Oklahoma Application for Settlement of Tax Liability

Application for Settlement of Tax Liability
Packet S-I Application for Settlement of Tax Liability for Individuals
Application
for Settlement
of Tax Liability
for Individuals
This Packet Contains:
•	 Information You Need to Know Before Submitting the Application for Settlement of Tax Liability
•	 Form OTC-600 - Application for Settlement of Tax Liability
•	 Information for Completing the Statement of Financial Condition for Individuals
•	 Form OTC-600-A - Statement of Financial Condition for Individuals
•	 Form OTC-600-D - Document Checklist
•	 Form BT-129 - Power of Attorney

Oklahoma Tax Commission
Oklahoma City, Oklahoma 73194
Packet S-I
Revised 12-2024

Information You Need to Know Before Submitting the Application for
Settlement of Tax Liability
What Are the Grounds for Requesting a Settlement of Tax Liability?
The Oklahoma Tax Commission (OTC), as authorized by 68 OS Sec. 219.1, will consider a settlement of tax liability when
it is determined that:
	

A.	 Collection of the tax, and interest and penalties accruing thereto, would reasonably result in the taxpayer declaring
bankruptcy;

	

B.	 The tax is uncollectible due to insolvency of the taxpayer resulting from factors beyond the control of the taxpayer 	
or for other similar cause beyond the control of the taxpayer;

	

C. The tax liability is attributable to actions of a person other than the taxpayer and it would be inequitable to hold the 	
taxpayer liable for the tax liability; or

	

D.	 In cases of nonpayment of trust fund taxes, the taxes were not collected by the taxpayer from its customer and the
taxpayer had a good faith belief that collection of the taxes was not required;

Administrative rules for the settlement process are found at 710:1-5-80 et. seq. of the Oklahoma Administrative Code.

Am I Eligible?
Taxpayers are eligible to file an Application for Settlement if they believe they qualify for settlement on one or more of the
grounds referenced above and the following eligibility requirements are met:
	

1)	 The tax liability must be final;

	

2)	 All administrative remedies and appeals must be exhausted;

	

3)	 The taxpayer must be current with all tax return filing requirements of the OTC;

	

4)	 The taxpayer must not be the subject of an open bankruptcy proceeding

	

5)	 The taxpayer must not be the subject of a State tax related criminal investigation or prosecution.

When Am I Not Eligible?
	

1) 		Settlement of liability is not available if the taxpayer does not meet one of the four grounds for settlement listed 	
above and all of the eligibility requirements.

	

2) 		Trust fund taxes collected, but not remitted to the OTC, can not be settled for less than the amount of tax
collected.

	

3) 		Appointed or elected officials are not eligible to seek relief.

Making an Offer for Settlement of Tax Liability
•	

An Application for Settlement of Tax Liability, Packet S-I and/or Packet S-T, must be submitted to the Oklahoma Tax
Commission.

•	

If the settlement is requested on grounds A or B, an Application for Settlement of Tax Liability must be accompanied
by (1) the appropriate Statement(s) of Financial Condition for Individuals and/or Businesses, and (2) all documentation
required to support the facts and figures on those forms.

•	

For individual taxpayers that apply for settlement on grounds A or B, proof of employment, income, commissions, fees,
pensions, etc., must be provided for the taxpayer, spouse and dependants. Although the taxpayer may be the only
person liable for the tax, this information is needed for equitable distribution of cost of living expenses.

•	

Applications submitted by individuals who are self employed or are business owners must include Statements of
Financial Condition for both individuals and businesses.

•	

When Settlement is requested by a business, Statements of Financial Condition for Individuals may also be required
of corporate officers or business partners.

•	

If the settlement is requested exclusively on grounds C or D, no Statements of Financial Condition is required. Additional
documentation in support of the taxpayerʼs claim may be requested based on individual circumstances.

•	

The Income Tax Accounts (ITA) Division will evaluate the Application and make a recommendation to the Commission
to accept or reject the offer. The ITA may request additional documentation to verify financial or other information
concerning the Application. The ITA’s financial investigation may require verifica­tion of financial data by visual inspection
of records and personal interview.

