We acknowledge your bills indicating a balance you claim
to be due you in the amount of $ _________.
This alleged debt is disputed for the following reasons:
As an offer in compromise, and without admitting
liability, we offer to settle this claim in full for the sum of
$___________. Our check in said amount is enclosed and
your depositing of the check will signify your agreement and will
discharge the entire amount claimed and release us from all
liability thereon.
Very truly yours,
___________________________
Form 111
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