Fillable OIC Schedule 2A (Individuals) Collection Information Statement for (Michigan)

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OIC Schedule 2A (Individuals) Collection Information Statement for (Michigan)

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Michigan Department of Treasury
5183 (Rev. 10-16)
OIC Schedule 2A (Individuals) — Collection Information Statement
for an Offer in Compromise Based on Doubt as to Collectability
Issued under authority of Public Act 122 of 1941 and Public Act 240 of 2014.
A taxpayer requesting a Michigan Offer in Compromised based on Doubt as to Collectability must submit the following items
before their submission can be reviewed and be considered complete:
You must include all applicable attachments listed below.
Copies of three months of the most recent earnings statement, etc., from each employer.
Copies of the most recent statement for each investment and retirement account.
Copies of the most recent statements from all other sources of income such as pensions, Social Security, rental income, interest and dividends
(including any received from a related partnership, corporation, LLC, LLP, etc.), court order for child support, alimony, and rent subsidies.
Copies of bank statements for the three most recent months.
Copies of the most recent statement from lender(s) on loans such as mortgages, second mortgages, vehicles, etc., showing monthly
payments, loan payoffs, and balances.
If you would like to designate a third party representative, attach an Authorized Representative Declaration (Power of Attorney), (Form 151).
If you have an interest in a business, you must include all applicable attachments listed below.
A current prot or loss income statement covering at least the most recent 12 month period.
Current balance sheet including cash and notes receivable.
Copies of the most recent statements from lenders on loans, mortgages (including second mortgages), monthly payments, loan payoffs, and
balances.
Copies of bank statements for the three most recent months.
PART 1: PERSONAL AND HOUSEHOLD INFORMATION
Filer’s First Name M.I. Last Name Social Security Number
Home Address City
Mailing Address (if different from above or Post Ofce Box number) City
Place of Residence (Check the one that applies):
State ZIP
State ZIP
Marital Status
Own your home Rent Other
(Shared rent, living w/ relative, etc. Include letter of explanation) Unmarried Married
Primary Telephone Number Secondary Telephone Number Fax Number
INFORMATION ABOUT YOUR SPOUSE
Spouse’s First Name M.I. Last Name Social Security Number Date of Birth (mm/dd/yyyy)
INFORMATION FOR ALL OTHER PERSONS IN THE HOUSEHOLD OR CLAIMED AS A DEPENDENT
Claimed as a dependent *Contributes to
Name Age Relationship on your MI-1040? household resources?
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
*Household resources include all income (taxable and nontaxable) received by all adult household members during the year, including income that might
be exempt from federal adjusted gross income.
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Social Security Number
PART 2: TAXPAYER AND SPOUSE EMPLOYMENT INFORMATION
If you or your spouse have self-employment income instead of, or in addition to, wage income, you must complete Business Information in Parts 6, 7
and 8.
Your Employer’s Name Do you have an ownership
interest in this business?
Occupation Length of employment with employer
Yes No
(years) (months)
Employer’s Address City State ZIP
Spouse’s Employer’s Name
Does spouse have ownership
interest in this business?
Spouse’s Occupation Length of employment with employer
Yes No
(years) (months)
Spouse’s Employer’s Address City State ZIP
PART 3: INDIVIDUAL ASSESSMENTS AFFECTED BY DOUBT AS TO COLLECTABILITY
List all outstanding tax debts to be considered in the Offer in Compromise as they apply to doubt as to collectability. Use additional
copies of this page if needed and submit with the Offer in Compromise.
Use assessment numbers and related information from the most recent Final Assessment (Bill for Taxes Due) notice or the most recent
Final Demand notice received from the Michigan Department of Treasury, Ofce of Collections. Your assessment numbers can be
located by looking at the “ASSESSMENT NUMBER” column of any correspondence received in reference to your collections account.
Valid assessment numbers are 7 characters in length and begin with a letter.
ASSESSMENT NUMBER TAX TYPE TAX YEAR/PERIOD BALANCE DUE
Total Balance Due. Enter here the total of all lines in the Balance Due column above. If multiple pages are
included, this line on each copy of the page will reect the total for all pages.
Complete and attach additional copies of this page if needed.
