Controversy Over  Amount of Tax Due   –  “I do not believe I owe this          amount.” You must include  a 
 detailed explanation of the reasons why you believe you do not owe the tax. 
 
      Insolvency   – “I have insufficient assets and income to pay the full amount.” REFER TO CHECKLIST FOR 
 ADDITIONAL ITEMS THAT MUST BE SUBMITTED WITH THIS FORM. 
 
 Item 10  –Amount of offer. 
 
 I/we offer to pay $              .  This amount cannot be zero or practically zero and must be reasonable for the 
 State to accept, consistent with your financial circumstances. 
 
      Paid with this offer. This payment is not deemed to be a payment on a payment plan agreement or settlement 
 of any kind. It will be accepted as a good faith payment and applied to the outstanding tax debt previously detailed 
 in this form. 
 
       Paid  in  full  within  30  days  of  acceptance  of  this  offer  by  the  Arkansas  Department  of  Finance  and 
 Administration. 
 
 Note: Make  all  checks  payable  to: Arkansas  Department  of  Finance  and  Administration.  Payments 
 other than cash must be made with certified funds, such as a cashier’s check or money order. Payment 
 by credit card is available for individual income tax only. 
 
 List the source of the funds in Item #10 on the line below: 
 
 By submitting this offer, I/we understand and agree to the following condition: 
 
 I/We understand that I/we remain responsible for the full amount of the tax liability, unless and until the 
 Department of Finance and Administration accepts the offer in writing and I/we have met all the terms 
 and conditions of the offer. The Department will not remove the original amount of the tax liability from 
 its records until I/we have met all the terms of the offer. 

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 Rev 1/2019 

                                 Explanation of Circumstances 
                                     (Individual Taxpayer/ Business Taxpayer)                                                   
 
 Please  explain  why  the  Department  of  Finance  and  Administration  should  consider  this  Offer  in  Compromise. 
 Please include a statement as  to why tax was  not collected or remitted for the period for which the offer is being 
 made. If any liabilities listed on the financial statements (433 A/B forms) are the result of debts to family members, 
 please  specifically  detail  the  nature  of  the  debt  and  the  family  relationship. Use  the  space  below  and  attach 
 additional sheets if necessary. 
 
                                                                                                                           _ 
 Taxpayer’s or Business Name (printed)     Prepared by (if other than taxpayer) 
 
 Signature of Taxpayer or Business Owner   Date                                            Corporate Title (if applicable) 

 Spouse’s Name (if applicable) (printed) 
                                                                                            
                               _         _      _ 
 Signature of Spouse (if applicable)       Date 

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 Instructions for the Form 2000-4, Settlement or Compromise of Tax Liability 
                                                                                                    
 Item # 
 
 1.  Complete if offer is for individual, partnership, or closely held corporation. 
 
 2.  Complete if the offer is for a business debt in the form of a Sole proprietorship, Corporation, 
 LLC, Partnership, or S Corporation. 
 
 3.  Self explanatory. 
 
 4.  Complete if the offer is for Sales tax owed.  If this number is not known, please call 501- 
 682-1895 for assistance. 
 
 5.  Complete if the offer is for Withholding tax, Income tax, or, if applicable, for other taxes. 
 
 6.  Check  the  appropriate  box  and  list  the  months/years  of  debt  owed  to  the  Department. 
 Attach  a  separate  sheet  if  necessary.  A  copy  of  a  Sales  Tax  Transcript,  showing  all 
 periods due, will suffice if the type of tax due is Sales tax. 
 
 7.  Complete if taxpayer filed bankruptcy.  If not, list NA. 
 
 8.  This question must be answered.  Please use an additional sheet if necessary. 
 
 9.  Check the appropriate box.  If Controversy over Amount of Tax due, an explanation must 
 be enclosed with the offer as to what part of the law the controversy is based. 
 
 10. Enter the amount that can be paid with the offer or within 30 days of the offer. The amount 
 entered cannot be zero.  If this item is not completed, the offer will not be reviewed.  It will 
 be considered an incomplete offer and will be withdrawn. In the space provided in the note, 
 include a statement identifying the source of the funds that are being used in the Offer in 
 Compromise  such  as,  borrowed  money  from  bank,  withdrew  savings,  etc.  The  amount 
 must be paid with certified funds payable to the Department of Finance and Administration. 
 
 Waiver of Penalty and or Interest. If the Form 2000-4 is submitted only for the purpose of waiver 
 of  penalty  and  or  interest  only  the  four  pages  must  be  completed.  You  must  include  on  the 
 explanation  of  circumstances  page  the  reason  the  waiver  is  being  requested  and  the  facts  and 
 circumstances that caused the penalty and or interest to be assessed. 
 
 Explanation of Circumstances.  This page must be completed.  Failure to complete this will result 
 in the offer not being reviewed. A separate page can be attached if necessary. This form must be 
 signed and dated. If the offer is for income tax filed by a taxpayer and spouse, both must sign the 
 offer.  If  the offer  is for a  business,  an  owner  and/or  a  corporate  officer  must  sign  and  date  the 
 form.  If  someone  other  than  the  taxpayer  prepared  the  2000-4  form,  please  indicate  this  in  the 
 space provided and attach a Power of Attorney. 

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            Arkansas Department of Finance and Administration 
                Offer in Compromise Checklist 
 
 ➢ If the Offer requests abatement of penalty and interest only or is submitted under 
   “Controversy over Amount of tax due,” submit items #1 and #11. 
 
 ➢ If the Offer is submitted under “Insolvency,” submit all items listed below. 
 
 Failure to include ALL requested documents will cause your offer to be withdrawn from review.       
 
 1.  Completed Offer in Compromise Form 2000-4. 
 
 2.  IRS form 433A or 433F and/or 433B. 433A or 433F is completed for an individual 
   and/or sole  proprietor and 433B is completed for a business. Please complete both 
   forms if the  offer is for a partnership, single member LLC, or closely held 
   corporation. 
 
 3.  Copy of the last two (2) years federal and state income tax returns, if required to 
   file. If not required to file, please state reasons why below and include the last two 
   (2) years income and financial statements. 
 
 4.  Copy of last three paycheck stubs or other income (i.e., pension, social security, 
   alimony, or rental) if applicable. 
 
 5.  Copy of bank statements with check copies or images for the last 6 months (or 12 
   months  if  tax  due  is  over  $25,000),  as  well  as  any  other  financial  institution 
   statements for which you have check writing authority. 
 
 6.  Credit report less than 30 days old. 
 
 7.  IRS information,  if  applicable,  copy of  IRS Offer in Compromise and acceptance 
   letter or other IRS arrangements. 
 
 8.  Affidavit concerning real and personal property transfers within last two (2) years. 
 
 9.  Copy of most recent real property and personal property tax assessments. 
 
 10. Order of Discharge from Bankruptcy, if applicable, complete copy of petition and 
   schedules, and Statement of Intent for Chapter 7. 
 
 11. Power of Attorney, if applicable. 
 
 Complete  and  include  this  checklist  with  the  application.  Additional  information  may  be 
 requested  after  receipt  of  the  Offer  in  Compromise.  Mail  your  completed  and  signed 
 application with the documents listed above to the address listed on Page 1 of Form 2000-4. 

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