Form De-999b - Offer In Compromise Financial Statement
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1
2
3OFFER IN COMPROMISE FINANCIAL STATEMENT
NOTE: Complete all blocks except shaded areas. Write “N/A” (not applicable) in those blocks that do not apply.
Acct. #:
Bus. Name:
Telephone: (
)
Personal Information
Applicant’s Name and Address
Married
Yes
No
If Yes, Spouse’s Name:
Applicant
Spouse
Social Security Number
Social Security Number
Name, address and telephone number of next of kin
Driver’s License Number
Driver’s License Number
Date of Birth
Date of Birth
Name, age and relationship of dependents living in your household (exclude yourself and spouse)
Current Assets
Cash
$
Bank Accounts (Include Savings & Loans, Credit Unions, IRA and Retirement Plans, Union Vacation Trust Funds, etc.)
Name of Institution
Address
Type of Account
Account Number
Balance
$
Accounts/Notes Receivable
Name
Address
Payment or Due Date
Amount
$
Available Credit Sources: Credit Unions, Lines of Credit, or Charge Cards with cash advance feature, etc.
Type of Account
Name and Address of
Amount
Minimum
Business or
Available
or Card
Financial Institution
Owed
Monthly Payment
Personal
Credit
$
$
$
Securities: Stocks, Bonds, Mutual Funds, Money Market Funds, Government Securities, etc.
Kind
Quantity or Denomination
Where Located
Value
$
Life Insurance
Name of Company
Policy Number
Type
Face Amount
Loan Value
$
$
Dept. Use Only
Section A
______________
DE 999B (7-03) (INTERNET)
Page 1 of 3
CU
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