Form Ct-656 - Offer Of Compromise Page 3
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3A. Credit: All loans, credit cards, installment accounts, other debts, or past due federal, state, or municipal taxes
Account
Current
Minimum Monthly
Name and Address of Creditors
Number
Credit Limit
Balance
Amount
B. Bank Accounts: Savings, checking, certifi cates of deposit, IRA, Keough, etc.
Name and Address of Institution
Account Number
Account Type
Balance
C. Real Estate
Location
Type of
% of
Estimated
Balance of
Mortgage
(Number, street, town, state, ZIP code)
Property
Ownership
Market Value
Mortgage
Holder
D. Automobiles, Furniture and Fixtures, Machinery and Equipment, Other Personal Property
Estimated
% of
Outstanding
Type of Property
Location
Market Value
Ownership
Liens
E. Government and Marketable Securities
Number of Shares/
Market
Source of
Description
Face Value of Bonds
In Name of
Value
Value
F. Receivables: Trade receivables, loans to offi cers, etc.
Current
Minimum Monthly
Name and Address of Creditors
Account Number
Credit Limit
Balance
Amount
Declaration: I declare under penalty of law that I have examined this application and to the best of my knowledge and
belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false application to DRS is a
fi ne of not more than $5,000 or imprisonment for not more than fi ve years, or both.
Applicant’s Signature
Title
Date
CT-656 Back (Rev. 03/08)
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Parent category: Financial