Form A-212 - Petition For Compromise Of Delinquent Taxes - Wisconsin Department Of Revenue Page 2
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48. Statement of assets and liabilities
The following is a true and complete statement of petitioner's financial condition as of
, 19
. If this statement is
not sufficient for your purpose, please attach a schedule. If explanatory comments are necessary, please attach a letter to the petition.
Assets (show at fair market value)
Liabilities
Cash on hand and in banks
*Bonds or mortgage indebtedness (see below)
Cash surrender value of life insurance
*Bills and accounts payable (see below)
(Total from section 9 below)
Taxes payable
Real estate (Total from section 9 below)
Property
Assets listed in section 11 below
Income (U.S.)
Bills and accounts receivable
Other liabilities
Inventories
Machinery
Other equipment (autos, etc.)
Furniture and fixtures
Securities, stocks, bonds, etc.
All other assets (specify)
Total liabilities
Total assets
Net worth (total assets less total liabilities
*If these liabilities (other than mortgages) exceed $2,000, attach schedule listing each creditor and amount owed.
NOTE: no depreciation reserve should be shown above since the assets are listed at fair market value.
9. Life insurance policies
Have Premiums Been
Cash
Balance
Paid to Date?
Company
Beneficiary
Amount
Surrender Value
on Loan
(Yes or No)
Is this insurance pledged with banks or other creditors?
Yes
No
10.Real Estate (include personal residence)
Fair Market
Balance Due
Date Mortgage
Unpaid Interest
Description
Cost
Value*
on Mortgage*
Recorded
and Taxes*
*Proof by documentation must accompany this petition. Copy of property tax bills to verify value and lender's statment to verify mortgage balance are required.
Back Property tax must also be verified.
11.Receivables, inventories, machinery and equipment, trucks and automobiles (for personal or business use), stocks and bonds, etc.
Fair Market
Amount of Indebtedness
Description
Cost
Value
If Pledged**
Date Pledged
** Submit written verification of the amount due.
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