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 
                                                             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          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. 1 (1-15) (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 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 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. 1 (1-15) (INTERNET)                            Page  3of 3