Form A-212 - Petition For Compromise Of Delinquent Taxes - Wisconsin Department Of Revenue Page 3
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412. Have you any other assets or interest in assets, either actual or contingent other than those listed herein?
Yes
No
(If yes, provide an explanation. Include any interest in a trust.)
13. Disposal of assets – Have you disposed of any assets or property by sale, transfer, exchange, gift or in any other manner during the past
18 months?
Yes
No (If yes, complete the schedule appearing below. Attach separate statement if necessary.)
Description of
Date of
Fair Market Value
Consideration
Relationship of Transferee
Asset
Transfer
When Transferred
Received
To Taxpayer
From
To
14. If individual, give an analysis of receipts and disbursements for the past 12 months
as follows (specify period covered at right):
Receipts
Disbursements
Salary and commisions (gross)
Debt reduction payments
Rents (net amount received)
Interest paid
Dividends
Insurance premiums
Interest
Automobile expense
Social security payments
Living expenses (attach schedule)
Other pensions
Other disbursemnents (specify)
Amounts borrowed
Sale of assets (net)
Other income (specify)
Total
Total
15. Prospect of increase in value of assets or in present income (describe and explain)
16. Are foreclosure, bankruptcy, receivership or assignment proceedings pending for the benefit of creditors?
Yes
No
17. Judgments
Date Recorded
Recorded in
Name of Creditor
Amount of Judgment
or Docketed
(District, County or State)
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