PDF document

- 1 -

DTF-5 (12/08)
New York State Department of Taxation and Finance
Statement of Financial Condition and Other Information
Please furnish the information requested on this form at the time you submit your offer in compromise, request for payment plan, or
other proposal if the offer is based in whole or in part on inability to pay the liability. It is important that you answer all questions. If a
question does not apply, please enter N/A. This will speed up consideration of your proposal.
Note: When making an offer in compromise you must file in duplicate. Also file Form DTF‑4, Offer in Compromise For Liabilities Not
Fixed and Final and Subject to Administrative Review, or Form DTF‑4.1, Offer in Compromise For Fixed and Final Liability.

I. A. Name of taxpayer(s) and/or trade or business names B. Date of birth C. Social security number(s)

D. Business ID number (EIN)

E. Home address F. Home telephone number

G. Business address H. Business telephone number

II. Name of representative, if any Telephone number

Address:

III. Names of Banks and Other Financial Institutes You Have Done Business with at Any Time During the Past Three Years
Name and Address Name and Address

A. B.

C. D.

E. Do you rent a safe deposit box in your name or in any other name? Yes No If Yes, give name and address of bank

IV. Proposal Filed by Individual
A. Name of spouse B. Spouse’s age C. Spouse’s social security number

D. Names of dependent children or relatives E. Relationship F. Social security number G. Age
1.
2.
3.
4.
5.
6.
7.

V. Life Insurance Policies Now in Force
D. Present
C. Amount Cash Surrender E. Policy F. Date G. Automatic H. Date
A. Number of Policy B. Name and Address of Company of Value Plus Loan Made Premium Made
Accumulated
Policy Dividends Payments

- 2 -

Page 2  DTF-5 (12/08)

Please furnish your most recent financial information. In the columns below, show the cost and fair market value of each asset you 
own directly or indirectly. Also show all your interests in estates, trusts and other property rights, including contingent interests and 
remainders.

  VI.  Statement of Assets and Liabilities as of
                                                                  (date)
     A.  Assets                                                                                                Cost Fair Market Value Appraisal Value
            1.  Cash
            2.  Cash surrender value of insurance    (see item V, page 1)
            3.  Accounts receivable (see item VIIIA, page 3)
            4.  Notes receivable (see item VIIIB, page 3)
            5.  Merchandise inventory
            6.  * Real estate(see item IX, page 3) * submit appraisal by qualified Real Estate Appraiser Broker
            7.  Furniture and fixtures  (see item X, page 4)
            8.  Machinery and equipment     (see item X, page 4)
            9.  Trucks and delivery equipment (see item XI, page 4)
     10.  Automobiles (see item XI, page 4)
     11.  Securities (see item XII, page 4)
     12.  Jewelry
     13.  Contingent claims or actions (lawsuits or insurance claims)
     14.  Other assets (list below)
     15,
     16.
     17.
     18.
     19.
     20.
     21.
     22.
     23.
     24.
     25.
Total assets

     B.  Liabilities                                                                                                                  Amount
            1.  Accounts payable
            2.  Notes payable (attach note agreement)
            3.  Mortgages (see item IX, page 3)
            4.  Accrued real estate taxes  (see item IX, page 3)
            5.  Judgments (see item XIII, page 4)
            6.  Federal income tax payable
            7.  Loans payable to relatives (attach loan agreement)
            8.  Loans payable to others (attach loan agreement)
            9.  Notes payable to relatives (attach copy of note)
     10.  Other liabilities (list below)
     11.
     12.
     13.
     14.
     15,
     16.
     17.
     18.
     19.
     20.
     21.
Total liabilities

- 3 -

DTF-5 (12/08) Page 3
VII. Life Insurance Policies Assigned or Pledged on Indebtedness
If any of the policies listed in item Vare assigned or pledged on indebtedness, except with insurance companies, give the following
information about each policy:
A. Number of Policy B. Name and address of Pledgee or Assignee C. Balance Due D. Date Pledged
Assigned or Pledged on Loan or Assigned
1.
2.
3.
4.
5.
6.
7.
VIII. Accounts and notes receivable
Name and Address Book Value Liquidation Value Balance Due on Date
Loan, if Pledged Pledged
A. Accounts receivable
1.

Total
B. Notes receivable
1.

Total
IX. Real estate*
A. Description B. Cost C. Fair Market D. Balance Due E. Date Mortgage F. Unpaid Interest
Value on Mortgage Recorded and Taxes
1.
2.
3.
4.
5.
6.
7.

Total
*Attach copy of indenture, mortgage, and deed for each.

- 4 -

Page 4  DTF-5 (12/08)
  X.  Furniture and Fixtures, Machinery and Equipment
                                                                                  C. Fair Market D. Balance Due on E. Date
                   A. Description                                         B. Cost Value          Loan, if Pledged  Pledged
 1.  Furniture and fixtures (business)
 2.  Furniture (household-residence)
 3.  Machinery (specify kind)

 4.
 5.
 6.
 7.  Equipment (except trucks and automobiles; specify)

 8.
 9.
 10.

Total
  XI.  Trucks and Automobiles (personal or used in business)
               A. Trucks                               Registration               Fair Market    Balance Due on    Date
        Make, Plate Number              Model  Year    Number             Cost    Value          Loan, if Pledged  Pledged
 1.
 2.
 3.
 4.
 5.
 6.
        B. Automobiles
        Make, Plate Number              Model  Year
 1.
 2.
 3.
 4.
 5.

Total
 XII.  Securities (Bonds, Stocks, etc.)
               A. Name of Company                      B. Number of Units C. Cost D. Fair Market E. Balance Due on F. Date
                                                                                  Value          Loan, if Pledged  Pledged
 1.
 2.
 3.
 4.
 5.
 6.
 7.
 8.

Total

   XIII.  Judgments
                                                            B. Amount          C. Balance Due
               A. Name of Creditor                          of Judgment           on Judgment D. Date Recorded E. Where Recorded
 1.
 2.
 3.
 4.

Total
Attach supplemental sheets if necessary

- 5 -

                                                                                                                  DTF-5 (12/08) Page 5
 XIV.  Statement of Income - Individual
Important:  Please furnish information requested below for the last 12 months.
          Attach the last three years’ federal returns with all schedules.
 A.  Gross receipts or income                                                 Source                                    Amount
       1. Salaries, wages, commissions
       2. Dividends
       3. Interest
       4. Income from business or profession
       5. Partnership income
       6. Gains or losses (from Form 1040, Schedule D)
  7. Annuities and pensions
       8. Rents and royalties
       9. Income for estates and trusts
       10. Other income (include accounts receivable from spouse, relatives,
        social security, unemployment, welfare, etc.)
  11. Gifts
       12.
       13.
Total
 B.  Disbursements                                                          To whom paid and relationship, if any Amount
       1. Interest (use space below if necessary)
       2. Taxes paid
       3. Loans paid
       4. Insurance premiums
       5. Medical expenses
       6. Automobile expenses
  7. Servant’s wages
       8. Gifts
       9. Living expenses (itemize below)
       Rent
       Notes paid
       Debt reduction (give details below)
    Other disbursements (give details below)

Total disbursements

- 6 -

Page 6 DTF-5 (12/08)
XV. Statement of Income - Corporation
Important: If the proposal is from a corporation, please furnish the information requested below (from income tax returns, as adjusted, for
past two years and from records for current year from January 1 to date).
Type of corporation: business not‑for‑profit P.C.
Attach a detailed statement of carry over/carry back loss intentions. If you do not intend to use this offset, attach a full explanation.
A. Gross income 20 20 Jan. 1 to 20
1. Gross sales or receipts (subtract returns and allowances)
2. Cost of goods sold
3. Gross profit — trading or manufacturing
4. Gross profit — from other sources
5. Interest income
6. Rents and royalties
7. Gains and losses (from Schedule D)
8. Dividends
9. Other (specify)

Total income

B. Deductions
1. Compensation of officers
2. Salaries and wages (not deducted elsewhere)
3. Rents
4. Repairs
5. Bad debts
6. Interest
7. Taxes
8. Losses
9. Dividends
10. Depreciation and depletion
11. Contributions
12. Advertising
13. Other (specify)

14.
Total deductions

C. Net income
D. Nontaxable income
E. Unallowable deductions
XVI. Salaries Paid to Principal Officers and Dividends Distributed - Corporation
Important: If the proposal is from a corporation, please show salaries paid to principal officers for past three years and amounts distributed
in dividends, if any, during and since the taxable years covered by this offer.
A. Salaries paid to (name and title) 20 20 20
1. , President
2. , Vice President
3. , Treasurer
4. , Secretary
5.
6.