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Social Security Number
PART 4: PERSONAL ASSET INFORMATION (INCLUDING SPOUSE)
Attach the most current statement for each type of account, such as checking, savings, money market and online accounts, stored value cards (such as a
payroll card from an employer), investment and retirement accounts (IRAs, Keogh, 401(k) plans, stocks, bonds, mutual funds, certicates of deposit), life
insurance policies that have a cash value, and safe deposit boxes. Asset value is subject to adjustment by Treasury based on individual circumstances.
Enter the total amount available for each of the following (if additional space is needed include attachments).
* Loan Balance: For certain items in Part 4, “Loan Balance” refers to an amount owed to pay back a loan. Any monthly loan payment should be reected
on line 5i of Part 5: Monthly Household Resources and Expense Information.
CASH AND INVESTMENTS (DOMESTIC AND FOREIGN)
Type of account
Checking Savings Money Market/CD Online Account Stored Value Card Cash
Financial Institution Name Account Number Value
Type of account
Checking Savings Money Market/CD Online Account Stored Value Card Cash
Financial Institution Name Account Number Value
If attaching a separate sheet listing additional bank accounts, record the total of those accounts here.
INVESTMENT ACCOUNTS
Type of account *Loan Balance
Stocks Bonds Other _____________________________
Financial Institution Name Account Number Current Market Value
Type of account *Loan Balance
Stocks Bonds Other _____________________________
Financial Institution Name Account Number Current Market Value
If attaching a separate sheet listing additional investment accounts, record the total of the current market value of those accounts here.
RETIREMENT ACCOUNTS
Type of account *Loan Balance
401K IRA Other _____________________________
Financial Institution Name Account Number Current Market Value
Type of account *Loan Balance
401K IRA Other _____________________________
Financial Institution Name Account Number Current Market Value
If attaching a separate sheet listing additional retirement accounts, record the total of the current market value of those accounts here.
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Social Security Number
PART 4: PERSONAL ASSET INFORMATION (INCLUDING SPOUSE) (CONTINUED)
CASH VALUE OF LIFE INSURANCE POLICIES
Insurance Company Name Policy Number Current Cash Value *Loan Balance
ZIP
If attaching a separate sheet listing additional life insurance policies, record the total of the current cash value of those accounts here.
REAL ESTATE
Enter information about any house, condo, co-op, time share, other real property (whether occupied or vacant), etc. that you own or are buying.
Property Address City State
County Country Is this your primary residence? Date Purchased Date of Final Payment
Yes No
How is title held? (Joint tenancy, etc.) Description of Property Current Market Value *Loan Balance (Mortgages, etc.)
Property Address City State ZIP
County Country Is this your primary residence? Date Purchased Date of Final Payment
Yes No
How is title held? (Joint tenancy, etc.) Description of Property Current Market Value *Loan Balance (Mortgages, etc.)
If attaching a separate sheet listing additional real estate, record the combined current market value of that real estate here.
MOTOR VEHICLES — Complete if owning or leasing a vehicle
Year Make License Number Vehicle ID Number Value Balance Owed
Year Make License Number Vehicle ID Number Value Balance Owed
If attaching a separate sheet listing additional motor vehicles, record the combined value of those motor vehicles here.
OTHER VALUABLE ITEMS
Enter information about other valuable items (boats, motorcycles, artwork, collections, jewelry, items of value in safe deposit boxes, interest in a
company or business that is not publicly traded, etc.).
Description of Asset Current Market Value *Loan Balance
Description of Asset Current Market Value *Loan Balance
Description of Asset Current Market Value *Loan Balance
Description of Asset Current Market Value *Loan Balance
Description of Asset Current Market Value *Loan Balance
Description of Asset Current Market Value *Loan Balance
Description of Asset Current Market Value *Loan Balance
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Social Security Number
PA
14. Additional sources of income used to support the household, e.g. non-liable spouse, or anyone else who
may contribute to the household resources. Provide the total amount of that income here, and attach an
explanation of those sources ........................................................................................................................... 14.
15. Business income for self-employed taxpayers and/or their spouses (all others skip to line 16):
15a. Gross prot ............................................................................... 15a.
