Offer In Compromise Business Request For Settlement Form Page 3
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5Financial Information Statement For Businesses
Section I - BUSINESS NAME AND ADDRESS (Complete All Blocks)
1. Business Name(s) And Address
2. Virginia Business Account No.
3. Federal ID No.
4. Business Phone No.
5a. Other Contact Phone No.
5b. Other Contact Name
6. Business Organization
Sole Proprietor
Partnership
Corporation
Other
7. Description Of Business
Section II - Officers, Owners, Shareholders, Partners Information
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. Pertinent Information On Officers, Owners, Shareholders, Partners, Etc.
Name And Title
Home Address
Telephone Number Social Security No.
Total Share Of
Interest
Section III - Banking, Credit And Property Information
9. Banking Information To Include Checking, Savings, Money Market, Payroll, Etc.
Name And Address Of Institution
Type of Account
Name Account Listed
Account No.
Balance
10. Current Available Credit To Include Loans, Credit Cards, Etc.
Name And Address Of Institution
Type Of Credit
Available Credit
Name On Account
Has Resource
Been Contacted?
Yes
No
Yes
No
Yes
No
11. Property To Include Real Estate, Non-Necessities, Etc.
Type Of Property
Ownership Listed As
Value
Location Of Property
Used As Collateral
For Previous Loans?
Yes
No
Yes
No
Attach additional information, if necessary
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Parent category: Financial