Statement of Financial Condition DTF-5 - tax.ny.gov

1 Department of Taxation and FinanceStatement of Financial ConditionDTF-5(8/18)Complete Form DTF-5 and include it with your request for a payment plan, offer in compromise, or other proposal. Form DTF-5 must be completed for each taxpayer assessed, except for joint taxpayers, where both spouses may submit one Form DTF-5 . For a business, a Form DTF-5 is required for that business, and for each individual assessed as a responsible person. To make an offer in compromise, you must include a completed Form DTF-5 for each taxpayer who submits either a: Form , Offer in Compromise for Fixed and Final Liabilities, or Form DTF-4, Offer in Compromise for Liabilities Not Fixed and Final, and Subject to Administrative must answer all questions and provide all required attachments listed on page 10. If a question does not apply, mark an X in the Not applicable box, or enter N/A. If you need additional space, attach sheets and label them accordingly.

2 Taxpayer informationAll other persons in your household or claimed as dependents Taxpayer s representative information I have no representative NameAgeRelationshipSocial Security numberCan be claimed as a dependent?Contributes to household income?Name of taxpayers: individuals or business Date of birth Social Security number Spouse s date of birth Spouse s Social Security number Employer identification number (EIN)Home address Telephone numberMailing address (if different from above, or if a PO Box number is used)Business address Telephone numberMailing address (if different from above, or if a PO Box number is used)Employer s name, address, and telephone numberSpouse s employer s name, address, and telephone numberDo you or your spouse have any business interests? (filed federal schedules C, E, F, etc.) .. Yes No If Yes, enter details on page 5. Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes NoName of representative, if any (attach Form POA-1, Power of Attorney, if required) Telephone numberAddressAttach additional sheets if 2 of 10 DTF-5 (8/18) Assets As of DateEnter the balance for each of the following, using the most current value.

3 If any of the following amounts are negative, enter on hand Box (A) Total cash on hand (also enter on page 7, line 1) $ Box (B) Total balance (also enter on page 7, line 2) $ Box (C) Total net value (also enter on page 7, line 3) $ Box (D) Total net value (also enter on page 7, line 4) $ Box (E) Total net cash value (also enter on page 7, line 5) $Bank accounts (domestic and foreign) Not applicableBrokerage accounts Not applicableRetirement accounts Not applicableCash value of life insurance policies Not applicableAttach additional sheets if necessary.(A)(B)(C)(D)(E)Name of Financial institutionInstitution or brokerage nameInstitution or custodian nameInstitution company nameAccount numberAccount numberAccount numberPolicy numberType*Type*Type*Type*BalanceNet valueNet valueNet valueLess: Loans, if anyLess: Loans, if anyLess: Loans, if anyMarket valueMarket valueCash value* Type may include: checking, savings, money market, stored value cards, etc.

4 * Type may include: stocks, bonds, other investments, etc.* Type may include: 401K, IRA, pension, profit sharing, etc.* Type may include: term, whole life, you rent a safe deposit box in your name, or in any other name? .. Yes No If Yes, give name and address of bank: DTF-5 (8/18) Page 3 of 10 Assets (continued) As of Date Box (F) Total net value (also enter on page 7, line 6) $ Box (G) Total net value (also enter on page 7, line 7) $ Box (H) Total net value (also enter on page 7, line 8) $ Box (J) Total loan balance, if any (enter Liability on page 7, line 18) $ Box (I) Total fair market value (enter Asset on page 7, line 9) $Accounts receivable Not applicableInventory Not applicableNotes receivable Not applicableValuable items, machinery, and equipment Not applicableAttach additional sheets if necessary.(F)(G)(H)(J)(I)Name and addressDetailed descriptionName and addressDescriptionBook valueBook valueBook valueDate recordedDate recordedDate recordedNet valueNet valueNet valueLoan balance, if anyDate pledged, if applicableDate pledged, if applicableDate pledged, if applicableFair market valueLess: Loans, if anyLess: Loans, if anyLess: Loans, if any(List any artwork, collections, jewelry, items in safe deposit boxes, tools, furniture, fixtures, etc.)

5 That you own fully or partially)Page 4 of 10 DTF-5 (8/18)Attach additional sheets if (continued) As of Date Box (M) Total unpaid property taxes (enter Liability on page 7, line 20) $ Box (L) Total mortgage balance (enter Liability on page 7, line 19) $ Box (K) Total fair market value (enter Asset on page 7, line 10) $Real estate Not applicableForeclosure proceedings: Not applicable(M)(L)(K)Complete addressUnpaid property taxesMortgage balance, if anyCurrent fair market valueOwnersDescription*(List any house, condo, co-op, timeshare, land, commercial property, etc. that you own fully or partially, located inside and outside of the country)* Description may include: primary residence, vacation home, rental property, foreclosure proceedings pending on any real estate which you own or have an interest in? .. Yes No If Yes, please give locations of the real estate: Was the New York State Tax Department made a party to the suit?

