Form Mo-656 - Offer In Compromise Application Page 10
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COMPLETE SECTIONS 6 THROUGH 8 ONLY IF YOU OWN A BUSINESS OR ARE SELF-EMPLOYED.
SECTION 6 BUSINESS INFORMATION
BUSINESS NAME
MISSOURI TAX ID
AVERAGE GROSS MONTHLY INCOME
BUSINESS ADDRESS
TOTAL EMPLOYEES
BUSINESS TELEPHONE NUMBER
BUSINESS WEB SITE
DO YOU OR YOUR SPOUSE HAVE ANY OTHER BUSINESS INTERESTS?
YES
NO
TYPE OF BUSINESS (SELECT ONE)
IF YES, COMPLETE ADDITIONAL ATTACHMENT FOR EACH BUSINESS INTEREST.
SOLE OWNERSHIP
PARTNERSHIP
LLC
CORPORATION
OTHER
DESCRIPTION OF BUSINESS
SECTION 7 BUSINESS FINANCIAL INFORMATION
BANK ACCOUNTS. INCLUDE CERTIFICATES OF DEPOSIT, ETC. ATTACH ALL PAGES OF THE MOST RECENT THREE MONTHS OF BANK STATEMENTS
FOR ALL ACCOUNTS OF EACH PERSON IN THE HOUSEHOLD. ATTACH ADDITIONAL PAGES AS NEEDED. IF YOU OWE MORE THAN $50,000, SIX
MONTHS BANK STATEMENTS ARE REQUIRED.
BALANCE
NAME OF INSTITUTION
ADDRESS
TYPE
DATE OPENED ACCOUNT NUMBER (CANNOT BE LESS THAN 0)
0
$
TOTAL OF ALL BANK ACCOUNTS WITH POSITIVE BALANCE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PERSONAL PROPERTY: INCLUDE AUTOMOBILES, BOATS, ATV’S, MOTORCYCLES, RECREATIONAL VEHICLES, AIRPLANES, MACHINERY, EQUIPMENT,
ETC., USED IN YOUR BUSINESS. ATTACH ADDITIONAL PAGES AS NEEDED. ATTACH SUPPORTING DOCUMENTATION OF PAYOFF AMOUNT(S).
CURRENT MARKET
AVAILABLE EQUITY
YEAR, MAKE, MODEL/STYLE, LICENSE NUMBER
LENDER/LIEN HOLDER
CURRENT PAYOFF
VALUE
(CANNOT BE LESS THAN 0)
0
$
TOTAL EQUITY OF ALL PERSONAL PROPERTY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
REAL PROPERTY: FOR EACH PROPERTY, INCLUDE COPIES OF DEED, HOMEOWNER’S/RENTER’S INSURANCE POLICY WITH RIDERS, SUPPORTING
DOCUMENTATION OF LOAN BALANCE, AND MOST RECENT PROPERTY TAX STATEMENT. ATTACH ADDITIONAL PAGES AS NEEDED.
PROPERTY 1
PHYSICAL ADDRESS, DESCRIPTION (SINGLE FAMILY HOME,
MULTI-FAMILY HOME, BARE LOT, ACREAGE, ETC.)
COUNTY
PARCEL NUMBER
MORTGAGE LENDER’S NAME AND ADDRESS
CURRENT
LOAN VALUE
AVAILABLE
MARKET VALUE
BALANCE
EQUITY
NAME(S) OF OWNER(S) ON DEED: ___________________________
PURCHASE PRICE: ___________________
PURCHASE DATE: ___________________
PROPERTY 2
PHYSICAL ADDRESS, DESCRIPTION (SINGLE FAMILY HOME,
MULTI-FAMILY HOME, BARE LOT, ACREAGE, ETC.)
COUNTY
PARCEL NUMBER
MORTGAGE LENDER’S NAME AND ADDRESS
CURRENT
LOAN VALUE
AVAILABLE
MARKET VALUE
BALANCE
EQUITY
NAME(S) OF OWNER(S) ON DEED: ___________________________
PURCHASE PRICE: ___________________
PURCHASE DATE: ___________________
MO-656 (5-2012)
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Parent category: Financial