15b. Total expenses.......................................................................... 15b.
15c. Net income. Subtract line 15b from line 15a.................................................................................................... 15c.
16. Total Monthly Household Income. Add lines 1 through 14. For taxpayers spouses that are self-employed,
add lines 1 through 14 and line 15c................................................................................................................. 16.
RT 5: MONTHLY HOUSEHOLD RESOURCES AND EXPENSE INFORMATION
The information below is for yourself, your spouse, and anyone else who contributes to household resources, including adult children. This information
is necessary for Treasury to accurately evaluate your offer.
Total household resources include all income (taxable and nontaxable) received by all adult household members during the year, including income that
might be exempt from federal adjusted gross income. Net losses from business activity may not be used to reduce total household resources.
If you or your spouse are self-employed, you must also complete Parts 6, 7 and 8. Amount calculations in those parts will be carried to line 15a and
15b below.
Self-employed taxpayers will complete lines 15a and 15b with information from a current prot or loss statement (attach to this form).
Monthly Household Resources
1. Primary Taxpayer’s Wages .............................................................................................................................. 1.
2. Primary Taxpayer’s Social Security (including Disability and Social Security income) .................................... 2.
3. Primary Taxpayer’s Pension(s)/other retirement distribution ........................................................................... 3.
4. Primary Taxpayer’s Miscellaneous Income (sources not mentioned below are reported on line 14)
4a. Unemployment ......................................................................... 4a.
4b. Government assistance (cash/food) ......................................... 4b.
4c. Vendor income.......................................................................... 4c.
4d. Total primary taxpayer’s miscellaneous income .............................................................................................. 4d.
5. Spouse’s/Other’s Wages ................................................................................................................................. 5.
6. Spouse’s/Other’s Social Security .................................................................................................................... 6.
7. Spouse’s/Other’s Pension(s)/other retirement distribution .............................................................................. 7.
8. Spouse’s/Other’s miscellaneous income
8a. Unemployment ......................................................................... 8a.
8b. Government assistance (cash/food) ......................................... 8b.
8c. Vendor income.......................................................................... 8c.
8d. Total spouse’s/other’s miscellaneous income.................................................................................................. 8d.
9. Combined Interest and Dividends ................................................................................................................... 9.
10. Combined Distributions (income from partnerships, sub-S corporations, etc.) ............................................... 10.
11. Combined Net Rental Income ......................................................................................................................... 11.
12. Combined Child Support Received ................................................................................................................. 12.
13. Combined Alimony Received........................................................................................................................... 13.
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Social Security Number
PART 5: MONTHLY HOUSEHOLD RESOURCES AND EXPENSE INFORMATION (CONTINUED)
Total allowable monthly expenses are calculated using the collection nancial standards for the Michigan Department of Treasury as well as those
provided by the Internal Revenue Service for: housing and utilities; food, clothing and other items; transportation costs; medical costs; actual
installment payments (e.g. child support, alimony, garnishments, etc.); and education and childcare expense.
Monthly Household Expenses
1. Housing and Utilities
1a. Mortgage (If paying more than one mortgage, provide proof
for all mortgages. Enter the total of all payments here.) ........... 1a.
1b. Rent .......................................................................................... 1b.
1c.
Property taxes (if not included in mortgage as listed on line 1a) ..
1c.
1d. Homeowner’s/renter’s insurance (if not included in mortgage
as listed on line 1a)................................................................... 1d.
1e. Utilities (if claiming more than $300, attach current billing
statements) ............................................................................... 1e.
1f. Telephone/cell phone/cable TV/internet ................................... 1f.
1g. Association dues ...................................................................... 1g.
1h. Total housing and utilities. Add lines 1a through 1g......................................................................................... 1h.
2. Transportation — Complete lines 2a and 2b if owning or leasing a vehicle; otherwise, complete line 2c.
2a. Ownership (provide a copy of the lease/loan agreement) ........ 2a.
2b. Operating costs (including maintenance, repairs, insurance,
fuel, registrations, licenses, inspections, parking, and tolls) ..... 2b.
2c. Public transportation ................................................................. 2c.
2d. Total transportation. Add lines 2a through 2c .................................................................................................. 2d.
