Form 656 - Offer In Compromise (Including Form 433-A (Oic), Form 433-B (Oic)) Page 11

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Page 5 of 7
Section 5
Business Income and Expense Information (for Self-Employed)
Note: If you provide a current profit and loss (P&L) statement for the information below, enter the total gross monthly income on line 18 and
your monthly expenses on line 30 below. Do not complete lines (13) - (17) and (19) - (29). You may use the amounts claimed for income and
expenses on your most recent Schedule C; however, if the amount has changed significantly within the past year, a current P&L should be
submitted to substantiate the claim.
Business Income (You may average 6-12 months income/receipts to determine your Gross monthly income/receipts.)
Gross receipts
(13) $
Gross rental income
(14) $
Interest income
(15) $
(16) $
Other income
(17) $
Gross Monthly Business Income - Add lines (13) through (17) = (18) $
Business Expenses (You may average 6-12 months expenses to determine your average expenses.)
Materials purchased
(19) $
(e.g., items directly related to the production of a product or service)
Inventory purchased
(20) $
(e.g., goods bought for resale)
Gross wages and salaries
(21) $
(22) $
(items used to conduct business and used up within one year, e.g., books, office supplies, professional equipment,
(23) $
(24) $
Vehicle costs
(25) $
(gas, oil, repairs, maintenance)
Business Insurance
(26) $
Current Business Taxes
(e.g., Real estate, excise, franchise, occupational, personal property, sales and employer's portion
(27) $
of employment taxes)
Other secured debts
(28) $
(not credit cards)
Other business expenses
(29) $
(include a list)
Total Monthly Business Expenses - Add lines (19) through (29) = (30) $
Box 2 Net Business Income
Subtract line (30) from line (18) and enter the amount in Box 2 =
Section 6
Monthly Household Income and Expense Information
Enter your household's gross monthly income. The information below is for yourself, your spouse, and anyone else who contributes to your
household's income. The entire household includes spouse, significant other, children, and others who contribute to the household. This is necessary
for the IRS to accurately evaluate your offer.
Monthly household income
Primary taxpayer
Social Security
Total primary taxpayer
+ $
+ $
(31) $
Social Security
+ $
+ $
Total spouse income
(32) $
Interest and dividends
(33) $
(34) $
(such as, income from partnerships, sub-S Corporations, etc.)
Net rental income
(35) $
Net business income from Box 2
(36) $
Child support received
(37) $
Alimony received
(38) $
Box 3 Total Household Income
Add lines (31) through (38) and enter the amount in Box 3 =
Are there additional sources of income used to support the household, e.g. non-liable spouse, roommate, etc.
433-A (OIC)
Catalog Number 55896Q
(Rev. 5-2012)


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