CITY OF CHICAGO DEPARTMENT OF FINANCE APPLICATION FOR OFFER IN COMPROMISE OF A TAX DEBT BASED ON FINANCIAL HARDSHIP CITY OF CHICAGO DEPARTMENT OF FINANCE (R-12/11)
FINANCIAL HARDSHIP APPLICATION 1) Who should pply? - This Finncil Hrdship Appliction ( Appliction ) is request for n greement etween usiness or n individul nd the Chicgo Deprtment of Finnce (the Deprtment ) tht resolves the usiness s or individul s tx liility to the City of Chicgo. Under section 3-4-153 of the Municipl Code of Chicgo, the City Comptroller (the Comptroller ), with the pprovl of the Deprtment of Lw, hs the uthority to te ny tx liilities tht hve een ssessed when the Comptroller determines tht there is n uncertinty s to the collectility of the ssessment within resonle period of time. The Comptroller s decision will e mde fter review of the recommendtions presented y the Finncil Hrdship Committee (the Committee ). It is expected tht the Committee will mke its recommendtion to the Comptroller within 45 dys of its receipt of completed Appliction, nd tht the Comptroller s decision will e mde within 30 dys of the Comptroller s receipt of the Committee s recommendtion. 2) Power of Attorney - If this Appliction is completed y someone other thn ) n owner or officer of the usiness tht hs een ssessed tx liility or ) n individul who hs een ssessed tx liility, completed Power of Attorney form must e on file with the Deprtment or sumitted with this Appliction. 3) Completed Appliction - This Appliction is complete when ll schedules nd line items hve een completed or nswered, nd ll supporting documents re ttched or included. The pplicnt will e contcted for ny missing required informtion. If no response is received from the pplicnt or the required informtion is not received within 45 dys of the letter requesting this informtion, the Appliction will e rejected s eing incomplete, nd the Deprtment will continue its efforts to collect the totl mount of the tx liility. 4) Post Assessment Periods - The usiness must provide ll City of Chicgo tx returns for the periods susequent to the close of the period for which the ssessment or ssessments hs een mde. If these returns hve previously een filed, mended returns must e filed which conform to the methodology tht the Deprtment used in computing the tx liility on the notice of ssessment. 5) Federl Income Tx Returns - Applicnt must provide copies of pplicnt s federl nd stte income tx returns tht were signed y pplicnt, including ll schedules, tht encompss the periods of the ssessment, s well s ny recent returns tht include periods susequent to the ssessment periods. 6) Other Supporting Documents - All documents tht support the pplicnt s clim of n inility to py tx liility owed to the City of Chicgo ecuse of finncil hrdship should e included. In ddition to the documents requested in the Appliction, supporting documents which must lso e sumitted re ) nk sttements for the lst six months, ) dets secured y liens or mortgges, nd c) for individuls, pycheck vouchers for the lst two months. 7) Responsile Owner/Officer/Prtner/Employee's Personl Credit Informtion - Any owner of sole proprietorship, or ny officer, employee, prtner or other individul who controls, supervises, or is responsile for the filing of Chicgo tx returns or the pyment of Chicgo txes must complete n ppliction for himself or herself nd provide nd include personl federl nd stte income tx returns for the sme periods s the usiness. 8) Relted Entity - For purposes of this ppliction, relted entity is ny compny, prtnership, or other legl entity, including ut not limited to individuls, tht owns the pplicnt, is owned y the pplicnt, or is owned y the owner of the pplicnt. Individuls re relted if they re spouses, prents, silings, children, grndprents, or grndchildren. SEND YOUR COMPLETED APPLICATION TO: FINANCIAL HARDSHIP COMMITTEE Chicgo Deprtment of Finnce 333 South Stte Street, Suite 300 Chicgo, Illinois 60604
SECTION I. GENERAL INFORMATION FOR BUSINESS 1) Nme of Business: FEIN: Street Address: Emil: City, Stte, ZIP: Phone Numer: ( ) 2) Is usiness currently going concern? Yes No. If no, ttch written sttement nd documenttion explining when nd why the usiness cesed opertions. 3) Is usiness currently in (check pplicle sttus nd ttch supporting documents): Bnkruptcy Assignment For the Benefit Of Creditors Receivership Finncil Hrdship with nother txing ody 4) Business is sole proprietorship prtnership corportion other (specify). 5) Complete for ech owner, prtner, mjor shreholder (25% or more), etc. (ttch seprte sheet if necessry): Nme Title Home Phone Ownership Address % 6) Descrie usiness of txpyer nd ll services nd products it provides (ttch seprte sheet if necessry): 7) Complete for ech prtner or officer nd riefly descrie their duties, identifying the person who controls, supervises, or is responsile for the filing of Chicgo tx returns nd pyment of txes (ttch seprte sheet if necessry): Nme Title Home Duties Address 2