3. Insurance/Medical Costs
3a. Health Insurance ...................................................................... 3a.
3b. Life Insurance ........................................................................... 3b.
3c. Medical (if younger than age 65, the maximum monthly
allowable is $60; for 65 and older, the maximum is $144)........ 3c.
3d. Total insurance/medical costs. Add lines 3a through 3c .................................................................................. 3d.
4. Food and Clothing
4a. Groceries .................................................................................. 4a.
4b. School Lunches ........................................................................ 4b.
4c. Personal (apparel, services, personal care products) .............. 4c.
4d. Total food and clothing. Add lines 4a through 4c ............................................................................................. 4d.
5. Installment Payments — Provide current billing statements as proof for all items in lines 5a-5i. (Some items may be listed on a pay stub.)
5a. Child Support ............................................................................ 5a.
5b. Alimony ..................................................................................... 5b.
5c. Garnishment ............................................................................. 5c.
5d. Other delinquent taxes ............................................................. 5d.
5e. 401(k) loan repayment.............................................................. 5e.
5f. Credit cards .............................................................................. 5f.
5g.
5h. Student loans............................................................................
5g. Union dues/employment cost ...................................................
5h.
5i. Loan Balance (see Part 4 instructions)..................................... 5i.
5j. Total installment payments. Add lines 5a through 5i........................................................................................ 5j.
6. Childcare and Education
— Provide current billing statements as proof for all items in lines 6a and 6b.
6a. Childcare .................................................................................. 6a.
6b. Tuition/education ...................................................................... 6b.
6c. Total education and childcare. Add lines 6a through 6b .................................................................................. 6c.
7. Total monthly household expenses. Add lines 1h, 2d, 3d, 4d, 5j and 6c .................................................... 7.
If you or your spouse are self-employed, you must complete Business Information in Parts 6, 7 and 8.
All others must skip Parts 6, 7 and 8, and continue to Part 9 and sign the document.
Continue on Page 7
5183, Page 7
Social Security Number
Self-employed taxpayers must complete Parts 6, 7 and 8.
ll other taxpayers will skip Parts 6, 7 and 8, and continue to Part 9.
ED INFORMATION
FEIN, ME or TR Number
A
PART 6: SELF-EMPLOY
Business Name/DBA
Business Address
Mailing Address (if different from above or Post Ofce Box number)
City State ZIP
City State ZIP
County of Business Location Primary Contact Number Secondary Contact Number Fax Number
Description of Business
Does the business engage in e-commerce? Business Web Site
Yes No
Is the business located at your primary residence? Is this business a state contractor? Does the business use a payroll service provider?
Yes No Yes No Yes No
Has business been located outside the U.S. for at least 6 months in the last 10 years? Does the business have any funds being held in trust by a third party?
Yes No Yes No
Is this business currently under bankruptcy court jurisdiction? Case number, if under bankruptcy court jurisdiction
Yes No
PART 7: ADDITIONAL INFORMATION REGARDING FINANCIAL CONDITION
Provide information on court proceedings, bankruptcies led or anticipated, transfers of assets for less than full value and changes in market conditions,
etc., that impact the nancial condition of the business. Include information regarding company participation in trusts, estates and prot sharing plans,
etc. Attach any copies of a DBA or Corporation lings as well as the most current Michigan Annual Report (MAR). Include your business name and
FEIN on all additional documents attached to this form.
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5183, Page 8
Social Security Number
PART 8: ASSET AND LIABILITY ANALYSIS
Attach the most current statement for each type of account, such as checking, savings, money market, online accounts, investment accounts, and life
insurance policies that have a cash value. Also, include statements of mortgages (including second mortgages), monthly payments, loan balances,
and accountant’s depreciation schedules, make/model/year of vehicles and current value of business assets. Asset value is subject to adjustment by
Treasury based on individual circumstances. Enter the total amount available for each of the following.
* Loan Balance: For certain items in Part 8, “Loan Balance” refers to an amount owed to pay back a loan.