6 Yes No Box (O) Total loan balance (enter Liability on page 7, line 21) $ Box (N) Total fair market value (enter Asset on page 7, line 11) $Vehicles (List any cars, boats, motorcycles, trucks, aircraft, etc. that you own) Not applicableLeased vehicles (List any cars, boats, motorcycles, trucks, aircraft, etc. that you lease) Not applicable(O)(N)Year, make, and modelYear, make, and modelLoan balanceTerm of leaseFair market valueDate of leaseOwnersLessee name(s)MileageMileagePlate number or Reg. numberPlate number or Reg. numberDTF-5 (8/18) Page 5 of 10 What is the prospect of an increase in value of any of your assets and your present income?Provide a detailed (continued) As of Date Increase in valueBusiness interests (from page 1, if you marked Yes) Not applicableIf you or your spouse have ownership in any business, complete the table below. You must complete this section if you: filed federal schedules C, E, F, and other federal business forms filed by an individual in the preceding 3 years.

7 Received federal schedules K-1 in the preceding 3 years. are a shareholder of a business that filed federal Form 1120, Corporation Income Tax Return, in the preceding 3 years. Box (Q) Total value of your investments (enter Assets on page 7, line 13) $(Q)Business nameOwnership percentageType of business*Employer identification numberValue of your investment**Annual cash received**Annual cash contributed** * List all types of businesses, including sole proprietorships, partnerships, S corporations, C corporations, etc. ** Annual cash contributed or received may include: Shareholder or partner contributions or distributions, etc. ** Value of your investment may include: Your share of net worth or your partner capital account, etc. Box (R) Total dollar amount (enter Assets on page 7, line 14) $(R)Name of payer(s)Date you expect to receive fundsDollar amountContingent claims or legal actions Not applicable(Potentially receivable or collectable, such as pending insurance claims, settlements, etc.)

8 Attach additional sheets if in trust or estate Not applicableAre you the grantor, donor, or trustee for any trust? .. Yes NoAre you the beneficiary of any trust or estate? .. Yes NoDo you have any life interest or remainder interest, either vested or contingent, in any trust or estate? .. Yes NoIf Yes to any of the above, furnish a copy of the instrument creating the trust or estate. Also, complete the table below. Box (P) Total value of your interest (enter Assets on page 7, line 12) $(P)Name of trust or estateAnnual income you received from this sourcePresent value of trust or estateValue of your interestPage 6 of 10 DTF-5 (8/18) Disposal of assets Not applicableAttach additional sheets if you transfer any assets with a fair market value of $ or more during the period beginning with the start of your proposal s tax period and the present? .. Yes NoIf Yes, attach a copy of the applicable transfer document ( sales agreement, closing Statement , HUD-1 Statement , etc.)

9 Also complete the table below. List all applicable transactions, including: transfer or sale of real estate transfer or sale of business interests assets that were transferred for less than fair market value disposal of any of the aboveAsset type and descriptionName of creditor(s)Relationship of transfereeDate recordedDollar amount you receivedCurrent balance due on judgmentFair market value when transferredDollar amount of judgment filedDate of transferWhere recorded Judgments As of Date Not applicable Box (S) Total balance due on judgments (enter Liability on page 7, line 22) $(S)Bankruptcy Not applicableUnlawful activities Not applicableAre bankruptcy or receivership proceedings pending? .. Yes NoIf a corporation or other business, is it in the process of liquidation? .. Yes NoIs the liability you are trying to compromise related to a crime for which you pleaded or were found guilty?.

10 Yes NoHave 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 5 years? .. Yes NoAre 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 NoIf Yes to any of the above, provide details: DTF-5 (8/18) Page 7 of 10 AssetsValues (from pages 2 through 6)Amount 1. Cash on hand (from page 2, Box (A)) 2. Bank accounts (from page 2, Box (B)) 3. Brokerage accounts (from page 2, Box (C)) 4. Retirement accounts (from page 2, Box (D)) 5. Cash value of life insurance (from page 2, Box (E)) 6. Accounts receivable (from page 3, Box (F)) 7. Inventory (from page 3, Box (G)) 8. Notes receivable (from page 3, Box (H)) 9.