•	

The Commission may consider additional circumstances when determining whether to enter a settlement agreement.
These circumstances may include, but are not limited to: whether the taxpayer has made efforts in good faith to comply
with the tax laws of Oklahoma; whether the taxpayer has benefited from nonpayment of the tax; and involvement of
the taxpayer in economic activity from which the liability originated.

•	

Power of Attorney must be submitted in all cases where the taxpayers designate another individual to submit their application.

If the Settlement Application Is Accepted
The ITA Division will notify the applicant by mail if the Application is accepted. Payment of the accepted settlement offer
must be made by the payment due date as indicated on the acceptance letter. Any issued and recorded tax lien subject to
the accepted settlement amount will be released and mailed upon full payment of the settlement amount. Payment of the
settlement amount by cash, cashierʼs check, money order, or charge to an approved credit card will assure faster release
of the lien. Compliance with all terms and conditions of the settlement agreement is required.
In the event the amount abated exceeds $25,000.00, the settlement agreement must be approved by Oklahoma County
District Court. In cases that require district court approval, lien releases will not be issued until the taxpayer provides
the Division with a certified copy of the Oklahoma County District Courtʼs order approving the agreement and fulfills all
requirements specified in the agreement.

If the Settlement Application Is Declined
The ITA Division will notify the applicant by mail if the application is declined. The applicant should immediately contact
the Oklahoma Tax Commission to arrange payment of the entire liability. If immediate payment of the entire liability is not
possible, the applicant may request an installment payment arrangement through the Collections Division of the Oklahoma
Tax Commission. Oklahoma law makes no provision for appeal of a declined Application.

The Commission May Reject the Application as not Processable
for any of the Following Reasons:
(1)	
(2)	
(3)	
(4)	
(5)	
(6)	
(7)	
(8)	

The applicant is not adequately identified (name, address, ID#, etc.) or required signatures are not provided.
The settlement offer includes an amount already collected or subject to refund.
The tax liability is not adequately identified.
The Application does not include a statement supporting the reason for the settlement.
Financial statements or other required documentation have not been included or are incomplete.
The Commissionʼs records indicate noncompliance with filing of required returns.
The applicant is currently under bankruptcy court jurisdiction.
Power of Attorney Form BT-129, if required, has not been included.

Other Information Concerning Settlement of Tax Liability
•	

	The

•	

	Any

•	

	All

•	

	Any collection by the Commission prior to approving a Settlement Agreement or any refund to which the Commission

•	

	Timely

•	

	Tax liens will be released only after an Application for a Settlement is accepted and all requirements of the settlement

•	

	Acceptance

•	

	No

Commission may suspend the enforcement of collection while a settlement offer is being considered. Any
installment payment arrangement already in effect will be continued while the settlement offer is considered. Interest
and penalty will continue to accrue on any unpaid tax debt while the settlement offer is being considered.
payment made with the Application for Settlement of Tax Liability will be applied to the outstanding liability. 	
Payments will not be refunded if the Application is declined or withdrawn.
information and statements provided by the applicant are subject to verification, and are submitted under oath.

is entitled cannot be considered part of the settlement offered.

filing of all tax returns is required while the Application is pending and during any pay-out period allowed.

agreement are fulfilled.

of an Offer in Compromise by the Internal Revenue Service does not guarantee acceptance by the
State. An Application for Settlement tendered to the Commission will be reviewed and evaluated on its own merits.
information written in this Application shall be construed as granting any legal right to any taxpayer for the 	
settlement of any tax liability. The decision of the Commission in denying a settlement offer shall be final and no 	
right of appeal to any court may be taken from such decision.
Mail the completed Application along with all supporting schedules and documents to:

	
	

Oklahoma Tax Commission
Oklahoma City, Oklahoma 73194

Looking for Additional Information?
No matter what the tax topic, the OTC invites you to visit us at tax.ok.gov to get any additional information you
might need.

Still can’t find what you need?
Contact our Taxpayer Resource Center at 405.521.3160.

