.

Your current occupation
Your current employer
If married, spouse's current occupation
Spouse's current employer
IRS LIABILITY
Total amount you owe per last IRS notice(s)
For which tax years or periods?
Type of tax (1040, 941, Trust Fund, etc)?
Have you defaulted on a prior IRS OIC?	Yes    No
STATE LIABILITY
For which State (or States) do you owe?
Total amount you owe per last State notice
For which tax years or periods?
Type of tax (income/employment)?
Have you defaulted on a prior State OIC?	Yes    No
Any prior seizures/levies on assets?	Yes    No
If YES, when and which agency (IRS/STATE)
Are your wages now being levied by IRS and/or STATE?	Yes    No       Agency:
Are you disputing the AMOUNT you owe?	Yes    No
Do you believe you can't pay what you owe?	Yes    No
Have you met with the IRS or STATE yet?	Yes    No
If YES, indicate IRS, STATE or BOTH.
When was your last contact with the IRS?
What was discussed?
When was your last contact with the STATE?
What was discussed?
Have you filed all required IRS returns?	Yes    No Years Not Filed:
Are you current in this year's IRS estimated tax payments or withholding credits?	Yes    No
Have you filed all required STATE  returns?	Yes    No Years Not Filed:
Are you current in this year's STATE estimated tax payments or withholding credits?	Yes    No
GENERAL FINANCIAL INFORMATION
ASSETS-LIQUID
Bank accounts (checking/savings)
Investments (stock, bonds, mutual funds)
IRA, 401(K), KEOGH, other retirement plan

. ASSETS-OTHER

Personal Residence  fair market value
Less: amount of secured loan(s) on your residence
Total fair market value of all other rental and vacation property
Less: total of secured loans on rental and vacation properties
Total fair market value of all cars you own
Less: total of loans against all cars
Total fair market value boats, RVs and planes
Less: total of loans against above
Total fair market value of other personal property
LIABILITIES
Total of any judgments against you
Back child support
Total of credit card balances
Total of personal loan balances
Total of other liabilites
MONTHLY INCOME/EXPENSES
HUSBAND gross monthly wages
Less: husband's withholding    (FICA/Income taxes/medicare)
SPOUSE gross monthly wages
Less: SPOUSE'S withholding    (FICA/Income taxes/medicare)
HUSBAND Net Self-employment earnings
S/E estimated taxes paid this year
SPOUSE Net Self-employment earnings
S/E estimated taxes paid this year
OTHER SOURCES OF INCOME
Interest Income
Dividend Income
Net Rental Income
Alimony Income
Child Support Income
Disability Income
Retirement Income
Other Income
MONTHLY EXPENSES
Mortgage payment or rent
Utilities (electricity)
(gas)
(water)
Property taxes (1/12 of annual amt)
Property/renter insurance
Auto loan payments
Auto lease payments
Auto gas expense
Auto insurance expense
Food (eating at home & restaurants)
Clothing purchases
Entertainment (cable TV, movies)
Health care (medical insurance)
Health care (out-of-pocket exp.)
Child care expenses
Court-ordered alimony
Court-ordered child support
Other court-ordered expenses
Credit card payments
List other monthly expenses
Comments regarding your monthly income or expenses
Your offer to the IRS must be more than the IRS can get through seizure and quick-sale of your assets, in addition to payments you could make over a period of months spanning the statute of limitations.  Offers to certain STATES are different.  What will be the source and the proposed amount of your offer  (include sources that the IRS and/or STATE could not get through collection efforts - such as loans from your family or friends)?

.

Have you ever filed bankruptcy?	Yes    No
If YES, in what month and year were you discharged?
Are you able to pay an estimated retainer of $1,000 ($2,000 for both IRS and STATE offers) to start the process?  NOTE: The amount of your retainer depends upon the complexity of your personal finances.  The estimates above are the minimum retainer amounts for wage earners and small service-oriented businesses.	Yes    No

End of Questionnaire