Form Fs-Oic - Financial Statement For Offer In Compromise Page 4
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4If you are currently living with another individual, family or friend, and are paying no monthly expenses, that
individual must read and understand the statement below and then sign and date this form.
Under penalties of perjury, I declare that the named individual(s) on this Financial Statement are currently
residing with me and pay no monthly living expenses.
__________________________________
____________________________________
______________________
Printed Name
Signature
Date
Additional Information
Offer in Compromise Information
List below your offer in compromise and the payment thereof.
Compromise Amount: $ _______________________
Paid in full within: __________________ days
Down Payment:
$ _______________________
Monthly Payment: $ __________________
Please explain how you determined these fi gures:
Before submitting your application, please review the following fi nal checklist:
Completed the Form FS-OIC in its entirety.
Included a Letter of Circumstance.
Attached all of the required supporting documentation (proof of income and expenses).
Under penalties of perjury, I declare that this statement of assets and liabilities and all other information included in this document
or attached thereto are true and correct to the best of my knowledge and belief. I authorize the Indiana Department of Revenue to
verify any and all facts included in this document.
_______________________________________
____________________________________________
Your Signature
Date
Spouse’s Signature
Date
Page 7
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Parent category: Financial