Form Cd 14C PDF Details

The Georgia Department of Revenue Form CD-14C, specifically designed for Collection Information, caters to wage earners and self-employed individuals grappling with personal income tax due on Form 500 and other specified tax liabilities. Created to streamline the process of gathering comprehensive financial data from individuals either employed or running their own business, this form serves as a critical instrument for those with personal responsibilities for excise, sales, withholding, or partnership liabilities, along with members of limited liability companies (LLCs) deemed disregarded entities. The structure of the form mandates complete sections based on employment status—wage earners filling out selected sections, while self-employed individuals are required to furnish details across all areas, underscoring the importance of thoroughness in providing personal, household, and business-related financial information. The introduction of sections dedicated to asset disclosures—spanning cash, investments, property, vehicles, and business assets—complements detailed income and expense records for both personal and business assessments. This comprehensive approach is designed to facilitate an accurate evaluation of an individual’s financial status, thereby aiding the Georgia Department of Revenue in making informed decisions regarding tax liabilities.

QuestionAnswer
Form NameForm Cd 14C
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesga earners self employed, cd 14c, cd 14b, georgia cd 14c

Form Preview Example

Georgia Department of Revenue

 

Form CD-14C

Collection Information Statement for

Wage Earners and

(June 2012)

Self-Employed Individuals

 

Use this form if you are

An individual who owes income tax on a Form 500, Georgia Individual Income Tax Return

An individual with a personal liability for an excise tax

An individual who is personally responsible for a sales tax or withholding tax liability

An individual who is personally responsible for a partnership liability

An individual member of a limited liability company (LLC) that is a disregarded entity

An individual who is self-employed or has self-employment income. You are considered to be self-employed if you are in business for yourself, or carry on a trade or business.

Wage earners Complete sections 1, 3, 6, and 7 including signature line on page 7.

Self-employed individuals Complete all sections and signature line on page 7

Note: Include attachments if additional space is needed to respond completely to any question.

Section 1

Last Name

Personal and Household Information

First Name

Date of Birth (mm/dd/yyyy)

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital status

Married Unmarried

Home Address (Street, City, State, ZIP Code)

Do you:

Own your home Rent

Other (specify e.g., share rent, live with relative, etc.)

County of Residence

 

 

 

Mailing Address (if different from above or Post Office Box number)

 

 

 

 

 

 

 

 

 

 

 

Primary Phone

 

Secondary Phone

 

 

 

 

 

 

 

(

)

-

(

)

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occupation

 

 

 

 

Employer's Address (Street, City, State, ZIP Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer's Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide information about your spouse.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse's Last Name

 

 

First Name

 

Date of Birth (mm/dd/yyyy)

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occupation

Employer's Address (Street, City, State, ZIP Code)

Employer's Name

Provide information for all other persons in the household or claimed as a dependent.

Name

Age

Relationship

Claimed as a dependent

Contributes to

on your Form 500?

household income?

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

 

 

 

 

 

 

Section 2

 

Self-employed Information

 

 

 

If you or your spouse is self-employed, complete this section.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is your business a sole proprietorship (filing Schedule C)?

Address of Business (If other than personal residence)

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Business

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Business Telephone Number

Employer Identification Number

Business Website

 

 

Trade Name or dba

(

 

)

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of Business

Total Number of Employees

Frequency of Tax Deposits

Average Gross Monthly

 

 

 

 

 

 

 

 

 

 

 

Payroll $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

www.dor.ga.gov

Form CD-14C (3-2012)

Page 2 of 7

Section 2

 

 

 

 

Self-employed Information - (Continued)

 

 

 

 

 

 

 

 

Do you or your spouse have any other business interests?

 

 

Business Address (Street, City, State, ZIP code)

 

 

Yes (Percentage of ownership:

)

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Business Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Business Telephone Number

Business Identification Number

 

 

 

(

)

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of business (Select one)

 

 

 

 

 

 

 

 

 

 

 

Partnership

 

Single member LLC

 

 

 

 

Corporation

 

Other

 

 

 

 

LLC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 3

 

 

 

 

 

 

Personal Asset Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If any total below results in a negative number, enter "0".

