Form Dtf-5 - Statement Of Financial Condition And Other Information - New York State Department Of Taxation And Finance

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DTF-5 (12/08)
New York State Department of Taxation and Finance
Statement of Financial Condition and Other Information
Please furnish the information requested on this form at the time you submit your offer in compromise, request for payment plan, or
other proposal if the offer is based in whole or in part on inability to pay the liability. It is important that you answer all questions. If a
question does not apply, please enter N/A. This will speed up consideration of your proposal.
Note: When making an offer in compromise you must file in duplicate. Also file Form DTF‑4, Offer in Compromise For Liabilities Not
Fixed and Final and Subject to Administrative Review, or Form DTF‑4.1, Offer in Compromise For Fixed and Final Liability.
I. A. Name of taxpayer(s) and/or trade or business names
B. Date of birth
C. Social security number(s)
D. Business ID number (EIN)
E. Home address
F. Home telephone number
G. Business address
H. Business telephone number
II. Name of representative, if any
Telephone number
Address:
III.
Names of Banks and Other Financial Institutes You Have Done Business with at Any Time During the Past Three Years
Name and Address
Name and Address
A.
B.
C.
D.
E. Do you rent a safe deposit box in your name or in any other name?
Yes
No If Yes, give name and address of bank
IV. Proposal Filed by Individual
A. Name of spouse
B. Spouse’s age
C. Spouse’s social security number
D. Names of dependent children or relatives
E. Relationship
F. Social security number
G. Age
1.
2.
3.
4.
5.
6.
7.
V. Life Insurance Policies Now in Force
D. Present
C. Amount
E. Policy
F. Date
G. Automatic
H. Date
Cash Surrender
A. Number of Policy
B. Name and Address of Company
Value Plus
of
Loan
Made
Premium
Made
Accumulated
Policy
Payments
Dividends
1.
2.
3.
4.
5.

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