Form De-999b - Offer In Compromise Financial Statement Page 3
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1
2
3Employment Information
Taxpayer’s employer or business
Date Employed
Bus. Phone
Occupation
Name:
(
)
Address:
Wage Earner
Sole Proprietor
Partner/Corp. Officer
Spouse’s employer or business
Date Employed
Bus. Phone
Occupation
Name:
(
)
Address:
Wage Earner
Sole Proprietor
Partner/Corp. Officer
Other information relating to your financial condition. If you check the yes box, please give dates and explain below.
Court Proceedings
Yes
No Bankruptcies
Yes
No
Repossessions
Yes
No Participation or beneficiary to trust, estate, etc.
Yes
No
Health considerations that will affect earning potential
Yes
No
Explanation:
Anticipated increase in income
Yes
No
If answer is “YES” give following information:
Source
Date increase is expected and frequency
Amount of increase expected
Recent transfer of assets of any kind
Yes
No
If answer is “YES” give following information:
Description
Date of Transfer
Relationship of Transferee
Fair Market
Consideration
to Applicant
Value
Received
CERTIFICATION
Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets,
liabilities, and other information is true, correct, and complete. I also understand any costs incurred to verify
questionable information submitted will be my responsibility.
Your Signature:
Date:
DE 999B (7-03) (INTERNET)
Page 3 of 3
CU
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