Form Mo-656 - Offer In Compromise Application Page 11
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SECTION 7 BUSINESS FINANCIAL INFORMATION
(CONTINUED)
OTHER VALUABLE ITEMS: INCLUDE CASH, ACCOUNTS RECEIVABLE, ARTWORK, COLLECTIBLES, BUSINESS EQUIPMENT, AND ANY OTHER
VALUABLE ITEMS. ATTACH ADDITIONAL PAGES AS NEEDED. ATTACH SUPPORTING DOCUMENTATION.
TYPE
LOCATION
RECORD OWNER
QUANTITY OR DENOMINATION
CURRENT VALUE
0.00
$
TOTAL VALUE OF ALL VALUABLE ITEMS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SECURITIES: INCLUDE STOCKS, BONDS, MUTUAL FUNDS, MONEY MARKET FUNDS, 401(k), ETC. ATTACH ADDITIONAL PAGES AS NEEDED.
ATTACH SUPPORTING DOCUMENTATION.
TYPE
LOCATION
RECORD OWNER
QUANTITY OR DENOMINATION
CURRENT VALUE
0.00
$
TOTAL VALUE OF ALL SECURITIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BUSINESS CREDIT CARDS AND UNSECURED LINES OF CREDIT.
TYPE
NAME OF CREDITOR
RECORD OWNER
BALANCE OWED
AVAILABLE CREDIT
0.00
$
TOTAL UNSECURED CREDIT BALANCE AMOUNT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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 _____________________________________
TAXES OWED TO THE IRS (PROVIDE PROOF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO
YES _____________________________________
TAXES OWED TO OTHER STATES, COUNTIES, DISTRICTS, AGENCIES, ETC. . . . . . .
NO
YES _____________________________________
OTHER DEBT (EXPLAIN). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO
YES _____________________________________
SECTION 8 BUSINESS INCOME AND EXPENSE ANALYSIS
ACCOUNTING METHOD USED:
CASH
ACCRUAL
INCOME AND EXPENSES DURING THE PERIOD (MMDDYYYY)
TO (MMDDYYYY)
TOTAL MONTHLY BUSINESS INCOME
TOTAL MONTHLY BUSINESS EXPENSES
SOURCE
GROSS MONTHLY
EXPENSE ITEMS
ACTUAL MONTHLY
GROSS RECEIPTS FROM SALES/SERVICES
$
MATERIALS PURCHASED
$
GROSS RENTAL INCOME
$
INVENTORY PURCHASED
$
INTEREST INCOME
$
GROSS WAGES & SALARIES
$
DIVIDENDS
$
RENT
$
CASH
$
SUPPLIES
$
OTHER INCOME (SPECIFY BELOW)
$
UTILITIES/TELEPHONE
$
$
VEHICLE GASOLINE/OIL
$
$
REPAIRS & MAINTENANCE
$
$
INSURANCE
$
$
CURRENT TAXES
$
$
OTHER EXPENSES (SPECIFY)
$
TOTAL INCOME
$
0.00
TOTAL EXPENSES
$
0.00
MO-656 (5-2012)
11
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