Fillable Dtf5 Fill In Form DTF-5:8/18:Statement of Financial Conition:dtf5

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Department of Taxation and Finance
Statement of Financial Condition
DTF-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 DTF-4.1, 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 Review.
You 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.
•
Taxpayer information
All other persons in your household or claimed as dependents
•
Taxpayer’s representative information I have no representative
Name Age Relationship
Social
Security number
Can 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identicationnumber(EIN)
Home address Telephone number
Mailing address
(if different from above, or if a PO Box number is used)
Business address Telephone number
Mailing address (if different from above, or if a PO Box number is used)
Employer’s name, address, and telephone number
Spouse’s employer’s name, address, and telephone number
Doyouoryourspousehaveanybusinessinterests?(led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 No
Name of representative, if any (attach Form POA-1, Power of Attorney, if required) Telephone number
Address
Attach additional sheets if necessary.
Page 2 of 10 DTF-5 (8/18)
•
Assets As of
Date
Enter the balance for each of the following, using the most current value. If any of the following amounts are negative, enter 0.
Cash 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 applicable
Brokerage accounts Not applicable
Retirement accounts Not applicable
Cash value of life insurance policies Not applicable
Attach additional sheets if necessary.
(A)
(B)
(C)
(D)
(E)
Nameofnancialinstitution
Institution or brokerage name
Institution or custodian name
Institution company name
Account number
Account number
Account number
Policy number
Type*
Type*
Type*
Type*
Balance
Net value
Net value
Net value
Less:
Loans, if any
Less:
Loans, if any
Less:
Loans, if any
Market value
Market value
Cash value
* Type may include: checking, savings,
money market, stored value cards, etc.
* Type may include: stocks, bonds, other
investments, etc.
* Type may include: 401K, IRA, pension,
prot sharing, etc.
* Type may include: term, whole life, etc.
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:
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 applicable
Inventory Not applicable
Notes receivable Not applicable
Valuable items, machinery, and equipment Not applicable
Attach additional sheets if necessary.
(F)
(G)
(H)
(J)
(I)
Name and address
Detailed description
Name and address
Description
Book value
Book value
Book value
Date recorded
Date recorded
Date recorded
Net value
Net value
Net value
Loan balance, if any
Date pledged,
if applicable
Date pledged,
if applicable
Date pledged,
if applicable
Fair market value
Less:
Loans, if any
Less:
Loans, if any
Less:
Loans, if any
(List any artwork, collections, jewelry, items in safe deposit boxes, tools, furniture, xtures, etc. that you own fully or partially)
Page 4 of 10 DTF-5 (8/18)
Attach additional sheets if necessary.
Assets (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 applicable
Foreclosure proceedings: Not applicable
(M)
(L)
(K)
Complete address
Unpaid property
taxes
Mortgage balance,
if any
Current fair
market value
Owners
Description*
(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, etc.
Are 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? ................................................................................ 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 applicable
Leased vehicles (List any cars, boats, motorcycles, trucks, aircraft, etc. that you lease) Not applicable
(O)
(N)
Year, make, and model
Year, make, and model
Loan balance
Term of lease
Fair market value
Date of lease
Owners
Lessee name(s)
Mileage
Mileage
Plate number or
Reg. number
Plate number or
Reg. number
DTF-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 explanation.
Assets (continued) As of
Date
•
Increase in value
Business interests (from page 1, if you marked Yes) Not applicable
If you or your spouse have ownership in any business, complete the table below. You must complete this section if you:
• ledfederalschedulesC,E,F,andotherfederalbusinessformsledbyanindividualinthepreceding3years.
• receivedfederalschedulesK-1inthepreceding3years.
• areashareholderofabusinessthatledfederalForm1120,U.S. 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 name
Ownership
percentage
Type of
business*
Employer
identicationnumber
Value 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 funds
Dollar amount
Contingent claims or legal actions Not applicable
(Potentially receivable or collectable, such as pending insurance claims, settlements, etc.)
Attach additional sheets if necessary.
Interest in trust or estate Not applicable
Are you the grantor, donor, or trustee for any trust? ......................................................................................................... Yes No
Areyouthebeneciaryofanytrustorestate? ................................................................................................................. Yes No
Do you have any life interest or remainder interest, either vested or contingent, in any trust or estate? ......................... Yes No
If 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 estate
Annual income you received
from this source
Present value of trust or
estate
Value of your
interest
Page 6 of 10 DTF-5 (8/18)
•
Disposal of assets Not applicable
Attach additional sheets if necessary.
Did you transfer any assets with a fair market value of $500.00 or more during the period beginning with the
start of your proposal’s tax period and the present? ..................................................................................................... Yes No
If Yes, attach a copy of the applicable transfer document (i.e. sales agreement, closing statement, HUD-1 statement, etc.).
