Dtf 5 Form PDF Details

If you're looking for a way to keep track of your sexual encounters, the Dtf 5 Form is perfect for you! This easy-to-use form will help you keep track of who you've slept with, when you did it, and other important information. Plus, it's great for keeping things organized! Whether you're single or in a relationship, the Dtf 5 Form can help make sure that your sex life stays safe and healthy.

The listing has got information about the dtf 5 form. It's really worth taking the time to study this prior to starting submitting your document.

QuestionAnswer
Form NameDtf 5 Form
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other namesdtf 5, dtf 5 ny, dtf forms form, nys dtf 5

Form Preview Example

Department of Taxation and Finance

DTF-5

 

Statement of Financial Condition

(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

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 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? (filed federal schedules C, E, F, etc.)

Yes

  If Yes, enter details on page 5.

 

No

All other persons in your household or claimed as dependents

Name

Age

Relationship

Social

Can be claimed as

Contributes to

Security number

a dependent?

household income?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

 

 

 

Yes

No

Yes

No

 

 

 

 

Yes

No

Yes

No

 

 

 

 

Yes

No

Yes

No

 

 

 

 

Yes

No

Yes

No

Taxpayer’s representative information

I have no representative

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 10DTF-5 (8/18)

AssetsAs 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)

(A)

$

Bank accounts (domestic and foreign)

 

 

Not applicable

 

 

 

 

Name of financial institution

Type*

Account number

Balance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* Type may include: checking, savings,

Box (B) – Total balance (also enter on page 7, line 2)

money market, stored value cards, etc.

(B)

$

Do you rent a safe deposit box in your name, or in any other name?

Yes

  If Yes, give name and address of bank:

 

No

Brokerage accounts

 

 

 

 

Not applicable

 

 

 

 

 

 

Institution or brokerage name

Type*

Account number

Market value

Less:

Net value

Loans, if any

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* Type may include: stocks, bonds, other

Box (C) – Total net value (also enter on page 7, line 3)

investments, etc.

(C)

$

Retirement accounts

 

 

 

 

Not applicable

 

 

 

 

 

 

Institution or custodian name

Type*

Account number

Market value

Less:

Net value

Loans, if any

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* Type may include: 401K, IRA, pension,

Box (D) – Total net value (also enter on page 7, line 4)

profit sharing, etc.

(D)

$

Cash value of life insurance policies

 

 

 

 

Not applicable

 

 

 

 

 

 

 

Institution company name

 

Type*

Policy number

Cash value

Less:

Net value

 

Loans, if any

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* Type may include: term, whole life, etc.

Box (E) – Total net cash value (also enter on page 7, line 5)

(E)

$

Attach additional sheets if necessary.

 

 

 

 

 

 

DTF-5 (8/18)  Page 3 of 10

 

 

 

 

 

 

 

 

Assets (continued)As of

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accounts receivable

 

 

 

 

 

 

Not applicable

 

 

 

 

 

 

 

 

Name and address

 

Date recorded

Book value

Less:

Date pledged,

Net value

 

Loans, if any

if applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Box (F) – Total net value (also enter on page 7, line 6)

(F)

$

Inventory

 

 

 

 

Not applicable

 

 

 

 

 

 

Detailed description

Date recorded

Book value

Less:

Date pledged,

Net value

Loans, if any

if applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Box (G) – Total net value (also enter on page 7, line 7)

(G)

$

Notes receivable

 

 

 

 

Not applicable

 

 

 

 

 

 

Name and address

Date recorded

Book value

Less:

Date pledged,

Net value

Loans, if any

if applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Box (H) – Total net value (also enter on page 7, line 8)

(H)

$

Valuable items, machinery, and equipment

Not applicable

(List any artwork, collections, jewelry, items in safe deposit boxes, tools, furniture, fixtures, etc. that you own fully or partially)

Description

Fair market value

Loan balance, if any

Box (I) – Total fair market value (enter Asset on page 7, line 9)

(I)

$

Box (J) – Total loan balance, if any (enter Liability on page 7, line 18)

(J)

$

Attach additional sheets if necessary.

Page 4 of 10DTF-5 (8/18)

Assets (continued)As of

Date

Real estate

Not applicable

(List any house, condo, co-op, timeshare, land, commercial property, etc. that you own fully or partially, located inside and outside of the country)

Complete address

 

Description*

Owners

Current fair

Mortgage balance,

Unpaid property

 

market value

if any

 

taxes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Box (K) – Total fair market value (enter Asset on page 7, line 10)

(K)

 

 

 

$

 

 

 

Box (L) – Total mortgage balance (enter Liability on page 7, line 19)

(L)

 

 

$

 

 

* Description may include: primary residence,

 

 

 

 

(M)

vacation home, rental property, etc.

 

Box (M) – Total unpaid property taxes (enter Liability on page 7, line 20)

$

 

Foreclosure proceedings:

 

 

 

 

 

 

Not applicable

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

 

 

 

 

 

Vehicles  (List any cars, boats, motorcycles, trucks, aircraft, etc. that you own)

 

Not applicable

 

 

 

 

 

 

 

 

 

Year, make, and model

 

Plate number or

Mileage

Owners

Fair market value

Loan balance

 

Reg. number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Box (N) – Total fair market value (enter Asset on page 7, line 11)

(N)

$

Box (O) – Total loan balance (enter Liability on page 7, line 21)

(O)

$

Leased vehicles  (List any cars, boats, motorcycles, trucks, aircraft, etc. that you lease)

Not applicable

Year, make, and model

Plate number or

Reg. number

Mileage

Lessee name(s)

Date of lease

Term of lease

Attach additional sheets if necessary.

