Vermont Department of Taxes     PO Box 429     Montpelier, VT  05601-0429
Phone:  (802) 828-2518
 VT Schedule                                                                              *196721100*
SAMPLEDATA1234           COLLECTION INFORMATION 
                                                                                          *196721100*
OIC-672                  STATEMENT FOR BUSINESSES                                                                                 Page 1
                                                                                          Attach to Form OIC-671
Complete this form if your business is a Corporation, Partnership, Limited Liability Company (LLC) classified as a 
corporation, other multi-owner/multi-member LLC, or single member LLC.  If your business is a sole proprietorship (filing 
federal Schedule C), do not use this form.  Instead, complete Form OIC-673, Collection Information Statement for Wage 
Earners and Self-Employed Individuals.
Include attachments if additional space is needed to completely answer any question.

SECTION 1  BUSINESS INFORMATION
Business Name                                                                             Federal ID Number

Trade Name or d/b/a                                                                       Description of Business

Mailing Address                                                                           County of Business Location

City                                                    State            ZIP Code         Primary Telephone Number

Foreign Country (if not United States)                  Business Website Address

Email Address

State Contractor?        Total Number of Employees      Frequency of Tax Deposits         Average Gross Monthly Payroll
   Yes             No
Does the business use a  If yes, enter Provider’s Name                            Mailing Address of Provider 
payroll service provider?
   Yes             No  City                                                     State   ZIP Code

Provide information about all partners, officers, LLC members, major shareholders (foreign and domestic), etc., associated 
with the business.
Partner, Officer, LLC Member, Major Shareholder, etc. #1
Last Name                              First Name                                 Initial Social Security Number

Home Mailing Address                                                                      Title

City                                                    State            ZIP Code         Primary Telephone Number

Foreign Country (if not United States)                  Percent of Ownership              Secondary Telephone Number    
                                                                                        %

Partner, Officer, LLC Member, Major Shareholder, etc. #2
Last Name                              First Name                                 Initial Social Security Number

Home Mailing Address                                                                      Title

City                                                    State            ZIP Code         Primary Telephone Number

Foreign Country (if not United States)                  Percent of Ownership              Secondary Telephone Number    
                                                                                        %

                                                                                                              Schedule OIC-672
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5454                                                                                                                   Rev 06/19

 Entity name

 Federal ID Number                                                                                                                        *196721200*
                                                                                                                                          *196721200*
                                                                                                                                                                                      Page 2

SECTION 2  BUSINESS ASSET INFORMATION
If any total in this section results in a negative number, enter -0-.
Enter the total amount available for each of the following (if additional space is needed, please include attachments).  Gather the most 
current statement from banks, lenders on loans, mortgages (including second mortgages), monthly payments, loan balances, and 
accountant’s depreciation schedules, if applicable.  Also, include make/model/year/mileage of vehicles and current value of businesses 
assets.  To estimate the current value, you may consult resources like Kelley Blue Book (www.kbb.com), NADA (www.nada.com), local 
real estate postings of properties similar to yours, and any other websites or publications that show what the businesses assets would be 
worth if you were to sell them.
Bank Accounts
 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           

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

                                                                                                                                          1d.  Total bank account(s) from attachment
 1d.     Total of bank account(s) listed from attachment ..................................
                                                                                                                                          1e.  Add Lines 1a through 1d
 1e.     Total of all bank accounts (Add Lines 1a through 1d)  .............................                                                                                          

Investment Accounts
 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)  ..............................                                                                                         

Notes Receivable
 Do you have notes receivable?                                                                                                            3.  Total notes receivable from attachment 
           No                 Yes.  Attach current listing which includes name and amount of note(s) receivable.