BUSINESS CASH/BANK ACCOUNTS
Type of account
Checking Savings Money Market/CD Online Account Stored Value Card Cash on Hand
Financial Institution Name Account Number Account Balance/Value
Type of account
Checking Savings Money Market/CD Online Account Stored Value Card Cash on Hand
Financial Institution Name Account Number Account Balance/Value
If attaching a separate sheet listing additional bank accounts, record the total of those accounts here.
INVESTMENT ACCOUNTS
Type of account *Loan Balance
Stocks Bonds Other _____________________________
Financial Institution Name Account Number Current Market Value
Type of account *Loan Balance
Stocks Bonds Other _____________________________
Financial Institution Name Account Number Current Market Value
If attaching a separate sheet listing additional investment accounts, record the total of the current market value of those accounts here.
Do you have notes receivable?
Yes No
If yes, attach current listing which includes
BANK CREDIT
Do you have accounts receivable, including e-payment, factoring companies, and any bartering or online auction accounts?
Yes No
If yes, attach a list of names, age and amount of the account(s) receivable.
name, age & amount of note(s) receivable.
AVAILABLE (LINES OF CREDIT, ETC.)
Name of Institution Credit Limit Amount Owed Credit Available
Address City State ZIP Monthly Payments
Name of Institution Credit Limit Amount Owed Credit Available
Address City State ZIP Monthly Payments
Check here if listing additional bank credit on an attached document. The lines below must reect combined totals of ALL bank credits.
Total Credit Limit Total Amount Owed Total Credit Available Total Monthly Payments
Continue on Page 9
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Social Security Number
PART 8: ASSET AND LIABILITY ANALYSIS (CONTINUED)
CASH VALUE OF LIFE INSURANCE POLICIES
Name of Insured Title of Insured Insurance
Policy Number
Insurance
Type Face Amount Available Loan Value
Name of Insured Title of Insured
Policy Number Type Face Amount Available Loan Value
If attaching a separate sheet listing additional life insurance policies, record the combined balance of those policies here.
REAL ESTATE
Property Address City State ZIP
County Country Date Purchased Date of Final Payment
Description of Property Ownership (mortgage, land contract) Current Market Value *Loan Balance
Property Address City State ZIP
County Country Date Purchased Date of Final Payment
Description of Property Ownership (mortgage, land contract) Current Market Value *Loan Balance
If attaching a separate sheet listing additional real estate, record the combined current market value of that real estate here.
LOANS FROM THE BUSINESS TO PROPRIETOR, PARTNERS, OFFICERS, SHAREHOLDERS OR OTHERS
Name of Loan Recipient Relationship
Payoff Date Status Amount Due
Name of Loan Recipient Relationship
Payoff Date Status Amount Due
Name of Loan Recipient Relationship
Payoff Date Status Amount Due
If attaching a separate sheet listing additional loans from the business, record the combined amount due on those loans.
Continue on Page 10
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Social Security Number
PART 8: ASSET AND LIABILITY ANALYSIS (CONTINUED)
BUSINESS VEHICLES — Complete if owning or leasing a vehicle
Year Make License Number Vehicle ID Number Value Balance Owed
Year Make License Number Vehicle ID Number Value Balance Owed
If attaching a separate sheet listing additional motor vehicles, record the combined value of those motor vehicles here.
OTHER BUSINESS ASSETS
Enter information about other business assets, including machinery, equipment, liquor license, merchandise inventory and other assets. Be specic. If
more space than provided below is needed, attach a separate sheet listing additional assets. Include your business name and FEIN on all attachments.
Asset Current Market Value *Loan Balance
Asset Current Market Value *Loan Balance
Asset Current Market Value *Loan Balance
Asset Current Market Value *Loan Balance
Asset Current Market Value *Loan Balance
Asset Current Market Value *Loan Balance
PART 9: CERTIFICATION
Under penalty of perjury, I declare that I have examined this information, including accompanying documents, and to the best of my knowledge it is
true, correct, and complete.
Authorized Signature Date
Authorized Signer’s Name (Print or Type) Title/Position Telephone Number
Authorized Signature Date
Authorized Signer’s Name (Print or Type) Title/Position Telephone Number
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OIC Schedule 2A (Individuals) Collection Information Statement for (Michigan)

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Completed 28 May 2021

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