Tax Resource Manual 37

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37 Form DJ TD-433 -- Statement of Financial Condition and Other Information -- Part 1 (of 2)

Form DJ TD-433 STATEMENT OF FINANCIAL CONDITION (1996) AND OTHER INFORMATION (Please file in duplicate with offer in compromise)
Please furnish the information requested in this form with your offer in compromise, if the offer is based in whole or in part on inability to pay the liability. It is important that you answer all questions. If a question does not apply, please enter N/A, except for items 22-28, which require a yes or no answer. This will speed up consideration of your offer.
a. Names(s) of Taxpayer(s)	b. Social Security Number	c. Employer Identification Number
d. Business Address	e. Bus. Tel. No.	2. Name and Address of Representative, if any
f. Home Address	g. Home Tel. No.

3. Kind of tax involved	Taxable period	Amount Due	Amount offered
a. ________________	_____________________	_____________________	_____________________
b. ________________	_____________________	_____________________	_____________________
c. ________________	_____________________	_____________________	_____________________
d. ________________	_____________________	_____________________	_____________________
e. ________________	_____________________	_____________________	_____________________

4. Due and unpaid Federal taxes, (except those covered by this offer in compromise)
Kind of Tax	Taxable period	Amount due
a. _________________________	b. _________________________	c. _________________________

5. Name of banks and other financial institutions you have done business with at any time during past 3 years--
Name and Address	Name and Address
a. ____________________________	b. ____________________________
c. ____________________________	d. ____________________________
e. Do you rent a safety deposit box in your name or in any other name? [ ] No [ ] Yes (If yes, give name and address of bank)
6. If income withholding or employment tax is involved, please complete 6a through f.
a. Were there employees; income withholding or employment taxes, due from employees on wages they received from employment, deducted or withheld from the wages paid during any period shown above? [ ] Yes [ ] No
b. If so, was the tax paid or deposited to the Internal Revenue Service? [ ] Yes [ ] No	c. If deducted but not paid or deposited to IRS, how did you dispose of the deducted amounts?
d. Has business in which you incurred such taxes been discontinued? [ ] No [ ] Yes	e. If so, on what date was it discontinued?
f. How did you dispose of assets of discontinued business?

7. Offer filed by individual
a. Name of Spouse	b. Age of Spouse	c. Age of Taxpayer
d. Name of dependent children or relatives	Relationship	Age
(1) _________________________	_________________________	_________________________
(2) _________________________	_________________________	_________________________
(3) _________________________	_________________________	_________________________
(4) _________________________	_________________________	_________________________
(5) _________________________	_________________________	_________________________
(6) _________________________	_________________________	_________________________
(7) _________________________	_________________________	_________________________

Please furnish your most recent financial information. In the columns below, show the cost and fair market value of each asset you own directly or indirectly. If you own any asset jointly with another person(s), please specify, on items 11-16, how the property is owned (e.g., community property, tenants in common, joint tenancy, or tenants by the entireties) and your interest in the property (e.g., 50%). Also show all your interests in estates, trusts, and other property rights, including contingent interests and remainders.
8. Statement of assets and liabilities as of __________ (date)

Please furnish your most recent financial information. In the columns below, show the cost and fair market value of each asset you own directly or indirectly. If you own any asset jointly with another person(s), please specify, on items 11-16, how the property is owned (e.g., community property, tenants in common, joint tenancy, or tenants by the entireties) and your interest in the property (e.g., 50%). Also show all your interests in estates, trusts, and other property rights, including contingent interests and remainders.

8. Statement of assets and liabilities as of __________ (date)

a. Assets	Cost	Fair market value
(1) Cash	$ ______________________	$ ______________________
(2) Cash surrender value of insurance (See item 9)	______________________	______________________
(3) Accounts receivable (See item 11)	______________________	______________________
(4) Notes receivable (See item 11)	______________________	______________________
(5) Merchandise Inventory (See item 12)	______________________	______________________
(6) Real Estate (See item 13)	______________________	______________________
(7) Furniture and fixtures (See item 14)	______________________	______________________
(8) Machinery and equipment (See item 14)	______________________	______________________
(9) Trucks and delivery equipment (See item 15)	______________________	______________________
(10) Automobiles (See item 15)	______________________	______________________
(11) Securities (See item 16)	______________________	______________________
(12)	______________________	______________________
(13)	______________________	______________________
(14)	______________________	______________________
(15)	______________________	______________________
(16)	______________________	______________________
(17)	______________________	______________________
(18)	______________________	______________________
(19)	______________________	______________________
(20)	______________________	______________________
(21)	______________________	______________________
(22)	______________________	______________________
(23)	______________________	______________________
(24)	______________________	______________________
(25)	______________________	______________________
(26)	______________________	______________________
(27) Total assets	$ ______________________	$ ______________________
b. Liabilities	Amount
(1) Loans on insurance (See items 9 and 10)	______________________	______________________
(2) Accounts payable	______________________	______________________
(3) Notes payable	______________________	______________________
(4) Mortgages (See item 13)	______________________	______________________
(5) Accrued real estate taxes (See item 13)	______________________	______________________
(6) Judgments (See item 17)	______________________	______________________
(7) Reserves (Itemize)	______________________	______________________
(8)	______________________	______________________
(9)	______________________	______________________
(10)	______________________	______________________
(11)	______________________	______________________
(12)	______________________	______________________
(13)	______________________	______________________
(14)	______________________	______________________
(15)	______________________	______________________
(16)	______________________	______________________
(17)	______________________	______________________
(18)	______________________	______________________
(19)	______________________	______________________
(20)	______________________	______________________
(21)	______________________	______________________
(22) Total liabilities	$ ______________________	$ ______________________

