Offer In Compromise Application (Continued) Form - California Franchise Tax Board (Page 2 of 3) in pdf

Offer In Compromise Application (Continued) Form - California Franchise Tax Board Page 2

State of California — Franchise Tax Board

Offer in Compromise Application (Continued)

3. SOURCE OF FUNDS

a. Is all or part of the amount being offered a loan?

Yes

If yes, please provide the following information and attach a copy of the loan agreement.

Amount borrowed $ __________________________________________

Name of lender ______________________________________________

Lender’s address ____________________________________________

Lender’s telephone number ____________________________________

b. Is all or part of the amount being offered a gift?

Yes

If yes, please provide the following information:

Amount of gift $______________________________________________

Name of donor ______________________________________________

Donor’s relationship to the entity_________________________________

c. Describe sources of offered funds other than those listed in a or b.

___________________________________________________________________________________________

4. OWNERSHIP

List any individual or corporate owners with 25% or more interest in this entity.

Name of Owner(s)

% Owned

________________________________________________________________________________________________

(Attach a separate sheet scheduling any parent or subsidiary entity relationship.)

FTB 4905BE C1 (NEW 05-2007)

Offer In Compromise Application (Continued) Form - California Franchise Tax Board Page 2