Offer In Compromise Application - Tennessee Department Of Revenue Page 18
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25CS-14C
Page 18
(If additional space is needed,
STATEMENT OF FINANCIAL CONDITION
State of Tennessee
FOR BUSINESSES
attach separate sheet)
Department of Revenue
SECTION I - BUSINESS IDENTIFICATION
1. Business Name and Address
2. Mailing Address (If Different From Street Address)
County
4. Daytime Phone Number
5. Number of Employees
3. Type of Business
6. Type of Ownership
[ ] LLC
7. Tennessee Entity ID:
[ ] Proprietorship
[ ] Partnership
[ ] Corporation
[ ] Other (Specify)
9. Ending Date of Business (If Closed) (mm/dd/yyyy)
8. Beginning Date of Business (mm/dd/yyyy)
Form
Tax Year Ended
Net Income
10. Last Franchise Excise Return Filed
$
11. Information About Owner, Partners, Officers, Major Shareholders, etc.
Effective
Monthly
Total Shares
Social Security
Date
Name
Title
Salary or Wages
or Interest
Number
(mm/yy)
$
SECTION II - ASSETS
12. Cash On Hand
$
TOTAL (Enter also on Page 3, Item 24-A)
13. Bank Accounts (General Operating, Payroll, Savings, Certificate of Deposit, etc.)
Balance
Name of Institution
Account Number
Type of Account
$
$
TOTAL (Enter also on Page 3, Item 24-B)
14. Bank Credit Available (Line of Credit, Credit Cards, etc.)
Credit
Credit
Amount
Name of Institution
Account Number
Limit
Owed
Available
$
$
$
$
TOTAL (Enter also on Page 3, Item 24-C)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial