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Department of Justice >
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Title 6 >
Tax Resource Manual prev | next |
| 14. Furniture and fixtures--Machinery and equipment |
| Description | Cost (less depreciation if applicable) | Liquidation Value | Amount of Indebtedness if Pledged | Date Pledged |
| a. Furniture and fixtures (Business) |
_____________ |
_____________ |
_____________ |
_____________ |
| b. Furniture (Household-residence) |
_____________ |
_____________ |
_____________ |
_____________ |
| c. Machinery (Specify kind) |
_____________ |
_____________ |
_____________ |
_____________ |
| d. | _____________ | _____________ | _____________ | _____________ |
| e. | _____________ | _____________ | _____________ | _____________ |
| f. | _____________ | _____________ | _____________ | _____________ |
| g. Equipment (Except trucks and automobiles) (Specify) |
_____________ |
_____________ |
_____________ |
_____________ |
| h. | _____________ | _____________ | _____________ | _____________ |
| i. | _____________ | _____________ | _____________ | _____________ |
| j. | _____________ | _____________ | _____________ | _____________ |
| k. Total | $ | $ | $ | _____________ |
| 15. Trucks and Automobiles | ||||
| a. Trucks | $ | $ | $ | _____________ |
| b. | _____________ | _____________ | _____________ | _____________ |
| c. | _____________ | _____________ | _____________ | _____________ |
| d. | _____________ | _____________ | _____________ | _____________ |
| e. | _____________ | _____________ | _____________ | _____________ |
| f. | _____________ | _____________ | _____________ | _____________ |
| g. Automobiles (Personal or used in business) |
_____________ |
_____________ |
_____________ |
_____________ |
| h. | _____________ | _____________ | _____________ | _____________ |
| i. | _____________ | _____________ | _____________ | _____________ |
| j. | _____________ | _____________ | _____________ | _____________ |
| k. | _____________ | _____________ | _____________ | _____________ |
| l. | _____________ | _____________ | _____________ | _____________ |
| m. Total | _____________ | _____________ | _____________ | _____________ |
| 16. Securities (Bonds, stocks, etc.) | |||||
| Name of Company | Number of Units | Cost | Fair Market Value | Amount of indebtedness if Pledged | Date Pledged |
| a. | ___________ | $ | $ | $ | ___________ |
| b. | ___________ | ___________ | ___________ | ___________ | ___________ |
| c. | ___________ | ___________ | ___________ | ___________ | ___________ |
| d. | ___________ | ___________ | ___________ | ___________ | ___________ |
| e. | ___________ | ___________ | ___________ | ___________ | ___________ |
| f. | ___________ | ___________ | ___________ | ___________ | ___________ |
| g. | ___________ | ___________ | ___________ | ___________ | ___________ |
| h. | ___________ | ___________ | ___________ | ___________ | ___________ |
| i. Total | ___________ | $ | $ | ___________ | ___________ |
| 17. Judgments | |||
| Name of Creditor | Amount of Judgment | Date Recorded | Where Recorded |
| a. | $ | _________________ | _________________ |
| b. | _________________ | _________________ | _________________ |
| c. | _________________ | _________________ | _________________ |
| d. | _________________ | _________________ | _________________ |
| e. Total | $ | _________________ | _________________ |
| 18. Statement of Income - - Corporation | |||
| IMPORTANT: If the offer in compromise is from a corporation, please furnish the information requested below (from tax returns, as adjusted, for past 2 years and from records for current year from January 1 to date) | |||
| a. Gross Income | 19 | 29 | Jan 1 to 19 |
| (1) Gross sales or receipts (Subtract returns and allowances) | $ | $ | $ |
| (2) Cost of goods sold | _________________ | _________________ | _________________ |
| (3) Gross profit - trading or manufacturing |
_________________ |
_________________ |
_________________ |
| (4) Gross profit- from other sources |
_________________ |
_________________ |
_________________ |
| (5) Interest Income | _________________ | _________________ | _________________ |
| (6) Rents and royalties |
_________________ |
_________________ |
_________________ |
| (7) Gains and losses (From Schedule D) |
_________________ |
_________________ |
_________________ |
| (8) Dividends | _________________ | _________________ | _________________ |
| (9) Other (Specify) | $ | $ | $ |
| b. Deductions | _________________ | _________________ | _________________ |
| (1) Compensation of Officers | $ | $ | $ |
| (2) Salaries and wages (Not deducted elsewhere) |
_________________ |
_________________ |
_________________ |
| (3) Rents | _________________ | _________________ | _________________ |
| (4) Repairs | _________________ | _________________ | _________________ |
| (5) Bad Debts | _________________ | _________________ | _________________ |
| (6) Interest | _________________ | _________________ | _________________ |
| (7) Taxes | _________________ | _________________ | _________________ |
| (8) Losses | _________________ | _________________ | _________________ |
| (9) Dividends | _________________ | _________________ | _________________ |