Form OTC-600 (Page 1)

Oklahoma Tax Commission
Application for Settlement of Tax Liability
	

1. Applicant(s) Name and Address

Social Security Number

	 ____________________________________________________________________

Social Security Number

	 ____________________________________________________________________

FEI Number

	 ____________________________________________________________________
	 ____________________________________________________________________

County
Daytime Phone Number (area code and number)

	 ____________________________________________________________________
	

2. Applicant(s) Mailing Address (If different from above)

	 ____________________________________________________________________
	 ____________________________________________________________________

3. Applicant(s) Legal Structure
	

Individual	

Proprietorship

	

Partnership	

Corporation

	

Trust/Estate	

Corporation Officer(s)

4. I/We agree to pay the amount of $____________________ 	to settle the tax liabilities listed in Section 5 below and will pay this 	
	 amount in the following manner: (Check One Only)
	 	

Paid in full with this agreement. (Make check payable to the “Oklahoma Tax Commission”)

		

A deposit of $___________________ 	is attached, the balance to be paid within 30 days from acceptance.

		

The settlement amount will be paid in________ monthly payments of___________________ .

5. Description of Tax Liabilities To Be Settled.
Tax Type

Account Number

Period(s)

Individual Income Tax

Other (Specify)

6. Grounds for settlement:
	 A	

Collection of the tax with interest and penalties would reasonably result in the taxpayer declaring bankruptcy.

	 B	
		

The tax liability is uncollectible due to the insolvency of the taxpayer resulting from factors beyond the control of the
taxpayer or other similar factors.

	 C	

The tax liability is the result of actions of a person other than the taxpayer and to hold taxpayer liable for the tax liability
would be inequitable.

	 D	

In case of “trust fund taxes”, the applicant must show that the tax was not collected and that the applicant had a good faith
belief that collection of the taxes was not required. (Trust fund taxes collected, but not remitted to the Commission, can not
be settled for less than the amount of tax collected.)

Form OTC-600 (Page 2)

	 7. If any or all of the amount offered is from a loan or gift, provide the name of the lender or donor.

	 _____________________________________________________________________________________________________________________
	 _____________________________________________________________________________________________________________________

	 8. If any or all of the amount offered is from a source other than a loan or gift, provide the name of the source.

	 _____________________________________________________________________________________________________________________
	 _____________________________________________________________________________________________________________________

	 9.1 If you marked Grounds A or B on page one, Item 6, or are requesting a settlement based in part on financial hardship,
provide (a) a detailed explanation of the events that resulted in the tax liability, (b) why the tax was not filed and/or paid
when it was due, and (c) the circumstances that presently prevent you from paying in full.
	 _____________________________________________________________________________________________________________________
	 _____________________________________________________________________________________________________________________
	 _____________________________________________________________________________________________________________________
	 _____________________________________________________________________________________________________________________
	 _____________________________________________________________________________________________________________________
	 _____________________________________________________________________________________________________________________
	 _____________________________________________________________________________________________________________________

	 9.2 If you marked Grounds C or D on page one, Item 6, provide a detailed explanation of the nature of the events that resulted in the tax liability. You may also include any other information that supports your grounds for settlement.
	 _____________________________________________________________________________________________________________________
	 _____________________________________________________________________________________________________________________
	 _____________________________________________________________________________________________________________________
	 _____________________________________________________________________________________________________________________
	 _____________________________________________________________________________________________________________________
	 _____________________________________________________________________________________________________________________
	 _____________________________________________________________________________________________________________________

Form OTC-600 (Page 3)

