Multi Agency Form For Offer In Compromise Page 8
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12SECTION 6. MONTHLY INCOME AND EXPENSE ANALYSIS
Monthly
Monthly
Agency Use
Income.
Gross
Net
Only
28.
Wages / Salaries (Taxpayer)
29.
Pension (Taxpayer)
30.
Overtime / Bonuses / Commissions (Taxpayer)
31.
Wages / Salaries (Spouse or RDP)
32.
Pension (Spouse or RDP)
33.
Overtime / Bonuses / Commissions (Spouse or RDP)
34.
Business income
35.
Rental income
36.
Interest / Dividends / Royalties (average monthly)
37.
Payments from Trusts / Partnerships / Entities
38.
Child Support
39.
Alimony
40.
Unemployment
41.
Disability
42.
Social Security
43.
Other income (describe)
Total Household Income >>
Monthly
Agency Use
Expenses.
Amount
Only
44.
Rent / Mortgage(principal and interest only)
45.
Real estate taxes
46.
Home Insurance:
$__________
Association fees:
$__________
47.
Groceries, number of people: (
)
$__________
48.
Electric:
$__________
Phone:
$__________
$__________
49.
Gas:
Water:
$__________
$__________
50.
Trash:
Sewer:
51.
Auto payments
52.
Auto insurance
53.
Gasoline, number of miles to work: (
)
54.
Life / Health insurance (not deducted from your paycheck)
55.
Medical payments (not covered by insurance)
56.
Estimated tax payments (if not deducted from paycheck)
57.
Court-ordered payments (alimony, child support, restitution)
58.
Garnishments (if not deducted from your paycheck)
59.
Delinquent tax payments (describe)
60.
Credit card payments (total monthly minimum) (from Section 4)
61.
Other expenses (describe)
62.
Other expenses (describe)
Total Household Expenses >>
63.
Net Difference (Total Income Less Expenses) >>
DE 999CA (6-06) (INTERNET)
Page 8 of 12
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