Fillable Printable Offer In Compromise Financial Statement (De 999B)
Fillable Printable Offer In Compromise Financial Statement (De 999B)
Offer In Compromise Financial Statement (De 999B)
DE 999B Rev. 1 (1-15) (INTERNET) Page 1 of 3 CU
OFFER IN COMPROMISE FINANCIAL STATEMENT
NOTE: Complete all blocks except shaded areas. Write “N/A” (not applicable) in those blocks that do not apply.
Account No.: Business Name: Phone: ( )
Personal Information
Applicant’s Name and Address Married/Registered Domestic Partner
Yes No
If Yes, Spouse’s Name:
Applicant Spouse
Social Security Number
Social Security Number
Name, address, and phone number of next of kin Driver’s License Number
Driver’s License Number
Date of Birth
Date of Birth
Name, age, and relationship of dependents living in your household (exclude yourself and spouse)
Current Assets
Cash $
Bank Accounts (Include Savings and Loans, Credit Unions, IRA and Retirement Plans, Union Vacation Trust Funds, etc.)
Name of Institution Address Type of Account Account Number Balance
$
Accounts/Notes Receivable
Name Address Payment or Due Date Amount
$
Available Credit Sources: Credit Unions, Lines of Credit, or Charge Cards with cash advance feature, etc.
Type of Account
or Card
Name and Address of
Financial Institution
Amount
Owed
Minimum
Monthly Payment
Business or
Personal
Available
Credit
$ $ $
Securities: Stocks, Bonds, Mutual Funds, Money Market Funds, Government Securities, etc.
Kind Quantity or Denomination Where Located Value
$
Life Insurance
Name of Company Policy Number Type Face Amount Loan Value
$ $
Department Use Only Section A
______________
DE 999B Rev. 1 (1-15) (INTERNET) Page 2 of 3
Personal Assets: Vehicles, Boats, RVs, Motorcycles, etc.
Make Year License Number Market Value Balance Due Payoff Date Equity
$ $ $
Department Use Only Section B
______________
Real Property Assets (Include Partnerships and Investments)
Ownership Physical Address County Market Value Monthly Payment Mortgage Balance Equity
$ $ $ $
Department Use Only Section C
______________
Monthly Income and Expense Information
Income
Necessary Living Expenses
Applicant Gross Wages/Salaries
$ Mandatory Payroll Deductions $
(Attach last six months pay stubs)
Medical Expenses
Spouse Gross Wages/Salaries
Insurance
(Attach last six months pay stubs)
Court Ordered Payments
Net Business Income Child/Spousal Support (Name and Age)
Commissions
Net Rental Income
Interest and Dividends Vehicle Expenses
Pension/Retirement Other Expenses (List)
Income from Estate or Trust
Alimony (Name and Address)
Department Use Only Section E
_____________
Current Liabilities
Balance Mo. Payment
Internal Revenue Service
Other Income (Identify) Other Tax Agencies (List)
General Creditors (List)
Department Use Only Section D
_____________
Department Use Only Section F
_____________
DE 999B Rev. 1 (1-15) (INTERNET)
Page 3 of 3
Employment Information
Taxpayer’s employer or business
Name:
Date Employed Business Phone
( )
Occupation
Address:
Wage Earner Sole Proprietor Partner/Corp. Officer
Spouse’s employer or business
Name:
Date Employed Business Phone
( )
Occupation
Address:
Wage Earner Sole Proprietor Partner/Corp. Officer
Other information relating to your financial condition. If you check the “Yes” box, please give dates and explain below.
Court Proceedings Yes No Bankruptcies Yes No
Repossessions Yes No Participation or beneficiary to trust, estate, etc. Yes No
Health considerations that will affect earning potential Yes No
Explanation:
Anticipated increase in income Yes No If answer is “Yes”, give the following information:
Source Date increase is expected and frequency Amount of increase expected
Recent transfer of assets of any kind Yes No If answer is “Yes”, give the following information:
Description Date of Transfer
Relationship of Transferee
to Applicant
Fair Market
Value
Consideration
Received
CERTIFICATION Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets,
liabilities, and other information is true, correct, and complete. I also understand any costs incurred to verify
questionable information submitted will be my responsibility.
Applicant Signature: Phone Number:
Date:
Spouse Signature: Phone Number:
Date:
