PDF document

- 1 -

Vermont Department of Taxes     PO Box 429     Montpelier, VT  05601-0429
Phone:  (802) 828-2518
                                                                                                     *196731100*
     VT Form          COLLECTION INFORMATION STATEMENT 
                                                                                                     *196731100*
                                       FOR WAGE EARNERS AND 
                                                                                                                                                        Page 1
OIC-673                        SELF-EMPLOYED INDIVIDUALS                                                  Attach to Form OIC-671
Complete this form if you are one of the following:
 •  an individual who owes income tax on Form IN-111,                     •  an individual with a personal liability for an excise tax
 Vermont Individual Income Tax Return                                     •  an individual member of a limited liability company 
 •  an individual who is personally responsible for sales and             (LLC) that is a disregarded entity, or
 use tax, meals and rooms tax, or withholding tax liability               •  an individual who is self-employed or has self-
 •  an individual who is personally responsible for a                     employment income.  You are considered to be self-
 partnership liability                                                    employed if you are in business for yourself, or carry 
                                                                          on a trade or business.
Wage earners:  Complete Sections 1, 3, 6, 7, and 8, including signature line on page 11.
Self-employed individuals:  Complete all sections and signature line on page 11.
                Include attachments if additional space is needed to respond completely to any question.

SECTION 1  PERSONAL AND HOUSEHOLD INFORMATION
Last Name                                  First Name                                        Initial  Social Security Number 

Mailing Address                                                          County of Residence          Date of Birth (mm dd yyyy)

City                                                  State              ZIP Code                     Primary Daytime Telephone Number

Foreign Country (if not United States)                Marital status                                  Secondary Telephone Number
                                                         Married                  Unmarried
Email Address                                                                                         Do you
                                                                                                           Own your home
Employer’s Name                                       Occupation                                           Rent
                                                                                                           Other (specify) ___________________
Employer’s Address - Street                City                                              State    ZIP Code

Spouse or CU Partner Last Name             First Name                                        Initial  Social Security Number 

Employer’s Name                                       Occupation                                      Spouse or CU Partner Date of Birth (mm dd yyyy)

Employer’s Address - Street                City                                              State    ZIP Code

Provide information for all other persons in the household or persons you claim as dependents.
     Name (First & Last Name)          Age  Social Security Number        Relationship        Claimed as a dependent            Contributes to 
                                                                                                     on your Form IN-111?      household income?
                                                                                                      Yes                 No  Yes                 No

                                                                                                      Yes                 No  Yes                 No

                                                                                                      Yes                 No  Yes                 No
 
                                                                                                      Yes                 No  Yes                 No

                                                                                                      Yes                 No  Yes                 No

                                                                                                                                Form OIC-673
                                                (continued on next page)                                                        Page 1 of 11
5454                                                                                                                                  Rev. 06/19

- 2 -

 Taxpayer Last Name OR Business Name

 Social Security or Federal ID Number                                                                                                     *196731200*
                                                                                                                                          *196731200*
                                                                                                                                                                                            Page 2
SECTION 2  SELF-EMPLOYED INFORMATION
                  If you or your spouse or civil union partner is self-employed, complete this section.
 Name of Business                                                                                                                         Social Security or Federal ID Number 

 Trade Name or d/b/a                                                                                                                      Business Telephone Number

 Mailing Address (if other than personal residence)                                                                                       Frequency of Tax Deposits

 City                                                                                   State ZIP Code                                    Total Number of Employees

 Foreign Country (if not United States)                                                                                                   Average Gross Monthly Payroll

 Description of Business                                                                Business Website                                  Is your business a sole proprietorship  
                                                                                                                                          (filing Schedule C)?  Yes              No

Do you or your spouse or civil union partner have  
          any other business interests?   .....................  Yes, continue in this section                                                No, go to next section
 Name of Business                                                                                                                         Social Security or Federal ID Number

 Mailing Address                                                                                                                          Business Telephone Number

 City                                                                                   State ZIP Code                                    Percentage of ownership

 Foreign Country (if not United States)                                                 Type of business (check ONE)
                                                                                         Partnership           Single member LLC           LLC           Corporation           Other

SECTION 3  PERSONAL ASSET INFORMATION
If any total in this section results in a negative number, enter -0-.  If you do not have the type of asset listed, enter -0- in each 
applicable total box.
Cash and Investments (domestic and foreign) 
Enter the total amount available for each of the following types of accounts.  Use the most current statement for each type of account, 
such as checking, savings, money market, and online accounts, stored value cards (such as a payroll card from an employer), investment 
and retirement accounts (IRAs, Keogh, 401(k) plans, stocks, bonds, mutual funds, certificates of deposit), life insurance policies that 
have a cash value, and safe deposit boxes.

Bank Accounts
List information for any bank accounts you own in whole or in part. 
 Account Type (check ONE)                                                                                                                 1a. Amount 
           Checking                Savings                Money Market                Online Account                Stored Value Card
 Bank Name                                                  Account Number                     

 Account Type (check ONE)                                                                                                                 1b. Amount 
           Checking                Savings                Money Market                Online Account                Stored Value Card
 Bank Name                                                  Account Number

                                                                                                                                          1c.  Total bank account(s) from attachment
 1c.     Total of bank account(s) listed from attachment ..................................
                                                                                                                                          1d.  Add Lines 1a through 1c
 1d.     Total of all bank accounts (Add Lines 1a through 1c) ..............................                                                                                                
                                                                                                                                                                   Form OIC-673
                                                            (continued on next page)                                                                                   Page 2 of 11
5454                                                                                                                                                                             Rev. 06/19

- 3 -

Taxpayer Last Name OR Business Name

Social Security or Federal ID Number *196731300*
*196731300*
Page 3

SECTION 3 PERSONAL ASSET INFORMATION (cont.)
Investment Accounts
List information for any investment accounts you own in whole or in part.
Account Type (check ONE) 2a. Amount (CMV x 0.8 - Loan Balance)
 Stocks  Bonds  Other
Name of Financial Institution Account Number

Current Market Value (CMV) Multiply Current Market Value by 0.8 Loan Balance

Account Type (check ONE) 2b. Amount (CMV x 0.8 - Loan Balance)
 Stocks  Bonds  Other
Name of Financial Institution Account Number

Current Market Value (CMV) Multiply CMV by 0.8 Loan Balance

2c. Total investment(s) from attachment
2c. Total of investment(s) listed from attachment (CMV x 0.8 - Loan Balance) .............
2d. Add Lines 2a through 2c
2d. Total of all investment(s) (Add Lines 2a through 2c) ..............................

Retirement Accounts
List information for any retirement accounts you own in whole or in part.
Account Type (check ONE) 3a. Amount (CMV x 0.7 - Loan Balance)
 401k  IRA  Other
Name of Financial Institution Account Number

Current Market Value (CMV) Multiply Current Market Value by 0.7 Loan Balance

Account Type (check ONE) 3b. Amount (CMV x 0.7 - Loan Balance)
 Stocks  Bonds  Other
Name of Financial Institution Account Number

Current Market Value (CMV) Multiply CMV by 0.7 Loan Balance

3c. Total retirement account(s) from attachment
3c. Total of retirement account(s) listed from attachment (CMV x 0.7 - Loan Balance) .......
3d. Add Lines 3a through 3c
3d. Total of all retirement account(s) (Add Lines 3a through 3c) ........................

Form OIC-673
(continued on next page) Page 3 of 11
5454 Rev. 06/19

- 4 -

Taxpayer Last Name OR Business Name

Social Security or Federal ID Number *196731400*
*196731400*
Page 4

SECTION 3 PERSONAL ASSET INFORMATION (cont.)
Life Insurance Policies
List information for any insurance policies you have.
Name of Insurance Company Policy Number 4a. Amount (CCV - Loan Balance)

Current Cash Value (CCV) Loan Balance

4b. Total investment(s) from attachment
4b. Total of life insurance policies listed from attachment (CCV - Loan Balance) ...........
4c. Add Lines 4a and 4b
4c. Total of all life insurance policies (Add Lines 4a and 4b) ...........................

Real Estate
Enter information about any house, condo, co-op, time share, etc. that you own or are buying.
Property Address (physical address) Primary Residence 5a. Value (CMV x 0.8 - Loan Balance)
 Yes  No
City State ZIP Code

Foreign Country (if not United States) How is the property titled (joint tenancy, etc.)

Description of property

Current Market Value (CMV) Multiply CMV by 0.8 Loan Balance

Property Address (physical address) Primary Residence 5b. Value (CMV x 0.8 - Loan Balance)
 Yes  No
City State ZIP Code

Foreign Country (if not United States) How is the property titled (joint tenancy, etc.)

Description of property

Current Market Value (CMV) Multiply CMV by 0.8 Loan Balance

5c. Total real estate from attachment
5c. Total of real estate listed from attachment (CMV x 0.8 - Loan Balance) ...............
5d. Add Lines 5a through 5c
5d. Total of all real estate (Add Lines 5a through 5c) .................................

Form OIC-673
(continued on next page) Page 4 of 11
5454 Rev. 06/19

- 5 -

Taxpayer Last Name OR Business Name

Social Security or Federal ID Number *196731500*
*196731500*
Page 5

SECTION 3 PERSONAL ASSET INFORMATION (cont.)

Vehicles
Enter information about any cars, boats, motorcycles, etc. that you own or lease.
Vehicle Make Model Year Mileage Lease or Loan? Monthly Lease / 6a. Value (CMV x 0.8 - Loan Balance)
 Lease Loan Payment If leased, enter -0-
 Loan
Current Market Value (CMV) Multiply CMV by 0.8 Loan Balance

Vehicle Make Model Year Mileage or Lease or Loan? Monthly Lease / 6b. Value (CMV x 0.8 - Loan Balance)
Use Hours  Lease Loan Payment If leased, enter -0-
 Loan
Current Market Value (CMV) Multiply CMV by 0.8 Loan Balance

Vehicle Make Model Year Mileage or Lease or Loan? Monthly Lease / 6c. Value (CMV x 0.8 - Loan Balance)
Use Hours  Lease Loan Payment If leased, enter -0-
 Loan
Current Market Value (CMV) Multiply CMV by 0.8 Loan Balance

6d. Total vehicle(s) from attachment
6d. Total of vehicle(s) listed from attachment (CMV x 0.8 - Loan Balance) ................
6e. Add Lines 6a through 6d
6e. Total of all vehicle(s) (Add Lines 6a through 6d) .................................

Other Valuable Items
Describe any other valuable items, including, but not limited to, artwork, collections, jewelry, items of value in safe deposit boxes, etc.
Description of asset 7a. Value (CMV x 0.8 - Loan Balance)

Current Market Value (CMV) Multiply CMV by 0.8 Loan Balance

Description of asset 7b. Value (CMV x 0.8 - Loan Balance)

Current Market Value (CMV) Multiply CMV by 0.8 Loan Balance

Description of asset 7c. Value (CMV x 0.8 - Loan Balance)

Current Market Value (CMV) Multiply CMV by 0.8 Loan Balance

7d. Total real estate from attachment
7d. Total of other valuable items listed from attachment (CMV x 0.8 - Loan Balance) ........
7e. Add Lines 7a through 7d
7e. Total of all valuable items (Add Lines 7a through 7d) ..............................

Form OIC-673
(continued on next page) Page 5 of 11
5454 Rev. 06/19

- 6 -

Taxpayer Last Name OR Business Name

Social Security or Federal ID Number *196731600*
*196731600*
Page 6
SECTION 4 BUSINESS ASSET INFORMATION (for self-employed)
List business assets such as bank accounts, tools, books, machinery, equipment, business vehicles, and real property that are owned,
leased, or rented. If you do not have the type of asset listed, enter -0- in each applicable total box.
Bank Accounts
List information for any bank accounts you own in whole or in part.
Account Type (check ONE) 8a. Amount
 Checking  Savings  Money Market  Online Account  Stored Value Card
Bank Name Account Number

Account Type (check ONE) 8b. Amount
 Checking  Savings  Money Market  Online Account  Stored Value Card
Bank Name Account Number

Account Type (check ONE) 8c. Amount
 Checking  Savings  Money Market  Online Account  Stored Value Card
Bank Name Account Number

8d. Total bank account(s) from attachment
8d. Total of bank account(s) listed from attachment ..................................
8e. Add Lines 8a through 8d
8e. Total of all bank accounts (Add Lines 8a through 8d) .............................

