Settlement Offer Application Form - Oregon Department Of Revenue Page 10
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Section 3. General financial information—personal and business (continued)
Other financial information. If you check “Yes,” provide dates, an explanation, and documentation. Attach additional pages as needed.
Court proceedings (litigation, probate, etc) .......
No
Yes _______________________________________________________________________________
Anticipated increase in income .........................
No
Yes _______________________________________________________________________________
Bankruptcies/receiverships ...............................
No
Yes _______________________________________________________________________________
Transfer assets in last 12 months ......................
No
Yes _______________________________________________________________________________
Beneficiary to trust, estate, profit sharing, etc. .
No
Yes _______________________________________________________________________________
Transferred property. Vehicles, equipment, or property sold, given away, donated, or repossessed in the last 3 years. Attach additional pages as needed.
Year, make, model of vehicle or equipment, or property address
Who took possession
Value
Section 4. Asset and debt analysis (values can’t be less than -0-)
Amount
Immediate assets. For lines 2-7, enter totals from Section 3.
1. Cash on hand
2. Bank accounts—total balance
3. Automobiles—total equity
4. Personal property—total equity
5. Life insurance—total loan/cash surrender value
6. Securities—total value
7. Safe deposit box contents—total value
8. Promissory notes owed to you
9. Business accounts receivable
10. Judgments/settlements receivable (legal action which may result in a payoff to you)
11. Interest in trusts
12. Interest in estates
13. Interest in partnership(s)
14. Business capital assets (major machinery or equipment used in your business, etc)
15. Business inventory (supplies, finished products on hand, etc)
16. Other personal property (collectibles, guns, jewelry, tools, antiques, coins, gold, silver, etc.)
17. Other asset (explain; don’t include everyday household items):
18. Other asset (explain; don’t include everyday household items):
$
19. Total value of all immediate assets
.....................................................................................................................
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