Virginia Offer In Compromise Business Request For Settlement Page 5
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Section VI - Income And Expense Statement
Period Ending
Period (Check One)
Annual
Quarterly
Monthly
14. Income
Income
15. Expenses
Monthly Payment
Gross Receipts From Sales, Service, Etc.
$
Materials Purchased
$
Gross Rental Income
Net Wages And Salaries
Interest
Rent
Dividends
Installment Payments
Other Income (Specify):
Supplies
Utilities/Telephone
Repairs And Maintenance
Insurance
Current Taxes
Other (Specify):
Total Income
$
Total Expenses
$
Net Difference
(Total Income - Total Expenses)
$
Comments:
Certification
Under penalties of perjury, I declare that to the best of my knowledge and belief, this statement of assets, liabilities and other
information is true, correct and complete.
Signature
Date:
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