SECTION II. GENERAL FINANCIAL INFORMATION FOR BUSINESSES 1) Bnk Accounts - Provide elow the nme, ddress, nd ccount numer of ll nk nd credit union ccounts. Include checking, pyroll, svings, nk certifictes of deposit, etc. (ttch seprte sheet if necessry): Nme of Institution Address Account Account Type Numer 2) Sfe Deposit Box - Provide the loction, ox numer, nd contents of ll sfe deposit oxes rented or ccessed (ttch seprte sheet if necessry): Nme of Institution Address Box Contents Numer 3) Interest in Rel Property - Provide the type, ddress, purchse price, dte of purchse, percentge of ownership nd type of ownership in ny rel property (ttch seprte sheet if necessry): Description Address Purchse Dte of Ownership Type of Price Purchse % Ownership 4) Securities - Provide the type nd quntity of ny securities owned (e.g., stocks, onds, mutul funds, nd money mrket funds, non-nk certifictes of deposit), or identify the rokerge firm in which these securities re held (ttch seprte sheet if necessry): Description/Institution Quntity/Account # 3
5) Life Insurnce - Identify the life insurnce policies owned, the eneficiry, nd fce mount (ttch seprte sheet if necessry): Nme of Insured Insurnce Policy Beneficiry Type Fce Compny Numer Amount 6) Notes/Accounts Receivle - Identify the notes nd receivles, including lons to compnies, prtnerships, officers, prtners, etc. (ttch seprte sheet if necessry): Nme of Detor Address Amount Dte Sttus Rte of Due Due Interest 7) Motor Vehicles - Identify the motor vehicles owned or lesed (ttch seprte sheet if necessry): Model Yer License Tg # Creditor/Lessor Owned or Lesed? 8) Lines of Credit - Provide the credit ville from finncil institution (ttch seprte sheet if necessry): Nme of Institution Address Credit Amount Credit Monthly Limit Owed Aville Pyments Are pyments current? Yes No. If no, how much in rrers? (mount). 9) Rentls - Identify long term rentls (one yer or more) nd the lessors (ttch seprte sheet if necessry): Rentl Property Lessor Lessor Length of Lese Pyment Address Lese 4
10) Is ny lessor, identified ove, relted entity? Yes No. If yes, explin how the rentl fee ws determined: 11) Future cpitl expenditures - Identify the pplicnt's commitments for future cpitl expenditures, explin the purpose of such commitments, nd identify the nticipted sources of funds needed to fulfill such commitments (ttch seprte sheets if necessry). Cpitl Yer Purpose Source of Expenditure Required Funds 5
SECTION III. BALANCE SHEET ANALYSIS FOR BUSINESS Description Mrket Vlue Amount Owing Equity Monthly Pyment Nme & Address of Creditor Dte of Det Lst Pymt Dte Csh on hnd Bnk ccounts Securities Accounts/notes receivle Life insurnce lon vlue Rel property: Vehicles: Mchinery & Equipment Inventory Other ssets: c Other liilities: c Txes owed Totls Net equity 6
SECTION IV. INCOME AND EXPENSE ANALYSIS FOR BUSINESS Income for period since lst federl income tx return Amount Totl Income Gross receipts from sles nd services Gross rentl income Interest Dividends Other income (specify) TOTAL INCOME Expenses for period since lst federl income tx return Amount Totl Expenses Purchses Wges, contrct services Rents pid Utilities Trnsporttion Repirs Insurnce Other (specify on ttchment) TOTAL EXPENSES NET INCOME for period since lst federl income tx return 7
SECTION V. GENERAL FINANCIAL INFORMATION FOR INDIVIDUALS NOTE: This section must e completed y ) ny individul ssessed for tx liility s responsile officer, prtner, employee, or limited liility compny mnger or memer who is requesting comprise of the ssessed liility; ) the owner of the sole proprietorship tht is requesting compromise of the usiness s tx liility; nd c) ech individul identified in Section I, prgrph 7, ove, who is responsile for filing, pying, or remitting Chicgo tx returns for the compny, prtnership, or limited liility compny tht is requesting compromise of the usiness s tx liility (the responsile individul ). The informtion for the spouse need only e provided where the spouse is jointly lile for the tx liilities or hs received property, including money, from the pplicnt or the responsile individul without dequte considertion. 1) Nme: 2) Residence Address: 3) Are you mrried? Yes No. If yes, provide nme: 4) Do you hve ny children? Yes No. If yes, provide nme nd ge of ech child living with you: 5) Is your spouse currently employed? Yes No. If yes, provide the nme nd ddress of employer: 6) Are you n employee of ny other usiness or enterprise? Yes No. If yes, provide the nme nd ddress of your employer, nd your jo title: 7) Hve you or your spouse filed for (check pplicle sttus nd ttch supporting documents): Bnkruptcy Finncil Hrdship with nother txing ody 8) Bnk Accounts - Provide the nme, ddress, nd ccount numer of ll nk ccounts over which the responsile individul hs signture uthority. Include checking, pyroll, svings, certifictes of deposit, etc. (ttch seprte sheet if necessry): Nme of Institution Address Account Account Type Numer 8