| (10) Depreciation and depletion | _________________ | _________________ | _________________ |
| (11) Contributions | _________________ | _________________ | _________________ |
| (12) Advertising | _________________ | _________________ | _________________ |
| (13) Other (Specify) | _________________ | _________________ | _________________ |
| (14) | _________________ | _________________ | _________________ |
| (15) Total deductions | $ | $ | $ |
| c. Net income (loss) | $ | $ | $ |
| d. Nontaxable income | $ | $ | $ |
| e. Unallowable deductions | $ | $ | $ |
| 19. Salaries paid to principle officers and dividends distributed - - Corporation | |||
| IMPORTANT: If the offer in compromise is from a corporation, please show salaries paid to principal officers for past 3 years and amounts distributed in dividends, if any, during and since the taxable years covered by this offer. | |||
| a. Salaries paid to (Name and Title) | 19 | 19 | 19 |
| (1)______________
President |
$ | $ | $ |
| (2)_______________
Vice President |
_________________ |
_________________ |
_________________ |
| (3)_______________
Treasury |
_________________ |
_________________ |
_________________ |
| (4)_______________
Secretary |
_________________ |
_________________ |
_________________ |
| (5) | _________________ | _________________ | _________________ |
| (6) | _________________ | _________________ | _________________ |
| (7) Total | $ | $ | $ |
| b. Year | Dividends Paid | Year | Dividends Paid | Year | Dividends Paid |
| (1) | $ | (8) | $ | (15) | __________ |
| (2) | ___________ | (9) | ___________ | (16) | ___________ |
| (3) | ___________ | (10) | ___________ | (17) | ___________ |
| (4) | ___________ | (11) | ___________ | (18) | ___________ |
| (5) | ___________ | (12) | ___________ | (19) | ___________ |
| (6) | ___________ | (13) | ___________ |
(20) Total |
___________ $ |
| (7) | ___________ | (14) | ___________ |
| 20. Statement of Income - - Individual | ||
| IMPORTANT: If the offer in compromise is from an individual or an estate, please furnish information requested below (from income tax returns as adjusted for past 2 years. | ||
| a. Gross Income | 19 | 19 |
| (1) Salaries, wages, commissions | $ | $ |
| (2) Dividends | __________________ | ________________________ |
| (3) Interest | __________________ | ________________________ |
| (4) Income from business or profession | __________________ | ________________________ |
| (5) Partnership income | __________________ | ________________________ |
| (6) Gains or losses (from Schedule D, Form 1040) |
__________________ |
________________________ |
| (7) Annuities and pensions | __________________ | ________________________ |
| (8) Rents and royalties | __________________ | ________________________ |
| (9) Income from estate and trust | __________________ | ________________________ |
| (10) | __________________ | ________________________ |
| (11) | __________________ | ________________________ |
| (12) | __________________ | ________________________ |
| (13) | __________________ | ________________________ |
| (14) | __________________ | ________________________ |
| (15) Total Income | $ | $ |
| b. Deductions | ||
| (1) Contributions | $ | $ |
| (2) Interest Paid | __________________ | ________________________ |
| (3) Taxes Paid | __________________ | ________________________ |
| (4) Casualty losses (by fire, storm, etc.) | __________________ | ________________________ |
| (5) Medical expenses | __________________ | ________________________ |
| (6) Bad Debts | __________________ | ________________________ |
| (7) | __________________ | ________________________ |
| (8) | __________________ | ________________________ |
| (9) | __________________ | ________________________ |
| (10) | __________________ | ________________________ |
| (11) | __________________ | ________________________ |
| (12) Total deductions | $ | $ |
| c. Net income (loss) | $ | $ |
| d. Nontaxable income | $ | $ |
| e. Unallowable deductions | $ | $ |
| 21. Receipts and disbursements - - Individuals | From | To |
| If the offer in compromise is from an individual or on behalf of an estate, please furnish below a complete analysis of receipts and reimbursement for the past 12 months. | ||
| Description | Source From Which Received | Amount |
| (1) Salary | __________________ | $ |
| (2) Commissions | __________________ | ________________________ |
| (3) Business or profession | __________________ | ________________________ |
| (4) Dividends | __________________ | ________________________ |
| (5) Interest | __________________ | ________________________ |
| (6) Annuities or pensions | __________________ | ________________________ |
| (7) Rents and royalties | __________________ | ________________________ |
| (8) Sale of assets (Net amount received) | __________________ | ________________________ |
| (9) Amounts borrowed | __________________ | ________________________ |
| (10) Gifts | __________________ | ________________________ |
| (11) | __________________ | ________________________ |
| (12) | __________________ | ________________________ |
| (13) | __________________ | ________________________ |
| (14) | __________________ | ________________________ |
