Form De 999ca - Multi-Agency Form For Offer In Compromise Page 5
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12SECTION 3. EMPLOYMENT / SELF- EMPLOYMENT INFORMATION
Taxpayer
Name and address of employer:
How long employed: ______Years ______Months
Occupation: ______________________________________________
Wage Earner
Sole Proprietor
Partner
Paid: Weekly
Biweekly
Monthly
Semimonthly
(
)
Phone Number:
Number of Exemptions claimed on Form W-4 or DE 4: ________
Spouse or RDP
Name and address of employer:
How long employed: ______Years ______Months
Occupation: ______________________________________________
Wage Earner
Sole Proprietor
Partner
Paid: Weekly
Biweekly
Monthly
Semimonthly
(
)
Phone Number:
Number of Exemptions claimed on Form W-4 or DE 4: ________
SECTION 4. GENERAL FINANCIAL INFORMATION
Bank accounts (include IRA and retirement plans, certificates of deposit, etc.). Attach additional pages as needed.
Name of Institution
Address
Type of Account
Account Number
Balance
Total. Enter this amount on line 2, Section 5 (Asset and Liability Analysis)>>
Vehicles. Attach additional pages as needed.
License
Current
Current
Year, Make, Model
Mileage
Lender/Title Holder
Balance
Number
Market Value
Payoff
Total. Enter this amount on line 3, Section 5 (Asset and Liability Analysis)>>
Life Insurance. Attach additional pages as needed.
Loan/Cash
Name of Insurance Company
Agent’s Name and Phone Number
Policy Number
Type
Face Amount
Surrender Value
Total. Enter this amount on line 4, Section 5 (Asset and Liability Analysis) >>
Securities (stocks, bonds, mutual funds, money market funds, securities, etc.). Attach additional pages as needed.
Quantity or
Type
Company Issuing Securities/Brokerage Firm
Owner of Record
Current Value
Denomination
Total. Enter this amount on line 5, Section 5 (Asset and Liability Analysis) >>
Safe deposit boxes rented or accessed (locations, box numbers, and contents). Attach additional pages as needed.
Name of Institution
Address
Box Identification
Contents
Current Value
Total. Enter this amount on line 6, Section 5 (Asset and Liability Analysis) >>
DE 999CA (6-06) (INTERNET)
Page 5 of 12
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Parent category: Financial