Form De 999ca - Multi-Agency Form For Offer In Compromise Page 7
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12SECTION 4. GENERAL FINANCIAL INFORMATION
(continued)
Last California income tax return filed.
Year
Total Exemptions Claimed
Adjusted Gross Income From Return
List any vehicles, equipment, or property (real or personal) sold, given away, or repossessed during the past three (3) years.
Attach additional pages if needed.
Description:
Who took possession
Value
Year, make, model of vehicle or property address
SECTION 5. ASSET AND LIABILITY ANALYSIS
Immediate assets.
1.
Cash
2.
Bank accounts / Balance (from Section 4)
3.
Vehicles / Available equity (from Section 4)
4.
Loan / Cash surrender value of life insurance (from Section 4)
5.
Securities (from Section 4)
6.
Safe deposit box value of contents (from Section 4)
Total Immediate Assets >>
Real Property (from Section 4)
Address or location
Current Market Value
Mortgage Payoff Amount
Equity
7.
A)
8.
B)
9.
C)
Total Equity >>
Other assets.
10.
Notes
11.
Accounts receivable
12.
Judgments / Settlements receivable
13.
Aircraft, watercraft
14.
Interest in trusts
15.
Interest in estates
16.
Partnership interests
17.
Corporate interests
18.
Other assets (describe)
19.
Other assets (describe)
20.
Other assets (describe)
Total Other Assets >>
21.
Sum Total of Assets (Immediate, Equity, and Other) >>
Current liabilities (include judgments, notes, and other charge accounts. DO NOT include vehicle or home loans)
22.
Lines of credit (amount owed) (from Section 4)
23.
Taxes owed to IRS (provide a copy of recent notice)
24.
Liabilities with other state taxing agencies (please specify)
25.
Other liabilities (describe)
26.
Other liabilities (describe)
27.
Other liabilities (describe)
Total Liabilities >>
DE 999CA (6-06) (INTERNET)
Page 7 of 12
CU
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