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                If Yes, Spouse’s Name:
                                                        Yes     No
                                                               Applicant                                                Spouse
                                                       Last 4 Digits of Social Security Number            Last 4 Digits of Social Security Number

Name, address, and phone number of next of kin              Driver License Number                                   Driver 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          Name and Address of                   Amount                    Minimum            Business or          Available 
     or Card                     Financial Institution         Owed                      Monthly Payment            Personal     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. 2 (2-19) (INTERNET)                            Page 1 of 3                                                                    CU

                            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       Monthly Payment
                                                                    Internal Revenue Service
                                                                    Other Tax Agencies (List)
Other Income (Identify)

                                                                    General Creditors (List)

Department Use Only        Section D  ____________

                                                                    Department Use Only        Section F       ____________

DE 999B Rev. 2 (2-19) (INTERNET)                       Page 2 of 3 

                                           Employment Information
Taxpayer’s employer or business                          Date Employed           Business Phone                       Occupation
Name: 
Address: 
                                                          Wage Earner           Sole Proprietor         Partner/Corp. Officer
Spouse’s employer or business                            Date Employed           Business Phone                       Occupation
Name: 
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         Fair Market                Consideration 
                                                                  to Applicant                   Value                 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: 

DE 999B Rev. 2 (2-19) (INTERNET)                             Page 3 of 3