Settlement Offer Application Form - Oregon Department Of Revenue Page 8
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Section 3. General financial information—personal and business
Bank accounts. Include IRAs, other retirement plans, certificates of deposit, etc. Attach copies of all pages of your last three months’ bank statements
for each account. Attach additional pages as needed. Write -0- in Balance column for accounts with negative balances (see page 4).
Balance
Name of institution
Address
Type
Date opened
Account number
Total of all bank accounts with positive balance.
$
Enter this amount on line 2, Section 4 (if -0- or less, enter -0-) ......................................................................
Automobiles. Attach supporting documentation of current payoff. Attach additional pages as needed.
Available equity
Year, make, model, licence number
Lender/lien holder
Current market value
Current payoff
(can’t be less than -0-)
$
Total equity of all automobiles. Enter this amount on line 3, Section 4 .......................................................
Personal property. Include boats, recreational vehicles, airplanes, machinery, etc., not used in your business. Attach additional pages as needed.
Available equity
Year, make, model, licence number
Lender/lien holder
Current market value
Current payoff
(can’t be less than -0-)
$
Total equity of all personal property. Enter this amount on line 4, Section 4 ..............................................
Life insurance. Attach additional pages as needed.
Loan/cash
Name of insurance company
Agent’s name and telephone number
Policy number
Type
Face amount
surrender value
$
Total value of all life insurance policies. Enter this amount on line 5, Section 4.........................................
Securities. Include stocks, bonds, mutual funds, money market funds, 401(k), etc. Attach additional pages as needed.
Quantity or denomination
Current value
Type
Location
Record owner
$
Total value of all securities. Enter this amount on line 6, Section 4 .............................................................
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