9. Life insurance policies now in force with right to change beneficiary reserved

No. of Policy	Name of Company	Amt. of Policy	Present Cash Surrender Value Plus Accumulated Dividends	Policy Loan	Date Made	Automatic Premium Payments*	Date Made
a. ____	________	$ _____	$ __________	$ _______	_____	$ _______	____
b. ____	________	_____	__________	_______	_____	_______	____
c. ____	________	_____	__________	_______	_____	_______	____
d. ____	________	_____	__________	_______	_____	_______	____
e. ____	________	_____	__________	_______	_____	_______	____
f. ____	________	_____	__________	_______	_____	_______	____
g. ____	________	_____	__________	_______	_____	_______	____
h. ____	________	_____	__________	_______	_____	_______	____
i. ____	________	_____	__________	_______	_____	_______	____
j. ____	________	_____	__________	_______	_____	_______	____

10. Life insurance policies assigned or pledged on indebtedness
If any of the policies listed in item 9 are assigned or pledged on indebtedness, except with insurance companies, give the following information about each policy:

Number of Policy Assigned or Pledged	Name and Address of Pledgee or Assignee	Amount of Indebtedness	Date Pledged or Assigned
a.	_________________	________________	_________________
b.	_________________	________________	_________________
c.	_________________	________________	_________________
d.	_________________	________________	_________________
e.	_________________	________________	_________________
f.	_________________	________________	_________________
g.	_________________	________________	_________________

11. Accounts and notes receivable

Name	Book Value	Liquidation Value	Amount of Indebtedness	Date Pledged if Pledged
a. Accounts Receivable
(1)	$ ____________	$ ____________	$ ____________	____________
(2)	____________	____________	____________	____________
(3)	____________	____________	____________	____________
(4)	____________	____________	____________	____________
(5)	____________	____________	____________	____________
(6)	____________	____________	____________	____________
(7)	____________	____________	____________	____________
(8)	____________	____________	____________	____________
(9)	____________	____________	____________	____________
(10)	____________	____________	____________	____________
(11)	____________	____________	____________	____________
(12) Total	$ ____________	$ ____________	$ ____________	____________
b. Notes Receivable
(1)	____________	____________	____________	____________
(2)	____________	____________	____________	____________
(3)	____________	____________	____________	____________
(4)	____________	____________	____________	____________
(5)	____________	____________	____________	____________
(6)	____________	____________	____________	____________
(7)	____________	____________	____________	____________
(8)	____________	____________	____________	____________
(9)	____________	____________	____________	____________
(10)	____________	____________	____________	____________
(11) Total	$ ____________	$ ____________	$ ____________	____________

12. Merchandise Inventory

Description	Cost	Fair Market Value	Liquidation Value	Amount of Indebtedness if Pledged	Date Pledged
a. Raw Material	$ _________	$ _________	$ _________	$ _________	_________
b. Work in Progress	_________	_________	_________	_________	_________
c. Finished goods	_________	_________	_________	_________	_________
d. Supplies	_________	_________	_________	_________	_________
e. Other (Specify)	_________	_________	_________	_________	_________
f. Total	$ _________	$ _________	$ _________	$ _________	$ _________

13. Real Estate

Description	Cost*	Fair Market Value	Balance Due on Mortgage	Date Mortgage Recorded	Unpaid Interest and Taxes
a.	$ _________	$ _________	$ _________	_________	$ _________
b.	_________	_________	_________	_________	_________
c.	_________	_________	_________	_________	_________
d.	_________	_________	_________	_________	_________
e.	_________	_________	_________	_________	_________
f.	_________	_________	_________	_________	_________
g.	_________	_________	_________	_________	_________
h.	_________	_________	_________	_________	_________
i. Total	$ _________	$ _________	$ _________	_________	$ _________

October 1997	Tax Resource Manual 37