Form 21 - Virginia Offer In Compromise Individual Request For Settlement Page 4
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4SECTION IV
GENERAL FINANCIAL INFORMATION
(Continued)
15. LIST AUTOMOBILES OWNED: (include boats, trailers, recreational vehicles, etc.)
Vehicle 1
Vehicle 2
Year, make, model
Estimated value:
Balance owed:
Year, make, model
Estimated value:
Balance
owed:
16. LIST REAL PROPERTY:
Brief description:
Address:
Estimated value:
Balance owed:
Brief description:
Address:
Estimated value:
Balance owed:
17. PLEASE ATTACH A STATEMENT IF ANY OF THE INFORMATION BELOW PERTAINS TO YOU:
a) Bankruptcy
c) Participation in profit sharing, estates, etc.
e) Recent federal tax audits
b) Repossession
d) Court proceedings
f) Sale of stocks, bonds, etc.
SECTION V
MONTHLY INCOME AND EXPENSE STATEMENT
18.
INCOME
NET INCOME
19.
EXPENSES
MONTHLY PAYMENT
Taxpayer - Net Wages/Salaries:
Mortgage/Rent (CIRCLE ONE)
Spouse - Net Wages/Salaries:
Secondary Mortgage Payment:
Interest Income:
Bank Cards: (Credit Cards)
Pension Income:
Department Store Cards/Payments:
Child Support Income:
Installment Loans:
Automobile:
Alimony Income:
Automobile:
Other: ________________
Rental Income:
Business Income:
Other: ________________
Distributions:
Groceries:
Other:
Utilities: Phone, Gas, Electric, Water
Child Support Payments:
Insurances: Life, Health, Home, Auto
Court Ordered Payments:
Transportation:
Tax Payments:
IRS Payment Plan:
Current Yr Federal Estimated Payments:
Current Yr Virginia Estimated Payments:
Other:
Other Expenses: (list and explain)
$
TOTAL MONTHLY INCOME:
$
TOTAL MONTHLY EXPENSES:
CERTIFICATION: Under penalties of perjury, I (we) declare that to the best of my (our) knowledge and belief,
this statement of assets, liabilities and other information is true, correct and complete.
20. Taxpayer’s Signature:
21. Spouse’s Signature:
Date:
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