Form Ftb 3861a C1 - Bank And Corporation - Statement Of Financial Condition And Other Information

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State of California — Franchise Tax Board
Bank and Corporation
California Statement of Financial Condition and Other Information – Part I
Federal Form 433-B may be submitted in place of Part I of this form, however Part II must still be submitted.
Please furnish the information requested on this form along with the Offer in Compromise. It is important that all questions
are answered. If a question does not apply, please enter N/A. This will expedite consideration of the offer.
1a. Name of Corporation
b. California Corporation Number
c. Corporate Address
d. Telephone Number
e. Trade or Business Name(s)
f. Business Address(es)
g. Business Telephone Number(s)
h. Type of Business(es)
2. Name of Representative
Daytime Telephone Number
Address
Provide Power of Attorney
3a. Bank accounts (Lists all types of accounts including payroll and general, savings, certificates of deposit, etc.) held during the past three years.
Name of Institution
Address
Type of Account
Account Number
Balance
Total (Also enter in item 4.a.1)
b. Bank credit available (Lines of credit, etc.)
Credit
Amount
Credit
Monthly
Name of Institution
Address
Limit
Owed
Available
Payments
c. Location, box number, and contents of all safe deposit boxes rented or accessed.
FTB 3861A C1 (REV 11-94) PAGE 1
PAGE 7

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