Assets
List information for any assets you own in whole or in part.
Description of asset 9a. Value (CMV x 0.8 - Loan Balance)

Current Market Value (CMV) Multiply CMV by 0.8 Loan Balance

Description of asset 9b. Value (CMV x 0.8 - Loan Balance)

Current Market Value (CMV) Multiply CMV by 0.8 Loan Balance

Description of asset 9c. Value (CMV x 0.8 - Loan Balance)

Current Market Value (CMV) Multiply CMV by 0.8 Loan Balance

9d. Total real estate from attachment
9d. Total of other valuable items listed from attachment (CMV x 0.8 - Loan Balance) ........
9e. Add Lines 9a through 9d
9e. Total of all valuable items (Add Lines 9a through 9d) ..............................

Notes Receivable
Do you have notes receivable? 10. Total notes receivable from attachment
 No  Yes. Attach current listing which includes name and amount of note(s) receivable.

TOTAL AVAILABLE ASSETS BOX 1 Total Available Assets
BOX 1 Add Lines 1d, 2d, 3d, 4c, 5d, 6e, 7e, 8e, 9e, and 10 .....................

Form OIC-673
(continued on next page) Page 6 of 11
5454 Rev. 06/19

- 7 -

 Taxpayer Last Name OR Business Name

 Social Security or Federal ID Number                                      *196731700*
                                                                           *196731700*
                                                                                                                                                 Page 7

SECTION 5  BUSINESS INCOME AND EXPENSE INFORMATION (for self-employed)
NOTE:  If you provide a current profit and loss (P&L) statement for the information below, enter the total gross monthly income on 
Line 18 and your monthly expenses on Line 30 below.  Do not complete Lines 13-17 and 19-29.  You may use the amounts claimed for 
income and expenses on your most recent Schedule C; however, if the amount has changed significantly within the past year, a current 
P&L should be submitted to substantiate the claim.
Business Income (You may average 6-12 months income/receipts to determine your gross monthly income/receipts.)

 13.  Gross receipts ............................ 13. ________________________

 14. Gross rental income. . . . . . . . . . . . . . . . . . . . . . . . 14.  ________________________

 15. Interest income ........................... 15.  ________________________

 16. Dividends  ............................... 16.  ________________________

 17. Other income ............................. 17.  ________________________

 18. Gross monthly business income (Add Lines 13 through 17) ..................  18. _______________________

Business Expenses (You may average 6-12 months expenses to determine your gross monthly expenses.)

 19.  Materials purchased (items directly related 
     to the production of a product or service) ....... 19.  ________________________

 20. Inventory purchased  
     (goods bought for resale)  ................... 20.  ________________________

 21. Gross wages and salaries .................... 21.  ________________________

 22. Rent .................................... 22.  ________________________

 23. Supplies (items used to conduct business and  
     used up within one year, such as books,  
     office supplies, professional equipment, etc.) .... 23.  ________________________

 24. Utilities/telephone ......................... 24.  ________________________

 25. Vehicle costs (gas, oil, repairs, maintenance) .... 25.  ________________________

 26. Business Insurance ........................ 26.  ________________________

 27. Current Business Taxes (real estate, excise,  
     franchise, occupational, personal property, sales  
     and employer’s portion of employment taxes) ... 27.  ________________________

 28. Other secured debts (not credit cards) .......... 28.  ________________________

 29. Other business expenses (include a list) ........ 29.  ________________________

 30.  Total monthly business expenses (Add Lines 19 through 29) .................  30.  _______________________

NET BUSINESS INCOME                                                                                           BOX 2 Net Business Income
BOX 2 Subtract Line 30 from Line 18  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

                                                                                                                    Form OIC-673
                                                  (continued on next page)                                          Page 7 of 11
5454                                                                                                                                   Rev. 06/19

- 8 -

 Taxpayer Last Name OR Business Name

 Social Security or Federal ID Number                                    *196731800*
                                                                         *196731800*
                                                                                                                                                              Page 8

SECTION 6  MONTHLY HOUSEHOLD INCOME AND EXPENSE INFORMATION
Enter your household’s gross monthly income.  The information below is for yourself, your spouse or civil union partner, and anyone 
else who contributes to your household’s income.  The entire household includes spouse or civil union partner, children, and others who 
contribute to the household.  This information is necessary for the Department to accurately evaluate your offer.
Monthly Household Income
Primary taxpayer

 31a.  Wages ................................. 31a.  ________________________

  31b. Social Security  .......................... 31b.  ________________________

  31c. Pension(s) .............................. 31c.  ________________________

 31.  Total primary taxpayer income (Add Lines 31a through 31c) ................  31.  _______________________
Spouse or civil union partner and other contributors to the household

