Form De 999ca - Multi-Agency Form For Offer In Compromise Page 6

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SECTION 4. GENERAL FINANCIAL INFORMATION
(continued)
Real Property you own or have an interest in. (Include a copy of the deed). Attach additional pages as needed.
A)
Physical address and description (single family
Mortgage lender’s name and address:
dwelling, multi-family dwelling, lot, etc.):
How title is held: _____________________________________________________
Parcel Number:
Purchase price: ____________________
Purchase date: _________________
B)
Physical address and description (single family
Mortgage lender’s name and address:
dwelling, multi-family dwelling, lot, etc.):
How title is held: _____________________________________________________
Parcel Number:
Purchase price: __________________
Purchase date: __________________
C)
Physical address and description (single family
Mortgage lender’s name and address:
dwelling, multi-family dwelling, lot, etc.):
How title is held: _____________________________________________________
Parcel Number:
Purchase price: __________________
Purchase date: __________________
Charge cards and lines of credit (enter minimum monthly payment only). Attach additional pages as needed.
Minimum
Credit
Type of Account
Name and Address of Credit Grantor
Monthly
Credit Limit
Balance
Available
Payment
Total Minimum Monthly Payments >>
Total Owed >>
Enter the total of “Minimum Monthly Payments” on line 60 in Section 6, “Monthly Income and Expense Analysis.”
Enter the “Total Owed” on line 22 in Section 5, “Asset and Liability Analysis.”
Please provide other information relating to your financial condition. If “Yes” is checked, please provide dates,
explanation, and documentation.
Court proceedings
No
Yes
Repossessions
No
Yes
Anticipated increase in income
No
Yes
Bankruptcies / Receiverships
No
Yes
Recent transfer of assets
No
Yes
Beneficiary to trust, estate,
profit-sharing, etc.
No
Yes
DE 999CA (6-06) (INTERNET)
Page 6 of 12
CU

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