Fill-out the following
table as completely as you can. Your thoroughness in this task will
help derive the most accurate settlement amount.
This information will
then be forwarded to us for assessment of your expenses and assets,
and computation of a settlement amount. We will then contact you
within 1-3 business days to inform you of OIC eligibility, and if so
present a settlement amount and share with you insider tips for how
you can lower this amount even further.
It is important that you
account for every dollar spent as it could ultimately effect your
offer amount by hundreds of dollars.
Privacy
Please note that the information you provide us will be used solely
for this purpose and will not be shared with other parties. This
information with will be kept completely confidential.
* Settlement amount quoted is
only a preliminary estimate based upon information that you provide
to us. Please be as accurate as possible.
Personal Data
Today's Date:
Name(s):
Address:
City:
State:
Zip Code:
County:
Country:
Contact
telephone (with area code):
E-mail
address:
Company name
(if applicable):
# of employees
(if applicable):
Amount IRS is
claiming you owe:
Year/periods
liability pertains to:
List all
parties liability pertains to:
Is the Tax
Liability (choose all that apply):
Payroll
Personal
Corporate
Current filing
status:
Number of
dependents living with you (other than your spouse):
What tax years
are unfiled?
When was your
most recent contact from the IRS?
What date do
you have to respond to the IRS?
Has the IRS
filed a Federal Lien against your property? If so, when?
Did the IRS
install a levy on your bank accounts, or wage garnishment? If
so, when?
If you have an
installment agreement in place with the IRS, what amount are you
paying monthly?
Income
Wage income
(including overtime):
Hourly:
Yearly:
Spouse Wage
(including overtime):
Hourly:
Yearly:
Monthly
business income (this year or average of last 3 years):
Monthly income
from rental properties:
Other monthly
income (child support, disability, etc.):
Monthly Expenses
Rent or
mortgage payment:
Utilities (includes basic phone service, not cable):
Daycare
expenses for children ages 7 and under (only applicable if you are a single parent
working, or if both parents are working full-time):
Term life
insurance/disability insurance:
Secured debt (home equity loan/second mortgage, furniture
payments, etc. Does not include credit
card debt.):
State tax
installment agreement (wage garnishment, etc.):
Union
dues/involuntary deduction (please specify):
Professional
association dues:
Power of
attorney (money borrowed to hire professional
representation with tax liability):
Other (please specify):
Assets (lowest positive balance in last 3
months)
Checking:
Savings:
CD's:
Investments:
Cash or loan
value of insurance:
Pension plan:
401K:
Amount you can
borrow on 401K:
I.R.A.:
Vehicles (If
more than three, provide information in the comment box.)
Year
Make
Model
Trade-in
Value
Amount
Still Owed
1.
2.
3.
If
you do not know the trade-in value of your vehicles, please
provide specifics about the model, features, mileage, and
condition of the vehicle to aid us in determining the trade-in
value.
Comments:
Property (If
more than three, provide information in the comment box.)
Property
Tax Assessed Value
Amount
Still Owed
Name(s)
Of Persons On Title Of Property
1.
2.
3.
If
you do not know the Tax Assessed value of your property, please
list the appraised value. You may also call the local tax
office for this information.
Comments:
Other Large Assets (motorcycle,
trailer, RV, etc. If more than three, provide information in the
comment box.)
Value
Amount
Still Owed
1.
2.
3.
Comments:
Personal Effects (wedding
rings, artwork, etc. If more than three, provide information in
the comment box.)
Value
Amount
Still Owed
1.
2.
3.
Comments:
Accounts
Receivable 90 Days Or Newer For Your Business (average monthly):