 32a.  Wages ................................. 32a.  ________________________

  32b. Social Security  .......................... 32b.  ________________________

  32c. Pension(s) .............................. 32c.  ________________________

 32.  Total spouse or civil union partner and other contributors to the  
       household income (Add Lines 32a through 32c) . . . . . . . . . . . . . . . . . . . . . . . . . . . .  32. _______________________
Other Income

 33.   Interest and dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   33.  _______________________

 34.   Distributions (such as income from partnerships, sub-S Corporations, etc.) .......   34.  _______________________

 35.   Net rental income ........................... . . . . . . . . . . . . . . . . . . . . . . . . .  35.  _______________________

 36.   Net business income from BOX 2  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  36.  _______________________

 37.   Child support received by the household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  37.  _______________________

 38.   Alimony received by the household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  38.  _______________________

 39.   Additional household income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  39.  _______________________

TOTAL HOUSEHOLD INCOME                                                                                            BOX 3         Total Household Income
BOX 3  Add Lines 31 through 39 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

                                                                                                                                Form OIC-673
                                      (continued on next page)                                                                  Page 8 of 11
5454                                                                                                                            Rev. 06/19

- 9 -

Taxpayer Last Name OR Business Name

Social Security or Federal ID Number                                                   *196731900*
                                                                                       *196731900*
                                                                                                                                                    Page 9
SECTION 6  MONTHLY HOUSEHOLD INCOME AND EXPENSE INFORMATION (cont.)

Monthly Household Expenses

Enter your average monthly expenses.  NOTE:   Expenses may be adjusted based on IRS Collection Financial Standards.

 40. Food, clothing, and miscellaneous (housekeeping supplies, personal care  
     products).  A reasonable estimate of these expenses may be used.  .............                              40.   _______________________

 41. Housing and utilities (rent or mortgage payment and average monthly cost  
     of property taxes, home insurance, maintenance, dues, fees, and utilities including  
     electricity, gas, or other fuels, trash collection, water, cable, telephone, and  
     cell phone). ........................................................                                        41.   _______________________

 42. Vehicle loan and/or lease payment(s) ....................................                                    42.   _______________________

 43. Vehicle operating costs (average monthly cost of maintenance, repairs,  
     insurance, fuel, registrations, licenses, inspections, parking, tolls, etc.).   
     A reasonable estimate of these expenses may be used.  ......................                                 43.   _______________________

 44. Public transportation costs (average monthly cost of fares for mass transit  
     such as bus, train, ferry, taxi, etc.).  A reasonable estimate of these expenses  
     may be used. .......................................................                                         44.   _______________________

 45. Health insurance premiums ............................................                                       45.   _______________________

 46. Out-of-pocket health care costs (average monthly cost of prescription drugs,  
     medical services, and medical supplies like eyeglasses, hearing aids, etc.).  ......                         46.   _______________________

 47. Court-ordered payments (monthly cost of any alimony, child support, etc.) ......                             47.   _______________________

 48. Child/dependent care payments (daycare, etc.). . . . . . . . . . . . . . . . . . . . . . . . . . . . .       48.   _______________________

 49. Life insurance premiums ..............................................                                       49.   _______________________

 50. Taxes (monthly cost of federal, state, and local tax, personal  
     property tax, etc.)  ...................................................                                     50.   _______________________

 51. Other secured debts (any loan where you pledged an asset as collateral not  
     previously listed).  Do not include unsecured debt such as credit cards. .........                           51.   _______________________

HOUSEHOLD EXPENSES                                                                                                BOX 4 Household Expenses
BOX 4 Add Lines 40 through 51 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
                                                                                                                  BOX 5 Remaining Monthly Income
BOX 5 Subtract Box 4 from Box 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

                                                                                                                        Form OIC-673
                                             (continued on next page)                                                   Page 9 of 11
5454                                                                                                                                      Rev. 06/19

- 10 -

Taxpayer Last Name OR Business Name

Social Security or Federal ID Number *196731000*
*196731000*
Page 10
SECTION 7 CALCULATE YOUR MINIMUM OFFER AMOUNT
The next steps calculate your minimum offer amount. The amount of time you take to pay your offer in full will affect your minimum
offer amount. Paying over a shorter period of time will result in a smaller minimum offer amount. NOTE: Amount in BOX 6 or 7 is
based on the selection you made on Form OIC-671, page 3, Section 5.