10.	 Terms and Conditions
By submitting this Application and signing below, I/we are requesting from the Oklahoma Tax Commission settlement of tax liability
as authorized by 68 OS Sec. 219.1. I/we understand and agree to the Terms and Conditions of the Application for Settlement of
Tax Liability as follows:
	 a)	 I/We voluntarily submit any payment made with this Application.
	 b)	 The Commission will apply any payment made with the Application to the oldest existing tax liabilities.
	c)	 If the Commission rejects the Application or if the Application is withdrawn, the Commission will treat any 		
amount paid with the Application as payment toward the outstanding tax liability.
	d)	 I/We will remain in compliance with all tax return filing and payment provisions of Oklahoma Statutes while 		
this Application is pending and during the period of any subsequent pay plan arrangement.
	 e)	 The Application remains pending until an authorized Commission official issues notification of acceptance or 		
rejection, or until the Application is withdrawn by me/us.
	 f)	 I/We understand that collection activities may continue during the review process, however, the Commission 		
may suspend its collection efforts if the interests of the State will not be compromised.
	g)	 Payments and refunds applied prior to receipt of the Application by the Commission cannot be considered 		
part of the settlement offer and are not subject to refund.
	h)	 I/We understand that the tax owed will remain a tax liability until all the terms and conditions of the settlement
agreement are met. If I/we file bankruptcy before the terms and conditions of the settlement agreement are completed,
any claim the Commission files in a bankruptcy proceeding will be a tax claim.

Under penalty of perjury, I/we declare that the information contained in this Application for Settlement of Tax Liability, Attachments,
and Schedules are true and correct to the best of my knowledge and belief.

__________________________________________	
	
Applicant’s Signature	

________________________
Date

__________________________________________	
	
Applicant’s Signature	

________________________
Date

__________________________________________	
	
Power of Attorney Signature	

________________________
Date

Mail to: 	Oklahoma Tax Commission
	
Oklahoma City, Oklahoma 73194
Note: If settlement is requested on grounds A or B, the Statement of Financial Condition for Individuals Form OTC-600-A, located
in Packet S-I, and/or Statement of Financial Condition for Businesses Form OTC-600-B, located in Packet S-T, must be completed,
signed and attached along with the required supporting documentation. In all cases, additional documentation may be requested
for verification of information.

Information for Completing the
Statement of Financial Condition for Individuals
Income Sources
Calculating Gross Monthly Wages and Salaries:

	•	
	•	
	•	

If paid weekly – multiply weekly gross wages by 4.33
If paid bi-weekly (every 2 weeks) – multiply bi-weekly gross wages by 2.17
If paid semi-monthly (twice each month) – multiply semi-monthly gross wages by 2

Salaries, Wages, Pensions and Social Security: Enter your gross monthly totals from these income sources.
Do not deduct payroll withholdings, allotments or other items you elect to take out of your pay, such as insurance
payments, credit union deductions, car payments, etc.
Net Rental Income: Enter your monthly net rental income. This is the amount remaining after you pay ordinary and
necessary monthly rental expenses. If your net rental income is a loss, enter “0”. Do not enter a negative number.
All income amounts are to be reported at Gross Amount except Rental Income.

Monthly Expenses
Expenses Generally Not Allowed:

	•	
	•	
	•	
	•	
	•	
	•	

Tuition for private secondary schools;
Tuition for public or private colleges;
Charitable contributions;
Voluntary retirement contributions;
Payments on unsecured debts such as credit card bills;
Other similar discretionary expenses.

Exceptions may be granted for expenses if you can prove that they are necessary for the health and welfare of you or
your family or for the production of income.

Form OTC-600-A (Page 1)

Oklahoma Tax Commission
Statement of Financial Condition for Individuals
The information requested in this statement should include all household income and expense.
Spouse and dependent information are required although only one person may be liable for the tax.
Section I - Personal Information
1. Taxpayerʼs Name(s) and Residence Address

2. Daytime Phone Number

3. Marital Status (Check One)
	Single	

________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
County _______________________ Do you own	

or rent	

?