                                                                                                                                                     Schedule OIC-672
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 Entity name

 Federal ID Number                                                                            *196721300*
                                                                                              *196721300*
                                                                                                                                                            Page 3
SECTION 2  BUSINESS ASSET INFORMATION (cont.)
Real Estate (Buildings, Lots, Commercial Property, etc.) 
 Property Address (physical address)                                                                          4a. Value (CMV x 0.8 - Loan Balance)

 City                                                       State  ZIP Code 

 Foreign Country (if not United States)                             

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

 Property Address (physical address)                                                                          4b. Value (CMV x 0.8 - Loan Balance)

 City                                                       State  ZIP Code 

 Foreign Country (if not United States)                             

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

                                                                                                              4c.  Total property(s) from attachment
 4c.  Total of property(s) listed from attachment (CMV x 0.8 - Loan Balance) ...............
                                                                                                              4d.  Add Lines 4a through 4c
 4d.  Total of all property(s) (Add Lines 4a through 4c)  ................................                                                                  
Business Vehicles 
 Vehicle Make      Model                Year Mileage or      Lease or Loan?  Monthly Lease /                  5a. 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 /                  5a. 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

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

Other Business Equipment  
 Current Market Value (CMV)             Multiply CMV by 0.8 Loan Balance                                      6a. Value (CMV x 0.8 - Loan Balance)

                                                                                                              6b.  Total business equipment from attachment
 6b.  Total of business equipment listed from attachment (CMV x 0.8 - Loan Balance) ........
                                                                                                              6c.  Add Lines 6a and 6b
 6c.  Total of all business equipment (Add Lines 6a and 6b) ............................                                                                    

Total Available Assets                                                                                        BOX 1 Total Available Assets
BOX 1 Add Lines 1e, 2d, 3, 4d, 5d, and 6c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                               
                                                                                                                    Schedule OIC-672
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Entity name

Federal ID Number                                                               *196721400*
                                                                                *196721400*
                                                                                                                                                                        Page 4
SECTION 3  BUSINESS INCOME INFORMATION
Enter the average gross monthly income of your business.  To determine your gross monthly income, use the most recent 6-12 months 
documentation of commissions, invoices, gross receipts from sales/services, etc.; most recent 6-12 months earnings statements, etc., from 
every other source of income (such as rental income, interest and dividends, or subsidies); or you may use a most recent 6-12 months 
Profit and Loss (P&L) to provide the informaiton of income and expenses.

  7.  Gross receipts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7.  _________________________

  8. Gross rental income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8.  _________________________

  9. Interest income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9.  _________________________

 10. Dividends  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.  _________________________

 11. Other income (specify on attachment) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11.  _________________________
                                                                                                                                   BOX 2 Total Business Income
BOX 2     Add Lines 7 through 11 and enter the amount in BOX 2 ................                                                                                         

SECTION 4  BUSINESS EXPENSE INFORMATION
Enter the average gross monthly expenses for your business using your most recent 6-12 months statements, bills, receipts, or other 
documents showing monthly recurring expenses.

 12. Materials purchased (e.g., items directly related to the production of a 
     product or service). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12.  _________________________

 13. Inventory purchased (e.g., goods bought for resale) . . . . . . . . . . . . . . . . . . . . . . . .13.  _________________________

 14. Gross wages and salaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14.  _________________________

 15. Rent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15.  _________________________

 16. Supplies (items used to conduct business and used up within one year,  
     e.g., books, office supplies, professional equipment, etc.) ...................16.  _________________________

 17. Utilities / telephones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17.  _________________________

 18. Vehicle costs (gas, oil, repairs, maintenance) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18.  _________________________

 19. Insurance (other than life) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19.  _________________________

 20. Taxes (e.g., real estate, state and local income tax, excise franchise, occupational, 
     personal property, sales and employer’s portion of employment taxes, etc.) .....20.  _________________________

 21. Other expenses (e.g., secured debt payments.  Specify on attachment.   
     Do not include credit card payments) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21.  _________________________
                                                                                                                                   BOX 3 Total Business Income
BOX 3     Add Lines 12 through 21 and enter the amount in BOX 3 ...............
                                                                                                                                   BOX 4 Remaining Monthly Income
BOX 4     Subtract BOX 3 from BOX 2 and enter the amount in BOX 4 ............                                                                                          
          If number is less than zero, enter -0-.

