Form A-212 Petition For Compromise Of Taxes Based On Inability To Pay Page 2

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9. Statement of Assets and Liabilities

The following is a true and complete statement of petitioner's financial condition as of

. If this statement is

not sufficient for your purpose, please attach a schedule. If explanatory comments are necessary, please attach a letter to the petition.

Assets (show at fair market value)

Liabilities

Cash on hand and in banks

*Bonds or mortgage indebtedness (see below)

Cash surrender value of life insurance

*Bills and accounts payable (see below)

(Total from section 10 below)

Taxes payable

Real estate (Total from section 11 below)

Property

Assets listed in section 12 below

Income (U.S.)

Bills and accounts receivable

Other liabilities

Inventories

Machinery

Other equipment (autos, etc.)

Furniture and fixtures

Securities, stocks, bonds, etc.

All other assets (specify)

0.00

Total liabilities

Net worth (total assets less total liabilities)

$0.00

Total assets

*If these liabilities (other than mortgages) exceed $2,000, attach schedule listing each creditor and amount owed.

NOTE: no depreciation reserve should be shown above since the assets are listed at fair market value.

10. Life Insurance Policies

Have Premiums

Cash

Balance

Been Paid to Date?

Company

Beneficiary

on Loan

Amount

Surrender Value

(Yes or No)

Is this insurance pledged with banks or other creditors?

Yes

11. Real Estate (include personal residence)

Balance Due

Date Mortgage

Unpaid Interest

Fair Market

Cost

on Mortgage*

and Taxes*

Description

Recorded

Value

*Proof by documentation must accompany this petition. Copy of property tax bills to verify value and lender's statement to verify mortgage balance are required.

Back Property tax must also be verified.

12. Receivables, inventories, machinery and equipment, trucks and automobiles (for personal or business use), stocks and bonds, etc.

Fair Market

Amount of indebtedness

Cost

if Pledged**

Description

Date Pledged

Value

** Submit written verification of the amount due.

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