Form Ct-656a - Offer Of Compromise Page 3
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3A. Bank Accounts: Savings, checking, certifi cates of deposit, IRA, Keough, etc.
Account
Name and Address of Institution
Number
Account Type
Balance
B. Real Estate
Location
Mortgage
Estimated
Balance of
Monthly
(Number, street, town, state, ZIP code)
Holder
Market Value
Mortgage
Payment
C. Other Assets: Cars, boats, RV’s, personal property
Current
Minimum Monthly
Name and Address of Creditors
Account Number
Credit Limit
Balance
Amount
D. Credit: All loans, credit cards, installment accounts, other debts
Current
Minimum Monthly
Name and Address of Creditors
Account Number
Credit Limit
Balance
Amount
Monthly Income
Monthly Expenses
Your net pay
$ ___________________
Rent
$ ____________________
Your spouse’s net pay
$ ___________________
Mortgage
$ ____________________
Social security or pensions
$ ___________________
Utilities (electricity, heating, etc.)
$ ____________________
Profi t from your business
$ ___________________
Transportation (gas, bus fares)
$ ____________________
Rental income
$ ___________________
Credit cards
$ ____________________
Child support income
$ ___________________
Groceries
$ ____________________
Alimony from former spouse
$ ___________________
Child support expense
$ ____________________
Other income: (source)
$ ___________________
Alimony expense to former spouse
$ ____________________
____________________________ $ ___________________
Loan payments: (list)
$ ____________________
____________________________ $ ___________________
Other: (explain)
$ ____________________
____________________________ $ ___________________
______________________________ $ ____________________
Total Income
$ ___________________
Total Expenses
$ ____________________
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.
Your Signature
Spouse’s Signature
Date
CT-656a Back (Rev. 03/08)
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