| (15) | __________________ | ________________________ |
| (16) | __________________ | ________________________ |
| (17) | __________________ | ________________________ |
| (18) | __________________ | ________________________ |
| Total receipts | $ | |
| b. Disbursements | ||
| Description | Amount | |
| (1) Debt Reduction | $ | |
| (2) Interest | ________________________ | |
| (3) Federal taxes | ________________________ | |
| (4) Other taxes | _______________________________ | |
| (5) Insurance premiums | _______________________________ | |
| (6) Medical expenses | _______________________________ | |
| (7) Automobile expenses | _______________________________ | |
| (8) Servant's wages | _______________________________ | |
| (9) Gifts | _______________________________ | |
| (10) Living expenses (Itemize) | _______________________________ | |
| _____________________________ | _______________________________ | |
| _____________________________ | _______________________________ | |
| _____________________________ | _______________________________ | |
| _____________________________ | _______________________________ | |
| _____________________________ | _______________________________ | |
| _____________________________ | _______________________________ | |
| _____________________________ | _______________________________ | |
| _____________________________ | _______________________________ | |
| _____________________________ | ______________________________ | |
| _____________________________ | _______________________________ | |
| _____________________________ | _______________________________ | |
| _____________________________ | _______________________________ | |
| _____________________________ | _______________________________ | |
| Total Disbursements | $ | |
| 22. Disposal of assets - - From the
beginning of the taxable period covered by this offer in
compromise to the present date, have you disposed of any assets or property with
a cost
or fair market value or more than $500, except for full value at the time of
sale, transfer,
exchange, gift or other disposition?
[] No [] Yes If yes, please furnish the following information. | ||
| Description of Asset | Date of Transfer | Fair Market Value When Transferred | Consideration Received | Relation ship of Transferee to Taxpayer |
| _____________ | _____________ | $ | $ | _____________ |
| _____________ | _____________ | _____________ | _____________ | _____________ |
| _____________ | _____________ | _____________ | _____________ | _____________ |
| _____________ | _____________ | _____________ | _____________ | _____________ |
| _____________ | _____________ | _____________ | _____________ | _____________ |
| _____________ | _____________ | _____________ | _____________ | _____________ |
| 23. Interest in or beneficiary of
estate or trust - - Have you any life interest or remainder
interest, either vested or contingent in any trust or estate, or are you a
beneficiary of any
trust?
[] NO [] YES If yes, please furnish a copy of the instrument creating the trust or estate - - Also give the following information) |
| Name of Trustee or Estate | Present Value of Assets | Value of Your Interest | Annual Income Received From This Source |
| _________________ | _________________ | _________________ | _________________ |
| _________________ | _________________ | _________________ | _________________ |
| _________________ | _________________ | _________________ | _________________ |
| _________________ | _________________ | _________________ | _________________ |
| 24. Grantor, donor, trustee, or
fiduciary - - Are you the grantor or donor of any trust, or
the trustee or fiduciary for any trust?
[] NO [] YES (If yes, please furnish a copy of the instrument creating the trust.
- - Also give present
value of corpus of trust, and any other pertinent information.)
|
| 25. Any other assets or interest in
assets - - Have you any other assets or an interest in
assets either actual or contingent, other than those listed here (i.e.,
Profit-sharing plan or
pension plan?
[] NO []YES (If yes, please describe the assets.)
|
| 26a. Are foreclosure
proceedings pending on any
real estate which you own
or have an interest in?
NO [] YES [] |
b. If yes, please give location of real estate. | c. Was the government
made a party to the suit?
NO [] YES [] |
| 27a. Are bankruptcy or receivership proceedings pending? [] no [] yes | b. If a corporation, is it in process of liquidation? [] no [] yes |
| 28. Is the sum offered in compromise
borrowed money? (IF yes, please give name and
address offender and list collateral, if any pledged to secure the
loan).
no [] yes [] |
| 29. What is the prospect of an increase
in value of assets or in present income? (Please
give general statement)
|
| 30. Affidavit |
| Under penalties of perjury, I declare that I have examined the information given in this statement and, to the best of my knowledge and belief, it is true, correct, and I further declare that I have no assets, owned either directly or indirectly, or income of any nature other that as shown in this statement. |
| a. Date of this statement | b. Signature |
| October 1997 | Tax Resource Manual 38 |
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