Form 656 - Offer In Compromise (Including Form 433-A (Oic), Form 433-B (Oic)) Page 8
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28Page 2 of 7
Section 2
Self-employed Information
(Continued)
Do you or your spouse have any other business interests?
Business Address
(Street, City, State, ZIP code)
Yes (Percentage of ownership:
)
No
Business Name
Business Telephone Number
Business Identification Number
(
)
-
Type of business
(Select one)
Partnership
LLC
Corporation
Other
Section 3
Personal Asset Information
Cash and Investments (domestic and foreign)
Use the most current statement for each type of account, such as checking, savings, money market and online accounts, stored value cards
(such as, a
, investment and retirement accounts
, life insurance
payroll card from an employer)
(IRAs, Keogh, 401(k) plans, stocks, bonds, mutual funds, certificates of deposit)
policies that have a cash value, and safe deposit boxes. Asset value is subject to adjustment by IRS based on individual circumstances. Enter the total
amount available for each of the following
(if additional space is needed include attachments).
If any line item is zero or less, enter "0". Do not enter negative numbers on this form.
Cash
Checking
Savings
Money Market
Online Account
Stored Value Card
Bank Name
Account Number
(1a) $
Checking
Savings
Money Market
Online Account
Stored Value Card
Bank Name
Account Number
(1b) $
Total value of bank accounts from attachment
(1c) $
Add lines (1a) through (1c) =
(1)
$
Investment Account:
Stocks
Bonds
Other
Name of Financial Institution
Account Number
Current Market Value
Less Loan Balance
= (2a) $
$
X .8 = $
– $
Investment Account:
Stocks
Bonds
Other
Name of Financial Institution
Account Number
Current Market Value
Less Loan Balance
= (2b) $
$
X .8 = $
– $
Total of investment accounts from attachment. [current market value X.8 less loan balance(s)]
(2c) $
Add lines (2a) through (2c) =
(2)
$
Retirement Account:
401k
IRA
Other
Name of Financial Institution
Account Number
Current Market Value
Less Loan Balance
= (3a) $
$
X .7 = $
– $
Retirement Account:
401k
IRA
Other
Name of Financial Institution
Account Number
Current Market Value
Less Loan Balance
= (3b) $
$
X .7 = $
– $
Total of investment accounts from attachment. [current market value X .7 less loan balance(s)]
(3c) $
Add lines (3a) through (3c) =
(3)
$
433-A (OIC)
Catalog Number 55896Q
Form
(Rev. 5-2012)
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