If you selected Payment Option #1 on Offer in Compromise Agreement, Form OIC-671, Section 5, indicating you will pay your offer
within 30 days, multiply “Remaining Monthly Income (BOX 5) by 12 to get “Future Remaining Income” (BOX 6).
BOX 6 Future Remaining Income
Enter amount from BOX 5 ________________________________ x 12 = BOX 6 ... .

If you selected Payment Option #2 on Offer in Compromise Agreement, Form OIC-671, Section 5, indicating you will begin making
installment payments within 30 days, multiply “Remaining Monthly Income (BOX 5) by 36 to get “Future Remaining Income” (BOX 7).
BOX 7 Future Remaining Income
Enter amount from BOX 5 ________________________________ x 36 = BOX 7 ... .

Determine your minimum offer amount by adding the total available assets from BOX 1 to amount in either BOX 6 or BOX 7.
Amount from BOX 1 Amount from either BOX 6 or BOX 7 BOX 8 MINIMUM OFFER AMOUNT Must
be more than zero. (BOX 1 plus BOX 6 or 7)

If you have any exceptional circumstances that would hinder you from paying this amount, explain them on Form OIC-671, Offer
in Compromise Agreement, page 2, Section 3 (“Exceptional Circumstances”).

SECTION 8 OTHER INFORMATION
Please provide additional information requested, which is needed to consider your offer.
A. Are you the beneficiary of a trust, estate, or life insurance policy? ............................  Yes  No
B. Are you currently in bankruptcy? .....................................................  Yes*  No
*NOTE: If you or your business are currently in a bankruptcy proceeding, the business is not eligible to apply for an offer.
C. Have you filed bankruptcy in the past 10 years? ..........................................  Yes  No
If “Yes,” Date Dismissed or Discharged (mm/dd/yyyy) _________________
County Filed ________________________________________________
D. Have you been party to a lawsuit? .....................................................  Yes  No
If “Yes,” Date the lawsuit was resolved (mm/dd/yyyy) _________________
G. In the past 10 years, have you transferred any assets for less than their full value? ...............  Yes  No
H. Have you lived outside the U.S. for 6 months or longer in the past 10 years? ...................  Yes  No
H. Do you have any funds being held in trust by a third party? .................................  Yes  No
If “Yes,” How much? $____________________
Where? _________________________________________________________________
I. Have you filed for an OIC with the IRS for the same periods included in this offer? ..............  Yes  No
If “Yes,” describe status or outcome of IRS OIC, understanding Vermont is not bound to adopt the same outcome.
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Form OIC-673
(continued on next page) Page 10 of 11
5454 Rev. 06/19

- 11 -

Taxpayer Last Name OR Business Name

Social Security or Federal ID Number *196731A00*
*196731A00*
Page 11

SECTION 9 SIGNATURES

Under penalties of perjury, I declare that I have examined this offer, including accompanying documents, and to the best of my knowledge, it is true,
correct, and complete.

Signature of Taxpayer Date (mm/dd/yyyy)

Remember to include all applicable attachments from list below.

 Page(s) with additional information for each section, as needed.

 Copies of the most recent pay stub, earnings statement, etc., from each employer.

 Copies of bank statements for the three most recent months for any accounts listed on Form OIC-673, Sections 3 and/or 4.

 Copies of the most recent statement or documentation to support income reported on Form OIC-673, Sections 5 and/or 6.

 Copies of the most recent statement from lender(s) on loans such as mortgages, second mortgages, vehicles, etc., showing
monthly payments, loan payoffs, and balances.

 List of Notes Receivable, if applicable.

 Accountant’s depreciation schedules, if applicable.

 Documentation for any claims of “Exceptional circumstances” made on Form OIC-671, Section 3. Examples of possible
documentation to include are: copies of actual monthly expenses, out-of-pocket medical expenses, physician’s statements
detailing illness, etc.

 Attach a Form PA-1, Power of Attorney, if you would like your attorney, tax preparer, or other party to represent you and
you do not have a current form on file with the Vermont Department of Taxes.

Form OIC-673
Page 11 of 11
5454 Rev. 06/19

PDF file checksum: 1244772810

(Plugin #1/9.12/13.0)