Total

- 7 -

DTF-5 (12/08) Page 7
XVI. (continued from page 6) Dividends Distributed - Corporation
B. Year Dividends paid Year Dividends paid Year Dividends paid
1. 8. 15.
2. 9. 16.
3. 10. 17.
4. 11. 18.
5. 12. 19.
6. 13. Total
7. 14. (add lines 1 through 19)

XVII. Disposal of assets — From the beginning of the taxable period of your liability(ies) to the present date, have you disposed of
any assets or other property with a cost or fair market value of more than $500, except for full value at the time of sale, transfer,
exchange, gift or other disposition?
Yes No If Yes, please furnish the following information and attach a copy of transfer document or bill of sale.
B. Date of C. Fair Market Value D. Consideration E. Relationship of Transferee
A. Description of Asset Transfer When Transferred Received to Taxpayer
1.
2.
3.
4.
5.
XVIII. Interest In or Beneficiary of Estate or Trust — Are you the grantor or donor of any trust, or the trustee for any trust?
Yes No If Yes, please furnish a copy of the instrument creating the trust or estate. Also give the following information.
A. Name of Trust or Estate B. Present Value C. Value of Your D. Annual Income Received
of Assets Interest From This Source
1.
2.
3.
4.
5.
XIX. Grantor, Donor, Trustee or Fiduciary — Have you any life interest or remainder interest, either vested or contingent in any trust
of estate, or are you a beneficiary of any trust?
Yes No If Yes, please furnish a copy of the instrument creating the trust. Also give present value of corpus of trust, and any
other pertinent information.
XX. Any Other Assets or Interests in Assets — Have you any other assets or an interest in assets either actual or contingent,
other than those listed here (i.e., profit-sharing plan or pension plan)?
Yes No If Yes, please describe the assets.

XXI. A. Are foreclosure proceedings pending B. If Yes, please give location of real estate: C. Was the Tax Department made a
on any real estate which you own or party to the suit?
have an interest in? Yes No Yes No

XXII. A. Are bankruptcy or receivership proceedings pending? B. If a corporation, is it in process of liquidation?
Yes No Yes No

XXIII. Is the sum offered in compromise or submitted as a partial payment borrowed money? Yes No
If Yes, please give name and address of lender and list collateral, if any, pledged to secure the loan.

XXIV. A. Have you (or any one of you) been convicted of any crime involving unlawful possession or acquisition of property
or income obtained by fraud, theft or other illegal means within the last five years?
Yes No If Yes, provide details.

B. Are you the subject of, or defendant in, any pending criminal or grand jury action or proceeding which may involve
or affect in any way, your right, title or interest to any real or personal property whether or not listed herein?
Yes No If Yes, provide details.

- 8 -

Page 8 DTF-5 (12/08)
XXV. What is the prospect of an increase in value of assets or present income? Please give a general statement.

XXVI. Items A, B and C must be attached; items D through L, if applicable, must be attached. Failure to provide these returns,
statements and documents will cause immediate rejection of your compromise request, request for payment plan or other
proposal.

A. Federal returns ‑ preceding three years, all schedules attached.
B. All bank statements (including checking accounts) for the preceding year.
C. Recent credit report from local bureau within last 30 days.
D. Real estate appraisal.
E. Chapter 7 discharge papers.
F. All mortgage indentures and conveyances, as grantor or grantee ‑ preceding 10 years.
G. Legal instruments related to pending claims (insurance or otherwise), rights to sue, subrogations, assignments and other assets.
H. Contracts of sale of any sizable assets, either pending or within last 5 years.
.I Federal Application to Compromise, with results.
J. Leases, both as landlord and as tenant.
K. Audited profit and loss statement (corporation only).
L. Loan agreements and instruments in evidence of assets pledged as collateral for any undertaking.

Statement
I declare that I have examined the information given in this statement and, to the best of my knowledge and belief, it is true, correct,
and complete, and I further declare that I have no assets, owned either directly or indirectly, or income of any nature other than as
shown in this statement. This statement is made with the knowledge that a willfully false representation is a misdemeanor punishable
under section 210.45 of the Penal Law of New York State.

Signature of taxpayer Date of the statement

PDF file checksum: 2113396679

(Plugin #1/9.12/13.0)