Offer In Compromise Application - Tennessee Department Of Revenue Page 12
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25CS-14B
Page 12
SECTION V - OBLIGATIONS
29.
Obligations
(Do Not Include Any Mortgages or Vehicle Loans)
Total Amount
Total Amount
Description
Description
Owed
Owed
$
Vehicle Leases
$
Notes Payable
Other Obligations:
Installment or Personal Loans
Education or Student Loans
Bank Revolving Credit
Judgments Payable
Past Due Federal Taxes
Past Due Other Taxes
$
TOTAL (Enter also on Page 3, Item 31)
SECTION VI - NET WORTH CALCULATION
30. Assets
$
A.
Cash
B.
Bank or Credit Union Accounts
C.
Bank Credit Cards
D.
Securities
E.
Real Property
F.
Vehicles
G.
Other Assets
$
Total Assets
31.
Obligations
$
$
32. Net Worth (“Total Assets” Minus “Liabilities”)
SECTION VII - OTHER INFORMATION
33. Are you currently in filing compliance with all Tennessee taxes?
[ ] Yes [ ] No If “No”, identify tax type and period:
34. If the tax liability was incurred in the operation of a business, has the business been discontinued?
[ ] Yes [ ] No Date discontinued:
35. Have you disposed of any assets or property by sale, transfer, exchange, gift, or in any other manner during the past 18 months?
[ ] Yes [ ] No If “Yes”, identify:
36. Is a foreclosure proceeding pending on any real estate that you own or have an interest in?
[ ] Yes [ ] No
37. Is anyone holding any assets on your behalf?
[ ] Yes [ ] No If “Yes”, identify:
Relationship:
38. Are you a party to any lawsuit now pending?
[ ] Yes [ ] No
39. Is there a likelihood that you will receive an inheritance within the next four years?
[ ] Yes [ ] No If “Yes”, from whom?
Relationship:
40. Have you previously petitioned the Department of Revenue for an offer in compromise for any tax liability?
[ ] Yes [ ] No
41. Are you or any business that you own currently under bankruptcy court jurisdiction?
[ ] Yes [ ] No Bankruptcy Case No.:
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