Cash and Investments (domestic and foreign)

Enter the total amount available for each of the following (if additional space is needed include attachments). Use 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, certificates of deposit), life insurance policies that have a cash value, and safe deposit boxes.

 

Bank Account:

Checking

Savings

Money Market

Online Account

Stored Value Card

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bank Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Account Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1a)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bank Account:

Checking

Savings

Money Market

Online Account

Stored Value Card

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bank Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Account Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1b)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total value of bank accounts from attachment

 

 

 

 

 

 

 

 

 

(1c)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Add lines (1a) through (1c) =

(1)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Investment Account:

 

 

 

Stocks

 

 

 

Bonds

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Financial Institution

 

 

 

 

 

 

 

 

 

Account Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Market Value

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Less Loan Balance

 

 

$

 

 

 

 

 

 

X .8 = $

 

 

 

 

 

– $

=

(2a)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Investment Account:

 

 

Stocks

 

 

 

Bonds

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Financial Institution

 

 

 

 

 

 

 

 

 

Account Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Market Value

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Less Loan Balance

(2b)

$

$

 

 

 

 

 

 

X .8 = $

 

 

 

 

 

– $

=

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total of investment accounts from attachment. [current market value X.8 less loan balance(s)]

(2c)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Add lines (2a) through (2c) =

(2)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Retirement Account:

 

 

401k

 

 

 

IRA

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Financial Institution

 

 

 

 

 

 

 

 

 

Account Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Market Value

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Less Loan Balance

 

 

$

 

 

 

 

 

 

X .7 = $

 

 

 

 

 

– $

=

(3a)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Retirement Account:

 

 

401k

 

 

 

IRA

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Financial Institution

 

 

 

 

 

 

 

 

 

Account Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Market Value

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Less Loan Balance

 

 

$

 

 

 

 

 

 

X .7 = $

 

 

 

 

 

– $

=

(3b)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total of investment accounts from attachment. [current market value X .7 less loan balance(s)]

(3c)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Add lines (3a) through (3c) =

(3)$

www.dor.ga.gov

Form CD-14C (3-2012)

Page 3 of 7

Section 3

 

 

 

 

 

 

Personal Asset Information - (Continued)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cash value of life insurance policies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Insurance Company

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Cash Value

 

 

 

 

 

 

 

 

 

 

 

Less Loan Balance

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

– $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

=

(4a)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total of life insurance policies from attachment.

 

 

 

Less Any Loan Balance(s)

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

– $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

=

(4b)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Add lines (4a) through (4b) =

(4)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Real Estate (Enter information about any house, condo, co-op, time share, etc. that you own or are buying)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Property Address (Street Address, City, State, ZIP Code)

 

 

 

 

 

 

 

Primary Residence

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

County and Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How is property titled? (joint tenancy, etc.)?

 

 

 

 

 

 

 

Description of Property

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Market Value

 

 

 

 

 

 

 

 

 

 

 

 

Less Loan Balance (Mortgages, etc.)

 

 

 

 

$

 

 

 

 

X .8 =

$

 

 

 

 

 

 

–

$

 

 

 

 

 

 

 

 

Total Value of Real Estate =

(5a)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Property Address (Street Address, City, State, ZIP Code)

 

 

 

 

 

 

 

Primary Residence

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

County and Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How is property titled? (joint tenancy, etc.)?

 

 

 

 

 

 

 

Description of Property

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Market Value

 

 

 

 

 

 

 

 

 

 

 

 

Less Loan Balance (Mortgages, etc.)

 

 

 

 

$

 

 

 

 

X .8 =

$

 

 

 

 

 

 

–

$

 

 

 

 

 

 

 

 

Total Value of Real Estate =

(5b)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Property Address (Street Address, City, State, ZIP Code)

 

 

 

 

 

 

 

Primary Residence

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

County and Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How is property titled? (joint tenancy, etc.)?

