Form Mo-656 - Offer In Compromise Application Page 4
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SECTION 4 PERSONAL FINANCIAL INFORMATION
(CONTINUED)
OTHER FINANCIAL INFORMATION.
IF YOU CHECK “YES”, PROVIDE DATES, AN EXPLANATION, AND DOCUMENTATION. ATTACH ADDITIONAL PAGES AS NEEDED.
COURT PROCEEDINGS (LITIGATION, PROBATE, ETC.) . . . . . . . . . . . . . . . . . . . . . . . . .
NO
YES _____________________________________
ANTICIPATED INCREASE IN INCOME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO
YES _____________________________________
BANKRUPTCIES/RECEIVERSHIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO
YES _____________________________________
TRANSFER OF ASSETS IN LAST 12 MONTHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO
YES _____________________________________
BENEFICIARY TO TRUST, ESTATE, PROFIT SHARING, ETC. . . . . . . . . . . . . . . . . . . . . .
NO
YES _____________________________________
TAXES OWED TO THE IRS (PROVIDE PROOF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO
YES _____________________________________
TAXES OWED TO OTHER STATES, COUNTIES, DISTRICTS, AGENCIES, ETC. . . . . . .
NO
YES _____________________________________
OTHER DEBT (EXPLAIN). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO
YES _____________________________________
SECTION 5 PERSONAL INCOME AND EXPENSE ANALYSIS
MONTHLY HOUSEHOLD DISPOSABLE INCOME. ATTACH DOCUMENTATION.
MONTHLY LIVING EXPENSES
GROSS MONTHLY INCOME
SOURCE
AMOUNT
SOURCE
TAXPAYER
SPOUSE
$
$
$
SALARY, WAGES, COMMISSIONS, TIPS
HOUSE OR RENT PAYMENT
SELF-EMPLOYMENT INCOME
INCOME TAXES (FEDERAL, STATE, FICA)
PENSIONS, DISABILITY & SOCIAL SECURITY
ESTIMATED TAX (IF APPLICABLE)
DIVIDENDS & INTEREST
GROCERIES
MEDICAL EXPENSES & PRESCRIPTIONS
GIFT OR LOAN PROCEEDS
UTILITIES:
RENTAL INCOME
ELECTRIC $ _________ +
GAS $ _________ +
0.00
ESTATE, TRUST & ROYALTY INCOME
WORKERS’ COMP. & UNEMPLOYMENT
WATER
$ _________ + PHONE $ _________ =
INSURANCE:
ALIMONY & CHILD SUPPORT
LIFE
$ _________ + HEALTH $ _________ +
0.00
SELLER CARRIED CONTRACTS
AUTO
$ _________ + HOME $ _________ =
SALES
COURT ORDERED PAYMENT
OTHER (SPECIFY)
PERSONAL LOAN PAYMENT
COURT ORDERED SETTLEMENT
CLOTHING & PERSONAL GROOMING
RESTITUTION
LEGAL FEES
TRANSPORTATION EXPENSE
VEHICLE LOAN/LEASE PAYMENT
PROPERTY TAXES
CHILD CARE
INSTALLMENT & CREDIT CARD PAYMENTS
TUITION PAYMENT
OTHER (SPECIFY)
$
0.00
$
0.00
SUBTOTAL
0.00
0.00
$
$
COMBINED MONTHLY INCOME
TOTAL MONTHLY LIVING EXPENSES
NET MONTHLY HOUSEHOLD DISPOSABLE INCOME
0.00
$
(“COMBINED MONTHLY INCOME” MINUS “TOTAL MONTHLY LIVING EXPENSES”). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MO-656 (5-2012)
9
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Parent category: Financial