Form Boe-490-C - Offer In Compromise Application Page 6

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Corporate Application
BOE-490-C REV. 1 (11-08)
SeCtION 4. BuSINeSS eNtItY INfOrmAtION (attach additional pages as needed)
NAME OF BUSINESS ENTITY
STATUS
CALIFORNIA BUSINESS NUMBER
D ATE INCORPORATED
ADDRESS
FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN)
TELEPHONE NUMBER
(
)
CORPORATE OFFICER/DIRECTOR/SHAREHOLDER’S NAME AND ADDRESS
TITLE
TELEPHONE NUMBER
(
)
AUTHORIZED REPRESENTATIVE’S ADDRESS (attach power of attorney)
TELEPHONE NUMBER
(
)
List of entity officers, general partners, managing members.
NAME OF OWNER(S)
BUSINESS ADDRESS
TELEPHONE NUMBER
TITLE
Other related businesses. List any of the business’ parent or subsidiary corporation relationships.
TRADE OR BUSINESS NAME
BUSINESS ADDRESSES OR CORP. NUMBER
TELEPHONE NUMBER
FEIN
SeCtION 5. GeNerAL fINANCIAL INfOrmAtION (attach additional pages as needed)
Bank Accounts (payroll, general, savings, certificates of deposit, etc.) List accounts held during the past 3 years.
NAME OF INSTITUTION
ADDRESS
TYPE
DATE OPENED
ACCOUNT NUMBER
BALANCE
TOTAL [Enter this amount on line 2, Section 6 (Asset and Liability Analysis)] >>
Bank credit available (lines of credit, etc.)
NAME OF INSTITUTION
ADDRESS
CREDIT LIMIT
CREDIT AVAILABLE
AMOUNT OWED
MO. PAYMENT
tOtAL
tOtAL [Enter this amount on line 19, Section 6 (Asset and Liability Analysis)] >>
OFFER IN COMPROMISE APPLICATION
7

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Parent category: Financial