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 above
Asset type and description
Name of creditor(s)
Relationship of transferee
Date recorded
Dollar amount you
received
Current balance
due on judgment
Fair market value
when transferred
Dollar amount of
judgmentled
Date of transfer
Where recorded
•
Judgments As of
Date
Not applicable
Box (S) – Total balance due on judgments (enter Liability on page 7, line 22)
$
(S)
Bankruptcy Not applicable
Unlawful activities Not applicable
Are bankruptcy or receivership proceedings pending? .................................................................................................... Yes No
If a corporation or other business, is it in the process of liquidation? ............................................................................... Yes No
Is the liability you are trying to compromise related to a crime for which you pleaded or were found guilty? .................. Yes No
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 5 years? ...................................................... Yes No
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 to any of the above, provide details:
DTF-5 (8/18) Page 7 of 10
Assets
Values
(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. Valuable items (from page 3, Box (I))
10. Real estate (from page 4, Box (K))
11. Vehicles (from page 4, Box (N))
12. Interestintrustorestate(from page 5, Box (P))
13. Businessinterests(from page 5, Box (Q))
14. Contingent claims or legal actions, receivable (from page 5, Box (R))
15. Other assets (list)
16. NewYorkStatetaxliabilities(not already included in Judgments on page 6)
17. Federal tax liabilities (not already included in Judgments on page 6)
18. Loans against valuable items (from page 3, Box (J))
19. Mortgage balances (from page 4, Box (L))
20. Unpaidpropertytaxes(from page 4, Box (M))
21. Loansagainstvehicles(from page 4, Box (O))
22. Balancedueonjudgments(from page 6, Box (S))
23. Accountspayable
24. Creditcardbalancespayable
25. Notespayable
26. Contingentclaimsandlegalactionspayable
27. Otherliabilities(list)
Attach additional sheets if necessary.
Liabilities
Total liabilities $
Total assets $
•
Statement of assets and liabilities As of
Date
Amount
Page 8 of 10 DTF-5 (8/18)
Enter your household’s gross monthlyincome,includingincomefromyou,yourspouse,signicantother,children,andotherswho
contribute to the household.
•
Household income and expenses – individual
Monthly gross receipts or income
AmountName of source
Monthly expenses
Amount
To whom paid
(and relationship)
Salaries, wages, commissions of applicant(s)
Salaries, wages, commissions of household members
Dividends
Interest
Net business income from all sole proprietorships and single-member LLCs
(from
federal schedule Cs)
Distributions from partnerships and S corporations (from your attached federal schedules K-1,
the partner or shareholder cash distributions you received on an average monthly basis)*
Net proceeds from sales of securities and other investments ((stocks, bonds, mutual funds,
real properties, etc.) on an average monthly basis)*
Income from annuities and pensions
Income from rents and royalties
Income from trusts and estates
Social Security
Welfare
Unemployment
Gifts
Money from relatives
Other income (list)
Food, clothing, and miscellaneous (such as housekeeping supplies, personal care products)*
Housing (rent or mortgage payment, plus property taxes, home insurance, maintenance, dues, or fees)
Utilities (electricity, gas, other fuels, trash collection, water, cable, phone)
Vehicle loan and lease payments
Vehicle operating costs (maintenance, repairs, insurance, fuel, registrations, licenses, inspections,
parking, tolls, etc.)*
Public transportation costs (fares for mass transit such as bus, train, ferry, taxi, etc.)*
Health insurance premiums
Out-of-pocket health care costs (prescription drugs, medical services, and medical supplies like
eyeglasses, hearing aids, etc.)*
Court-ordered payments (alimony, child support, etc.)
Child or dependent care (daycare, home health care, etc.)
Life insurance premiums
Taxes (monthly cost of federal, state, and local tax, etc.)
Debt service payments (monthly payment for loans where you pledged an asset as collateral; do not
include payments on unsecured debt such as credit cards.)
Other expenses (list)
Total monthly household expenses: $
Total monthly household income: $
Attach additional sheets if necessary.
* You may provide reasonable estimates for certain income and expenses on an average monthly basis.
DTF-5 (8/18) Page 9 of 10
If this proposal is from a business, enter the information below for the last two calendar (scal) years and most recent interim
period (year-to-date). Attach a detailed statement of carryover and carryback loss intentions. If you do not intend to use this offset,
attach a full explanation.
