Offer In Compromise Business Request For Settlement - State Of Virginia Page 4
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4SECTION VI
INCOME AND EXPENSE STATEMENT
(Continued)
Period Ending____________________
Annual ______ Quarterly_______ Monthly ________
14.
INCOME
INCOME
15.
EXPENSES
MONTHLY PAYMENT
$
Gross receipts from sales, services, etc
Materials purchased
Gross rental income
Net wages and salaries
Interest
Rent
Dividends
Installment payments
Other Income (Specify):
Supplies
Utilities/Telephone
Repairs and maintenance
Insurance
Current taxes
Other (specify)
TOTAL INCOME:
$
TOTAL EXPENSES:
$
NET DIFFERENCE
$
COMMENTS
:
CERTIFICATION
Under penalties of perjury, I declare that to the best of my knowledge and belief,
this statement of assets, liabilities and other information is true, correct and complete.
16. Signature:
Date:
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