Form Cd Lo-14b - Statement Of Financial Condition For Individuals Page 3
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4CD LO-14B (Rev. 02/03)
Page 3
SECTION V – LIABILITIES
29. Liabilities (Do Not Include An y Mortgages or Veh icle Loans)
Total Amount
Total Amount
Description
Owed
Description
Owed
Notes Payable
$
Past Due Other Taxes
$
Installm ent or Personal Loans
Veh icle Lease: Make _____________ Yr _____
Education or Student Loan s
Veh icle Lease: Make _____________ Yr _____
Bank Revolving Credit
Other Liabilities:
Judgments Payable
Past Due F eder al Taxes
Past Due State T axes
TOT AL (Enter also on Pag e 3, Item 31) $
SECTION VI – NET WORTH CALCULATION
30. Assets
A. C ash
$
B. Bank or Cr edit Union Accounts
C. Bank Cr edit Cards
D. Securities
E. Real Propert y
F. Vehicles
G. Other Assets
Total Assets
$
31. Liabilities
$
32. Net W orth
(“Total Assets” Minus “Liabilities”)
$
SECTION VII – OT HER INFORMATION
33. Are you cur rently in filing complian ce with all Georgia taxes?
[ ] Yes [
] No
If “No”, identif y t ax t yp e and p eriod: _______________________________________________________________
34. If the tax liabilit y was in curred in the oper ation of a business, h as the business b een discontinued?
[ ] Yes [
] No
[ ] N/A If “Yes”, d ate discontinued: _____________________________________
35. Have you dispo sed of an y assets or propert y b y sale, transfer , exchang e, gift, or in an y other mann er during the p ast 18 months?
[ ] Yes [
] No
If “Yes”, identif y: _______________________________________________________________________________
36. Is a foreclo sure pro ceeding pending on an y r eal est ate that you o wn or have an interest in?
[ ] Yes [
] No
37. Is an yone holding an y assets on your beh alf?
[ ] Yes [
] No
If “Yes”, identif y: ______________________________________ Relationship: ____________________________
38. Are you a part y to an y lawsuit no w pending?
[ ] Yes [
] No
39. Is there a likelihood that you will r eceive an inher itance within the n ext four year s?
[ ] Yes [
] No
If “Yes”, from whom? __________________________________ R elationship: ____________________________
40. Have you previously petitioned the Departm ent of Revenue for an offer in compromise for an y tax liabilit y?
[ ] Yes [
] No
?
41. Are you or an y busin ess that you o wn currently under b ankruptcy court jurisdiction
[ ] Yes [
] No B ankruptcy Case No.: ___________________________________
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