 

 

 

 

DTF-5 (8/18) 

Page 5 of 10

 

 

 

 

 

 

 

Assets (continued)As of

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

Interest in trust or estate

 

 

Not applicable

Are you the grantor, donor, or trustee for any trust?

 

 

Yes

No

Are you the beneficiary 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.

 

 

 

 

 

 

 

Name of trust or estate

Annual income you received

Present value of trust or

Value of your

from this source

estate

interest

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Box (P) – Total value of your interest (enter Assets on page 7, line 12)

$

(P)

 

 

 

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:

filed federal schedules C, E, F, and other federal business forms filed 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 filed federal Form 1120, U.S. Corporation Income Tax Return, in the preceding 3 years.

Business name

Employer

identification number

Type of

business*

Ownership percentage

Annual cash contributed**

Annual cash

received**

Value of your investment***

Box (Q) – Total value of your investments (enter Assets on page 7, line 13)

(Q)

$

*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.

Contingent claims or legal actions

Not applicable

(Potentially receivable or collectable, such as pending insurance claims, settlements, etc.)

Name of payer(s)

Date you expect to

receive funds

Dollar amount

Box (R) – Total dollar amount (enter Assets on page 7, line 14)

(R)

$

Increase in value

What is the prospect of an increase in value of any of your assets and your present income? Provide a detailed explanation.

Attach additional sheets if necessary.

Page 6 of 10DTF-5 (8/18)

Disposal of assets

Not applicable

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

Relationship of transferee

Date of transfer

Fair market value

Dollar amount you

when transferred

received

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

JudgmentsAs ofNot applicable Date

Name of creditor(s)

Date recorded

Where recorded

Dollar amount of

judgment filed

Current balance due on judgment

Box (S) – Total balance due on judgments (enter Liability on page 7, line 22)

(S)

$

Bankruptcy

Not applicable

Are bankruptcy or receivership proceedings pending?

Yes

If a corporation or other business, is it in the process of liquidation?

Yes

No No

Unlawful activities

Not applicable

Is the liability you are trying to compromise related to a crime for which you pleaded or were found guilty?

Yes

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

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

If Yes to any of the above, provide details:

No

No

No

Attach additional sheets if necessary.

 

 

DTF-5 (8/18)  Page 7 of 10

 

 

 

Statement of assets and liabilities  As of

Date

pages 2 through 6)

 

 

Values (from

 

 

 

Assets

 

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)

Total assets

$

Liabilities

Amount

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)

Total liabilities

$

Attach additional sheets if necessary.

Page 8 of 10DTF-5 (8/18)

Household income and expenses – individual

Enter your household’s gross monthly income, including income from you, your spouse, significant other, children, and others who contribute to the household.

Monthly gross receipts or income

Name of source

 

Amount

 

 

 

 

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total monthly household income:

$

 

Monthly expenses

To whom paid

 

Amount

(and relationship)

 

 

 

 

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:

$

 

*  You may provide reasonable estimates for certain income and expenses on an average monthly basis.

 

Attach additional sheets if necessary.

DTF-5 (8/18)  Page 9 of 10

Income and expenses – business

If this proposal is from a business, enter the information below for the last two calendar (fiscal) 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.

 

 

 

 

 

 

 

Most recent interim period

Gross receipts or income

Year before last

Last year

 

(year-to-date)

20 

 

 

20 

 

 

 

 

 , 20 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gross sales or receipts (net of returns and allowances)

 

 

 

 

 

 

 

 

 

 

 

Less: Cost of goods sold

 

 

 

 

 

 

 

 

 

 

 

Gross profit

 

 

 

 

 

 

 

 

 

 

 

Dividend income

 

 

 

 

 

 

 

 

 

 

 

Interest income

 

 

 

 

 

 

 

 

 

 

 

Gross rents

 

 

 

 

 

 

 

 

 

 

 

Gross royalties

 

 

 

 

 

 

 

 

 

 

 

Ordinary income (loss) from partnerships, estates and trusts, if applicable

 

 

 

 

 

 

 

 

 

 

 

Net farm profit (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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total income

$

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

Most recent interim period

Deductions

Year before last

Last year

 

(year-to-date)

20 

 

 

20 

 

 

 

 

 , 20 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Compensation of officers

 

 

 

 

 

 

 

 

 

 

 

Guaranteed payments to partners

 

 

 

 

 

 

 

 

 

 

 

Salaries and wages (not deducted elsewhere)

 

 

 

 

 

 

 

 

 

 

 

Pension, profit-sharing, retirement plans, etc.

 

 

 

 

 

 

 

 

 

 

 

Employee benefit 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 deductions

$

 

 

$

 

 

$

 

 

 

Total capital contributed by shareholders, partners, or owners

 

 

 

 

 

 

 

 

 

 

 

of the business

$

 

 

$

 

 

$

 

 

 

Total distributions or dividends paid to shareholders, partners, or

 

 

 

 

 

 

 

 

 

 

 

owners of the business

$

 

 

$

 

 

$

 

 

 

Annual benefit paid to principal officers and owners – Enter the total annual benefit paid to each of the principal officers and owners of the business. Annual benefit 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attach additional sheets if necessary.

Page 10 of 10DTF-5 (8/18)

Attachments

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.

You must attach:

1. Federal returns for the preceding three years, with all schedules and statements attached. If you were not required to file, 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).

You must attach, if applicable:

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 five 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-profit organization, professional corp, etc.): We may request the audited, reviewed, or company-prepared financial statements for the preceding three years. In addition, we may request an Accounts Receivable Aging Report for any business.

Declaration

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 financial 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.

Taxpayer’s signature(s)

Date

Attach additional sheets if necessary.

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