                                                                                                                                         Schedule OIC-672
                                                 (continued on next page)                                                                Page 4 of 6
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 Entity name

 Federal ID Number                                                                          *196721500*
                                                                                            *196721500*
                                                                                                                                         Page 5
SECTION 5  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 4 or 5 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 from written acceptance, multiply “Remaining Monthly Income” (BOX 4) by 12 to get “Future Remaining Income” 
(BOX 5).
                                                                                              BOX 5 Future Remaining Income
Enter amount from BOX 4  ________________________________          x 12    =    BOX 5  ... .  

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 4) by 36 to get “Future Remaining Income” (BOX 6).
                                                                                              BOX 6 Future Remaining Income
Enter amount from BOX 4  ________________________________          x 36    =    BOX 6  ... .  

Determine your minimum offer amount by adding the total available assets from BOX 1 to amount in either BOX 5 or BOX 6.
 Amount from BOX 1                 Amount from either BOX 5 or BOX 6                          BOX 7 MINIMUM OFFER AMOUNT  Must  
                                                                                              be more than zero.  (BOX 1 plus BOX 5 or 6)

SECTION 6  OTHER INFORMATION
Please provide the additional information requested, which is needed to consider your offer.
  A. Is the business currently in bankruptcy? ................................................                 Yes*        No
     *NOTE:  If this business is currently in a bankruptcy proceeding, the business is not eligible to apply for an offer.
 B.  Has the business ever filed bankruptcy?  ................................................                 Yes         No
            If “Yes,” Date Filed (mmddyyyy) _________________
            Date Dismissed or Discharged (mmddyyyy) _________________
            Petition No. _________________      
            Location ____________________________________________________________
 C.  Does this business have other business affiliations (e.g., subsidiary or parent companies)? .........     Yes         No
            If “Yes,” Name ___________________________________________________  
            Employer Identification Number _________________________
 D.  Do any related parties (e.g., partners, officers, employees) owe money to the business? ...........       Yes         No
 E.  Has the business been party to a lawsuit? ...............................................                 Yes         No
            If “Yes,” Date the lawsuit was resolved (mmddyyyy): __________________________
 F.  In the past 10 years, has the business transferred any assets for less than their full value? ..........  Yes         No
 G.  Has the business been located outside the U.S. for 6 months or longer in the past 10 years? ........      Yes         No
 H.  Does the business have any funds being held in trust by a third party? .........................          Yes         No

                                                (continued on next page)

                                                                                                                    Schedule OIC-672
                                                                                                                          Page 5 of 6
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 Entity name

 Federal ID Number                                                          *196721600*
                                                                            *196721600*
                                                                                                                                                      Page 6
SECTION 6  OTHER INFORMATION (cont.)
 I. Does the business have any lines of credit? ..............................................            Yes             No
            If “Yes,” Credit limit: $____________________      
            Amount owed: $____________________
            What property secures the line of credit? __________________________________________
 J. 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.
             _________________________________________________________________________________________________
             _________________________________________________________________________________________________
             _________________________________________________________________________________________________

SECTION 7  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 Responsible Officer                          Title                                     Date

     Printed name                                              Email address

Remember to include all applicable attachments from list below.

           A current Profit and Loss statement covering at least the most recent 6-12 month period, if appropriate.

           Copies of the three most recent statements for each bank, investment, and retirement account.

           If an asset is used as collateral on a loan, include copies of the most recent statement from lender(s) on loans, monthly 
            payments, loan payoffs, and balances.

           Copies of the most recent statement of outstanding notes receivable (if applicable).

           Copies of the most recent statements from lenders on loans, mortgages (including second mortgages), monthly payments, 
            loan payoffs, and balances.

           Copies of accountant’s depreciation schedules, if applicable.

           Documentation for any claims of “Exceptional circumstances” made in 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, account or tax preparer, or other party to represent 
            you and you do not have a current form on file with the Vermont Department of Taxes.

           IRS Information:  If applicable, copy of IRS OIC and acceptance letter or other IRS arrangements.

                                                                                                               Schedule OIC-672
                                                                                                                    Page 6 of 6
5454                                                                                                                Rev 06/19