9) Sfe Deposit Box - Provide the loction, ox numer, nd contents of ll sfe deposit oxes rented or ccessed (ttch seprte sheet if necessry): Nme of Institution Address Box Contents Numer 10) Interest in Rel Property - Provide the type, ddress, purchse price, dte of purchse, percentge of ownership nd type of ownership in ny rel property, including eneficil interests in trusts tht own rel property (ttch seprte sheet if necessry): Description Address Purchse Dte of Ownership Type of Price Purchse % Ownership 11) Securities - Provide the type nd quntity of ny securities owned (e.g., stocks, onds, mutul funds, money mrket funds, non-nk certifictes of deposit), or identify the rokerge firm in which these securities re held (ttch seprte sheet if necessry). Include IRA s nd ll retirement ccounts: Description/Institution Quntity/Account # 12) Trusts - Identify the trusts of which you re either the cretor, the designted eneficiry, or the trustee (ttch seprte sheet if necessry): Nme of Trust Trustee Cretor Beneficiry Type 13) Life Insurnce - Identify the life insurnce policies owned, the eneficiry, nd fce mount: Nme of Insured Insurnce Policy Beneficiry Type Fce Compny Numer Amount 9
14) Notes/lons - Identify the notes nd lons, including lons to compnies, reltives, etc. (ttch seprte sheet if necessry): Nme of Detor Address Amount Dte Sttus Rte of Due Due Interest 15) Motor Vehicles - Identify the motor vehicles owned or lesed (ttch seprte sheet if necessry): Model Yer License Tg # Creditor/Lessor 16) Interests in other usinesses - Provide the nme, ddress, nd percentge of ownership in ll other enterprises (ttch copy of the lnce sheet of ech usiness): Nme Address Ownership % 17) Lines of Credit - Provide the credit ville from finncil institution (ttch seprte sheet if necessry): Nme of Institution Address Credit Amount Credit Monthly Limit Owed Aville Pyments 18) Interest In Other Assets - Identify elow (ttch seprte sheet if necessry) the type of ll other ssets, include items such s stmp or coin collections, rtwork, personl property pwned, etc. nd identify nd explin ny relted legl clims or encumrnces. 19) Credit Crds - Provide the credit ville from credit crds (ttch seprte sheet if necessry): Nme of Institution Account Credit Amount Credit Monthly Numer Limit Owed Aville Pyments 10
SECTION VI. BALANCE SHEET ANALYSIS FOR INDIVIDUAL Description Mrket Vlue Amount Owing Equity Monthly Pyment Nme & Address of Creditor Dte of Det Lst Pymt Dte Csh on hnd Bnk ccounts Securities Accounts/notes receivle Life insurnce lon vlue Rel property: Vehicles: Other ssets: c Other liilities: c Txes owed Totls Net equity 11
SECTION VII. INCOME AND EXPENSE ANALYSIS FOR INDIVIDUAL Income for most recent qurter Amount Totl Income Wges (txpyer) Wges (spouse) Interest, dividends Retirement/pension (txpyer) Retirement/pension (spouse) Rents received Alimony received Child support received Other TOTAL INCOME Living Expenses for qurter Amount Totl Expenses Food & clothing Personl & miscellneous Housing Utilities Trnsporttion Helth cre & insurnce Txes (income & FICA) Life insurnce Child/dependent cre Court ordered pyments Secured dets (other thn house or uto pyments) Other (specify on ttchment) TOTAL EXPENSES SURPLUS INCOME for qurter 12
SECTION VIII. OFFER IN COMPROMISE OF TAX LIABILITY 1) Identify the tx type, totl mount ssessed, nd interest ccrued to dte (ttch supporting documents): Tx #1 Tx #2 Tx #3 Totls Tx Type Periods Principl Tx Due Assessed Interest Penlties Additionl interest to dte Totls 2) Identify the tx type nd totl mounts owed for periods susequent to the dte of the ssessment s of the dte of this Appliction (ttch supporting documents): Tx Type Periods Principl Tx Due Interest Penlties Totls Tx #1 Tx #2 Tx #3 Totls 3) The totl mount offered in compromise of the tx liilities due in prgrph 1 ove is $. 4) Will the mount offered e pid in full with this offer? Yes No. If no, explin why pplicnt is unle to py the full mount due in prgrph 1 ove. 5) If the mount offered will not e pid in full s lump sum, descrie how nd when full pyment will e mde. 13
6) From wht source(s) will the mount offered e pid? 7) Identify nd explin ny known commitments or events tht ffect the pplicnt's offer of compromise nd the pplicnt s ility to py the mount offered which hve not otherwise een identified in this Appliction (ttch dditionl sheets if necessry). CERTIFICATION I,, the undersigned, under penlty of perjury, certify tht I hve exmined this Appliction, nd tht the sttements set forth in this instrument nd its ccompnying ttchments re true, correct nd complete. I understnd tht flsifiction of this Appliction, or ny prt thereof will e grounds for rejection of this Appliction s well s the rescission of ny susequent settlement greement sed upon ny mteril misrepresenttions of fct found y the Chicgo Deprtment of Finnce. Under penlty of perjury, I further certify tht ll required City of Chicgo tx returns hve een filed s of the dte of this Appliction. Signture Dte Print Nme Print Title FHA (12/11) 14