6. Previous Address If At Current Address Less Than Two Years
________________________________________________________
________________________________________________________
________________________________________________________

Married

	 Separated	Divorced
4. Social Security Number

5. Date of Birth

Taxpayer:_____________________

Taxpayer:_____________________

Spouse:______________________

Spouse:______________________

7. Income Tax Return Information
A. Year of Last Filed Federal Income Tax Return	 __________________
B. Federal Adjusted
	 Gross Income From Last Return	

$___________________

C. Year of Last Filed
	 Oklahoma Income Tax Return	

__________________

Section II - Employment Information
8. Taxpayerʼs Employer or Business - Name and Addresss
________________________________________________________
________________________________________________________

9. Employer Phone Number

10. Occupation

11. Length of Employment

12. Work Relationship
	Employee	

Proprietor

	

Officer

________________________________________________________

Years_________	Months________

13. Spouseʼs Employer or Business - Name and Address

14. Employer Phone Number

15. Occupation

16. Length of Employment

17. Work Relationship

________________________________________________________
________________________________________________________

Partner	

	Employee	

Proprietor

	

Officer

________________________________________________________

Years_________	Months________

18. Taxpayerʼs Part-time and Previous Employment

19. Spouseʼs Part-time and Previous Employment

Employerʼs Name

Employment Dates

Partner	

Employment Dates

Employerʼs Name

To

To

To

To

To

To

Section III - Dependent Information
20. Dependent Name (Other Than Spouse)

Social Security
Number

Date of Birth

Relationship

Monthly Income
$
$
$
$
$

Form OTC-600-A (Page 2)

Section IV - Assets
21. Cash on Hand

	

TOTAL (Enter also on Page 3, Item 28-A) $

22. Bank or Credit Union Accounts (Checking, Savings, Certificate of Deposit, etc.)
Account Number

Name of Institution and Address

Type of Account

Balance
$
$

	

TOTAL (Enter also on Page 3, Item 28-B) $

23. Investments (Stocks, Bonds, Mutual Funds, IRA, Government Securities, Money Market Funds, etc.)
Quantity or
Denomination

Issuer

Type

Current
Value
$
$
$

	

TOTAL (Enter also on Page 3, Item 28-C) $

24. Real Property (Personal Residence, Vacation or Second Home, Investment Property, Unimproved Land, etc.)
Description

Current Market
Value

Address

Equity in
Property

Amount
Owed
$
$
$

	

TOTAL (Enter also on Page 3, Item 28-D) $

25. Vehicles - Excluding Leased Vehicles (Including Motor Homes, Campers, Motorcycles, Boats, Trailers, etc.)
Description

Make

Model

VIN
Number

Year

Current Market
Value

Amount
Owed

Equity in
Vehicle
$
$
$

	

TOTAL (Enter also on Page 3, Item 28-E) $

26. Other Assets
Current
Appraised Value

Current
Appraised Value
Notes Receivable

$

Furniture/Personal Effects

$

Cash Surrender Value of Life Insurance

$

Jewelry

$

Judgments or Settlements Receivable

$

Timber, Mineral or Drilling Rights

$

Vested Retirement Account

$

Patents or Copyrights

$

Collectibles, Antiques or Artwork

$

Other (Specify)

$

	

TOTAL (Enter also on Page 3, Item 28-F) $

Form OTC-600-A (Page 3)

Section V - Liabilities
27. Liabilities (Do not include any amounts owed listed in Section IV above)
Description

Total Amount Owed

Description

Total Amount Owed

Notes Payable

$

Past Due Other Taxes

$

Installment or Personal Loans

$

Vehicle Leases

$

Education or Student Loans

$

Other Liabilities (specify)

$

Bank Revolving Credit/Credit Card Debt

$

$

Judgements Payable

$

$

Past Due Federal Taxes

$

$

Past Due State Taxes

$

$
TOTAL (Enter this total on Item 29 below)

$

Section VI - Net Worth Calculation
28. Assets
A. Cash

$

B. Bank or Credit Union Accounts

$

C. Investments

$

D. Real Property

$

E. Vehicles

$

F. Other Assets

$
$

Total Assets
29. Liabilities

$

30. Net Worth (“Total Assets” Minus “Liabilities”)

$

Section VII - Other Information
31. Are you currently in filing compliance with all Oklahoma taxes?	
	

No

Yes	

No

If “No”, identify tax type and period:___________________________________________________________

32. If the tax liability was incurred in the operation of a business, has the business been discontinued?	
	

Yes	

Date discontinued:_________________________________________________________________________

33. Have you disposed of any assets or property by sale, transfer, exchange, gift, or in any other manner during the past 18 months?
	
