Offer In Compromise Business Request For Settlement Form Page 4
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5Section IV - Accounts And Notes Receivable Information
12. Accounts/Notes receivable (Include Loans To Stockholders, Officers, Partners, etc.)
Name
Address
Amount Due
Date Due
Status
$
$
$
$
$
Section V - Assets And Liability Statement
13. Asset And Liability Analysis (Total)
Description
Current Market
Liabilities Balance Equity In Asset
Amount Of
Name/Address Of
Contact Telephone
Value
Due
Payment
Institution Lien Holder
Number To Verify
Cash On Hand
Bank Accounts
Account/
Notes Receivable
Real Property
1
2
3
4
Vehicles
1
)
2
(model,yr.,license
3
Machinery/
Equipment
1
2
3
Merchandise
Inventory
Other Assets
1
2
3
Other Liabilities
1
2
3
Federal Taxes
State Taxes
Local Taxes
Total
$
$
$
$
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Parent category: Financial