Offer In Compromise Application - Tennessee Department Of Revenue Page 21
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25CS-14C
Page 21
SECTION V - INCOME & EXPENSE ANALYSIS
27. Business Income and Expenses For: (Check One) [ ] Fiscal Year Ending
OR [ ] Period
to
(mm/yyyy)
(mm/yyyy)
(mm/yyyy)
Accounting Method: (Check One)
[ ] Cash [ ] Accrual Other:
Income
Amount
Expenses
Amount
$
$
Materials Purchased
Gross Receipts From Sales, Services, etc.
Net Wages & Salaries
Gross Rental Income
Interest Income
Rent or Mortgage Expenses
Installment & Lease Payments
Dividends & Capital Gain Distribution
Supplies & Office Expenses
Royalty Income
Commissions
Utilities
Other Income (Specify)
Transportation Expenses
Repairs & Maintanance
Insurance
Current Taxes
Bad Debts
Travel & Entertainment
Advertising
Other Expenses (Specify)
$
Total Income
Total Expenses
$
28. Net Income (“Total Income” Minus”Total Expenses”)
$
SECTION VI - OTHER INFORMATION
29. Is this business currently in filing compliance with all Tennessee taxes?
[ ] Yes
[ ] No
If “No”, identify tax type(s) and period(s):
30. Has this business 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”, receiving party:
31. Is a foreclosure proceeding pending on any real estate, equipment or other property that this business owns or has an interest in?
[ ] Yes
[ ] No
32. Is another party holding any assets on behalf of this business?
[ ] Yes
[ ] No
If “Yes”, identify:
33. Is this business a party to any lawsuit now pending?
[ ] Yes
[ ] No
34. Is this business currently under bankruptcy court jurisdiction?
[ ] Yes
[ ] No
If “Yes”, Bankruptcy Case No.:
I/we have examined this Statement of Financial Condition for Businesses and hereby affirm that to the best of my/our knowledge and belief it is true,
correct and complete.
Taxpayer’s Signature
Date
Taxpayer’s Signature
Date
POA Signature
Date
(Attach Power of Attorney - Use Department of Revenue Form RV-F0103801)
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