Form Fs-Oic - Financial Statement For Offer In Compromise
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4Indiana Department of Revenue
FS-OIC
Offer in Compromise
State Form 50112
(R2 / 8-12)
Financial Statement for Offer in Compromise
Please refer to pages 1-3 of this document to determine your eligibility and the requirements for this program. Your failure to follow
all instructions provided and submitting all required documentation will result with your application being rejected. You will be
notifi ed within 15 to 20 working days, or less, if you have been accepted into or rejected from the Offer in Compromise program.
Personal Information
Name:
Spouse’s Name:
Social Security Number:
Spouse’s Social Security Number:
Address:
Address:
City, State, Zip:
City, State, Zip:
Home Telephone Number: (
)
Home Telephone Number: (
)
Cell Phone: (
)
Cell Phone: (
)
Email Address:
Email Address:
Date of Birth:
Date of Birth:
Dependents
Please list the name, age and relationship of all dependents who live with you.
Name
Age
Relationship
Employment Information
Your Employer’s Name:
Spouse’s Employer’s Name:
Years Employed:
Years Employed:
Address:
Address:
City, State, Zip:
City, State, Zip:
Telephone Number: (
)
Telephone Number: (
)
Bank Account(s) Information
Please include all checking, savings, credit union accounts, Certifi cates of Deposit,
and list safety deposit boxes held by you, your spouse and dependents.
Type of Account
Financial Institution Name
Account Number
Present Balance
Page 4
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Parent category: Financial