Form Boe-490 - Offer In Compromise Application Page 10
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11BOE-490 (S4B) REV. 1 (1-06)
SECTION 8. MONTHLY INCOME AND EXPENSE ANALYSIS
INCOME
GROSS
NET
BOE USE
ONLY
28. Wages/Salaries (Taxpayer)
29. Pension (Taxpayer)
30. Overtime/Bonuses/Commissions (Taxpayer)
31. Wages/Salaries (Spouse/Reg. Domestic Partner)
32. Pension (Spouse/Reg. Domestic Partner)
33. Overtime/Bonuses/Commissions (Spouse/Reg.
Domestic Partner)
34. Business Income (Taxpayer or Spouse/Reg.
Domestic Partner)
35. Rental Income
36. Interest/Dividends/Royalties (Average Monthly)
37. Payments from Trusts/Partnerships/Entities
38. Child Support
39. Alimony
40. Unemployment
41. Disability
42. Other Income (include description)
43. Other Income
TOTAL HOUSEHOLD INCOME >>
EXPENSES (Please pro-rate expenses if household expenses are shared and if income is not provided in items 28-43.)
AMOUNT
BOE USE ONLY
44. Rent/Mortgage
45. Real Estate Taxes
46. Home Insurance: (
) Association Fees: (
)
47. Groceries, number of people: (
)
48. Utilities
49. Electric: (
)
Phone: (
)
50. Gas:
(
)
Water : (
)
51. Trash:
(
)
Sewer: (
)
52. Auto Payments
53. Auto Insurance
54. Gasoline, Number of Miles to Work: (
)
55. Life/Health Insurance (if not deducted from your paycheck)
56. Medical Payments (not covered by insurance)
57. Estimated Tax Payments (if not deducted from your paycheck)
58. Court Ordered Payments (alimony, child support, restitution)
59. Garnishments (if not deducted from your paycheck)
60. Delinquent Tax (non-BOE)
61. Credit Card Payments (total monthly minimum) from section 6
62. Other Expenses (include description)
63. Other Expenses
TOTAL HOUSEHOLD EXPENSES >>
Please provide documentation and verification of income and expenses listed above.
64. NET DIFFERENCE (TOTAL INCOME LESS EXPENSES)
CLEAR
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