Form 21 - Virginia Offer In Compromise Individual Request For Settlement Page 3
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4FINANCIAL INFORMATION STATEMENT
SECTION I
PERSONAL INFORMATION
(complete all blocks)
1. Taxpayer(s) Name(s) and Address:
2a) Taxpayer’s Social Security #:
3. Home Phone #:
4. Taxpayer Daytime
(______)__________________
Phone #
2b) Birth date:____________
Best time to contact:________
(_____)____________
2c) Spouse’s Social Security #:
5a) # of Dependents: (_______)
6. Spouse’s Daytime
Phone #
2d) Birth date: ____________
5b) Ages: _________________
(_____)_____________
SECTION II
EMPLOYMENT INFORMATION
7. Name and Address of Taxpayer’s Employer:
8a) (circle as appropriate):
9a) Other Income: (explain) (examples are part
time, social security, unemployment, etc.):
Owner
Commissioned Partner
Salaried
Hourly
8b) Annual GROSS Income:
$
9b) Other monthly income amount: $
10. Name and Address of Spouse’s Employer:
11a) (circle as appropriate):
12a) Other Income: (explain) (examples are part
time, social security, unemployment, etc.):
Owner
Commissioned Partner
Salaried
Hourly
11b) Annual GROSS Income:
12b) Other monthly income amount: $
$
SECTION III
GENERAL FINANCIAL INFORMATION
13. BANK ACCOUNTS: ASSETS (includes checking, saving, IRA, Certificates of Deposit, other investments, etc)
Name of Institution:
Address:
Type of Account:
Account Number:
Balance:
14. BANK ACCOUNTS: LIABILITIES (Includes mortgages, automobiles, charge and credit cards, line of credit, etc.)
Name of Institution:
Address:
Type of Account:
Account Number:
Monthly
Balance:
Payment:
(Attach additional sheets, if necessary)
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