•
Income and expenses – business
Gross receipts or income
Year before last
20
Year before last
20
Last year
20
Last year
20
Most recent interim period
(year-to-date)
, 20
Most recent interim period
(year-to-date)
, 20
Deductions
Gross sales or receipts (net of returns and allowances)
Less: Cost of goods sold
Gross prot
Dividend income
Interest income
Gross rents
Gross royalties
Ordinary income (loss) from partnerships, estates and trusts, if applicable
Netfarmprot(loss)(federal schedule F (Form 1040))
Gains from sales of assets (federal Form 4797))
Capital gain net income (federal schedule D (Form 1120))
Other income (list)
Compensationofofcers
Guaranteed payments to partners
Salaries and wages (not deducted elsewhere)
Pension,prot-sharing,retirementplans,etc.
Employeebenetprograms
Rents
Repairs and maintenance
Taxes and licenses
Depreciation, amortization, depletion
Bad debts
Interest expense
Contract labor, commissions, and fees paid
Legal and professional services
Car and truck expenses
Travel, meals, and entertainment
Contributions, charitable giving
Other operating expenses (list)
Total income $ $ $
Total deductions $ $ $
Annual benet paid to principal ofcers and owners – Enterthetotalannualbenetpaidtoeachoftheprincipalofcersandowners
ofthebusiness.Annualbenetmayinclude,butnotbelimitedto,thefollowingsources:wages,guaranteedpaymentstopartners,shareholder/partner
distributions, management fees, commissions, and shareholder/partner loans received from the business.
Name and title 20
20 20
, President
, Vice President
, Treasurer
, Secretary
Total capital contributed by shareholders, partners, or owners
of the business $ $ $
Total distributions or dividends paid to shareholders, partners, or
owners of the business $ $ $
Attach additional sheets if necessary.
Page 10 of 10 DTF-5 (8/18)
4. Federal application to compromise, with the results.
5. Recentmortgageorhomeequityloanstatements(s)datedwithin30daysofsubmission.Thestatement(s)mustshowmonthly
payment amounts and current balance outstanding. We may request a real estate appraisal.
6. All mortgage indentures and conveyances, as grantor or grantee, for the preceding 10 years.
7. Lease agreements, both as landlord and tenant.
8. Loan agreements, both for note(s) receivable and note(s) payable. Include the security/collateral agreements for all secured
loans.
9. Contractsofsaleofanyassetshavingafairmarketvalueofover$500.00withinthelastveyears.Forexample,sales
agreement, closing statement, HUD-1 statement, etc.
10. Copies of legal instruments related to pending claims (insurance or otherwise), rights to sue, subrogations, assignments, and
other assets.
11. Bankruptcy discharge papers, if applicable.
12. Foranybusiness(corporation,partnership,scorp,non-protorganization,professionalcorp,etc.):Wemayrequestthe
audited,reviewed,orcompany-preparednancialstatementsfortheprecedingthreeyears.Inaddition,wemayrequestan
Accounts Receivable Aging Report for any business.
1. Federalreturnsfortheprecedingthreeyears,withallschedulesandstatementsattached.Ifyouwerenotrequiredtole,
include an explanation. In addition:
• for all sole proprietorships or single-member LLC’s (Schedule C), also include the balance sheets for the preceding three
years, as of each year-end. These balance sheets may be self-prepared.
• includeallfederalschedulesK-1fromForm1120SorForm1065,orboth,fortheprecedingthreeyears,asapplicable.
2. Completecreditreportsissuedbyacreditbureaudatedwithin30daysofthissubmission.
3. Allbankaccountstatements,brokerageaccountstatements,andretirementaccountstatementsforthepreceding12months.
• If you receive certain statements on a quarterly basis, provide the four most recent quarterly statements for the applicable
account(s).
• If you receive certain statements on an annual basis, provide the most recent annual statement for the applicable
account(s).
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. I make this statement with the knowledge that a willfully false representation is a misdemeanor punishable under New
YorkStatePenalLawsection210.45.
I authorize the New York State Department of Taxation and Finance (DTF) to contact certain third parties, including but not limited to
nancialinstitutionsandconsumercreditreportingagencies,andtoobtainmyconsumercreditreportforthepurposeofverifyingthe
information I provided to DTF for determining my eligibility for an installment payment agreement or other payment terms. In addition, I
authorize DTF to use my Social Security number when requesting my credit history from consumer reporting agencies or when verifying
the information provided. I understand that DTF will not notify me about which third parties, if any, are contacted by DTF as part of this
review process.
•
Attachments
•
Declaration
Taxpayer’s signature(s) Date
Items1,2,and3mustbeattached;items4through12,ifapplicable,mustalso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.
Attach additional sheets if necessary.
You must attach, if applicable:
You must attach:
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Dtf5 Fill In Form DTF-5:818:Statement of Financial Conition:dtf5

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Completed 23 March 2020

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