Offer In Compromise Business Request For Settlement - State Of Virginia Page 3
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2
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4SECTION IV
ACCOUNTS AND NOTES RECEIVABLE INFORMATION
12. ACCOUNTS/NOTES RECEIVABLE (include loans to stockholders, officers, partners, etc)
Name
Address
Amount Due
Date Due
Status
$
$
$
$
$
SECTION V
ASSET AND LIABILITY STATEMENT
13. ASSET AND LIABILITY ANALYSIS (Total)
Description
Current
Liabilities
Equity in
Amount of
Name/Address of
Contact Telephone
Market
Balance Due
Asset
Payment
Institution Lien Holder
Number to Verify
Value
Cash on Hand
$
Bank Accounts
Accounts/Notes
Receivable
Real Property
1
2
3
4
Vehicles
1
(model, yr, license)
2
3
1
Machinery/Equipment
2
3
Merchandise Inventory
Other Assets
1
2
3
Other Liabilities
1
2
3
Federal Taxes
State Taxes
Local Taxes
TOTAL
$
$
$
$
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