Vt Schedule Oic-672 - Collection Information Statement For Businesses Page 6
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6Entity name
*176721600*
Federal ID Number
* 1 7 6 7 2 1 6 0 0 *
SECTION 6
OTHER INFORMATION (cont.)
I.
Does the business have any lines of credit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
If “Yes,” Credit limit: $____________________
Amount owed: $____________________
What property secures the line of credit? __________________________________________
J.
Have you filed for an OIC with the IRS for the same periods included in this offer? . . . . . . . . . . . . . . Yes
No
If “Yes,” describe status or outcome of IRS OIC, understanding Vermont is not bound to adopt the same outcome.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
SECTION 7
SIGNATURES
Under penalties of perjury, I declare that I have examined this offer, including accompanying documents, and to the best of my knowledge, it is true,
correct, and complete.
Signature of Responsible Officer
Title
Date
Printed name
Email address
Remember to include all applicable attachments from list below.
A current Profit and Loss statement covering at least the most recent 6-12 month period, if appropriate.
Copies of the three most recent statements for each bank, investment, and retirement account.
If an asset is used as collateral on a loan, include copies of the most recent statement from lender(s) on loans, monthly
payments, loan payoffs, and balances.
Copies of the most recent statement of outstanding notes receivable (if applicable).
Copies of the most recent statements from lenders on loans, mortgages (including second mortgages), monthly payments,
loan payoffs, and balances.
Copies of accountant’s depreciation schedules, if applicable.
Documentation for any claims of “Exceptional circumstances” made in Form OIC-671, Section 3. Examples of possible
documentation to include are: copies of actual monthly expenses, out-of-pocket medical expenses, physician’s statements
detailing illness, etc.
Attach a Form PA-1, Power of Attorney, if you would like your attorney, account or tax preparer, or other party to represent
you and you do not have a current form on file with the Vermont Department of Taxes.
IRS Information: If applicable, copy of IRS OIC and acceptance letter or other IRS arrangements.
Schedule OIC-672
Page 6 of 6
5454
10/17
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