	

If “Yes”, identify:___________________________________________________________________________	Yes	

No

34. Is a foreclosure proceeding pending on any real estate that you own or have an interest in?	

Yes	

No

35. Is anyone holding any assets on your behalf?	

Yes	

No

	

If “Yes”, identify type of assets and value: ___________________________ Relationship of asset holder:___________________________

36. Are you a party to any lawsuit now pending?	

Yes	

No

37. Is there a likelihood that you will receive assets or income from an estate in probate?	

Yes	

No

	

If “Yes”, from whom? ____________________________________________ Relationship:_______________________________________

38. Have you previously petitioned the Commission for settlement of any tax liability?	
	

	

No

Yes	

No

Yes	

No

If “Yes”, from whom?_______________________________________________________________________

41. Do you anticipate any increase in household income in the next two years?	
	

Yes	

Bankruptcy Case Number:__________________________________________________________________

40. Do you have income sources other than your business or employer?	
	

No

If “Yes”, identify tax type and period:___________________________________________________________

39. Are you or any business that you own currently under bankruptcy court jurisdiction?	
	

Yes	

If “Yes”, how much will the income increase? $ ________________________ Why will it increase?_________________________________

42. Do you have credit available on credit cards? (i.e. Visa, MasterCard) If yes, attach schedule indicating the amount available on each card.

Form OTC-600-A (Page 4)

Section VIII - Income and Expense Analysis
43. Monthly Household Disposable Income
Gross Monthly Income
Source

Monthly Living Expenses
Taxpayer

Spouse

Source

Amount

Salary, Wages, Commissions and Tips

$

$

House or Rent Payment

$

Self-Employment Income

$

$

Income Taxes (Federal, State, FICA)

$

Pensions, Disability and Social Security

$

$

Estimated Quarterly Tax (If Applicable)

$

Dividends, Interest and Investments

$

$

Groceries

$

Gift or Loan Proceeds

$

$

Medical Expenses and Prescriptions

$

Net Rental Income

$

$

Utilities:

Estate, Trust and Royalty Income

$

$

Electric	

$

+

Workersʼ Compensation and Unemployment $

$

Water	

$

+ Phone	 $

= $

Alimony and Child Support

$

$

Insurance:

Other (Specify)

$

$

Life	

$

+ Health	 $

+

$

$

Auto	

$

+ Home	 $

= $

$

$

Court Ordered Payment

$

$

$

Child Care

$

$

$

Clothing and Personal Grooming

$

$

$

Transportation Expense

$

$

$

Vehicle Loan Payment

$

$

$

Vehicle Lease Payment

$

$

$

Property and Ad Valorem Taxes

$

$

$

Other (Specify)

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Subtotal

Gas	 $

+

Total Monthly Living Expenses

$

44. Net Monthly Household Disposable Income (“Combined Monthly Income” Minus “Total Monthly Living Expenses”)

$

Combined Monthly Income

$

Form OTC-600-A (Page 5)

Oklahoma Tax Commission
Oklahoma City, Oklahoma 73194

Statement of Financial Condition for Individuals
I/We have examined this Statement of Financial Condition for Individuals and hereby affirm that to the best of my/our
knowledge and belief, it is true, correct and complete.

__________________________________________	
	
Applicant’s Signature	

________________________
Date

__________________________________________	
	
Applicant’s Signature	

________________________
Date

__________________________________________	
	
Power of Attorney Signature	

________________________
Date

(Attach Form BT-129 Power of Attorney)

Form OTC-600-D

Oklahoma Tax Commission
Application for Settlement of Tax Liability
Document Checklist
An application submitted pursuant to the provisions of 68 OS Sec. 219.1 will require an in-depth analysis of your
financial condition. To expedite this process, it is necessary that you provide the following additional information and
documents along with your initial application.

	

Provide proof of gross earnings, pension, social security and other income, including statements showing
deductions for the past three months.

	

Provide copies of federal income tax returns for three most current years, and copy of your IRS Offer-in
Compromise agreement. If you filed your return electronically, you do not submit your federal return. Only
provide a copy of your offer and acceptance letter from the IRS.

	

Provide copies of bank statements for all checking and savings accounts, personal and business, for the three
most current periods.

	

Provide copies of statements, showing the value of your interest in all retirement accounts, pensions, and
profit sharing plans for the three most current periods.

	

A list of all stocks, bonds, and/or other securities you own, along with the current market value for each.
Provide the most current brokerage statements where available.

	

A statement from the insurance company for each life insurance policy showing the current cash loan value,
accumulated dividends and interest, dates and amounts of policy, loans, and the amount of loan.

	

Statements for all mortgages of real estate you own or have interest in. Also appraisals, if any, on all real
estate you own or have interest in.

	

Statement from lending institutions and other creditors that clearly indicates current balances owed, and
payment schedules on all notes payable and/or revolving accounts.

	

Copies of any judgements or legal decrees, (excluding bankruptcy), for past six years.

	

Copies of medical bills not covered by insurance and documentation from insurance company indicating the
items are not covered.

	

Copies of expenses including utilities, rent, insurance, property taxes for last ninety days.

	

A list of all your business equipment, office furniture, and other business assets, including fair market value of
each item, copies of documents, etc.

	

A list of all accounts and loans receivable, showing the payer, amount due, age, and status of each account.

Return this document checklist with your Application For Settlement of Liability and Statement(s) of Financial
Condition. For any item above that is not required, mark “NA”.

Form BT-129
Revised 11-2021

Oklahoma Tax Commission
Oklahoma City, Oklahoma 73194

Power of Attorney
(Please Type or Print.)

Taxpayer Name and Address:

Social Security/Federal Employer Identification Number(s):
Daytime Telephone Number:

Permit Number(s):

Hereby appoints:
Representative(s) Name and Address:

Daytime Telephone Number:

Fax Number:

Representative(s) Name and Address:

Daytime Telephone Number:

Fax Number:

Note: If you appoint an organization, firm or partnership, you must also name an individual within the organization to act on your behalf.
As attorney(s)-in-fact to represent taxpayer before the Oklahoma Tax Commission (OTC) and/or acquire any tax form(s) and/or documents that taxpayer would be entitled to receive.
Type of Tax
(Income, Sales, etc.)

State Tax Number or
Description of Tax Document

Year(s) or Period(s)
(Date of Death if Estate Tax)

The attorney(s)-in-fact (or either of them) are authorized, until written revocation is received, to represent the taxpayer before the OTC
and receive confidential information and to acquire any and all tax forms and/or documents that the principal(s) can receive with respect
to the above specified matter(s) unless exceptions are noted below:

▼

Retention/Revocation of Prior Power(s) of Attorney. The filing of this Power of Attorney automatically revokes all earlier power(s) of
attorney on file with the OTC for the same matters and years or periods covered by this document.
If you do not want to revoke a prior Power of Attorney, check here..................................................................................................
Attach a copy of any Power of Attorney you want to remain in effect.
Taxpayer(s) Signature and Date. If signed by a corporate officer, partner or fiduciary on behalf of the taxpayer, I certify that I
have the authority to execute this Power of Attorney on behalf of the taxpayer.
Signature

Title (If applicable)

Date

Type or print your name below if signing for a taxpayer who is not an individual.
Name

Title (If applicable)

Date

Declaration of Representative

Under penalties of perjury, by my signature below, I declare that:
	
•	 I am authorized to represent the taxpayer identified above for the matter(s) specified there; and
	
•	 I am one of the following:
	
	
	

Attorney – A member in good standing of the bar of the highest court of the jurisdiction shown below.
Certified Public Accountant – Duly qualified to practice as a certified public accountant in the jurisdiction shown below.
Enrolled Agent – Enrolled as an agent by the Internal Revenue Service per the requirements of IRS Circular 230.

	

Officer – A bona fide officer of the taxpayer organization.

	
	

Full-Time Employee – A full-time employee of the taxpayer.
Family Member – A member of the taxpayer’s immediate family.

	

Tax Return Preparer

	Other __________________________________________________________________________________________

Signature of Representative

Title (If applicable)

Date