 

 

 

 

 

 

 

Description of Property

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Market Value

 

 

 

 

 

 

 

 

 

 

 

 

Less Loan Balance (Mortgages, etc.)

 

 

 

 

$

 

 

 

 

X .8 =

$

 

 

 

 

 

 

–

$

 

 

 

 

 

 

 

 

Total Value of Real Estate =

(5c)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total value of property(s) from attachment [current market value X .8

less any loan balance(s)]

 

 

(5d)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Add lines (5a) through (5d) =

(5)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicles (Enter information about any cars, boats, motorcycles, etc. that you own or lease)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle Make

 

 

Year

 

Model

 

Mileage

 

 

 

Lease

 

 

Monthly Lease/Loan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Loan

 

 

Amount $

 

 

 

 

Current Market Value

 

 

 

 

 

 

 

 

Less Loan Balance

 

 

 

 

 

 

 

 

 

 

$

 

 

X .8 = $

 

 

 

 

 

– $

 

 

 

 

 

 

 

 

Total value of vehicle (if the vehicle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

is leased, enter 0 as the total value) =

(6a)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle Make

 

 

Year

 

Model

 

Mileage

 

 

 

Lease

 

 

Monthly Lease/Loan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Loan

 

 

Amount $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Market Value

 

 

 

 

 

 

 

 

Less Loan Balance

 

 

 

 

 

 

 

 

 

 

$

 

 

X .8 = $

 

 

 

 

 

– $

 

 

 

 

 

 

 

 

Total value of vehicle (if the vehicle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

is leased, enter 0 as the total value) =

(6b)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle Make

 

 

Year

 

Model

 

Mileage

 

 

 

Lease

 

 

Monthly Lease/Loan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Loan

 

 

Amount $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Market Value

 

 

 

 

 

 

 

 

Less Loan Balance

 

 

 

 

 

 

 

 

 

 

$

 

 

X .8 = $

 

 

 

 

 

– $

 

 

 

 

 

 

 

 

Total value of vehicle (if the vehicle

(6c)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

is leased, enter 0 as the total value) =

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

www.dor.ga.gov

 

 

 

 

 

Form CD-14C (3-2012)

Page 4 of 7

Section 3

 

 

 

 

 

 

 

 

Personal Asset Information - (Continued)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total value of vehicles listed from attachment [current market value X .8 less any loan balance(s)]

(6d)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Add lines (6a) through (6d) =

(6)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other valuable items (artwork, collections, jewelry, items of value in safe deposit boxes, etc).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of asset:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Market Value

 

 

 

 

 

 

 

 

 

Less Loan Balance

 

 

$

 

 

 

 

 

 

 

 

 

X .8 = $

 

 

 

 

 

 

– $

=

(7a)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of asset:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Market Value

 

 

 

 

 

 

 

 

 

Less Loan Balance

 

 

$

 

 

 

 

 

 

 

 

 

X .8 = $

 

 

 

 

 

 

– $

=

(7b)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total value of valuable items listed from attachment [current market value X .8 less any loan balance(s)]

(7c)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Add lines (7a) through (7c) =

(7)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 4

 

 

 

 

 

 

Business Asset Information (for Self-Employed)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List business assets such as bank accounts, tools, books, machinery, equipment, business vehicles and real property that is

owned/leased/rented. If additional space is needed, attach a list of items.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bank Account:

 

 

Checking

 

 

 

 

Savings

 

 

Money Market

 

Online Account

 

Stored Value Card

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bank Name

 

 

 

 

 

 

 

 

 

 

Account Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(8a)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bank Account:

 

 

Checking

 

 

 

 

Savings

 

 

Money Market

 

Online Account

 

Stored Value Card

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bank Name

 

 

 

 

 

 

 

 

 

 

Account Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(8b)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total value of bank accounts from attachment

 

 

 

 

 

 

 

(8c)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Add lines (8a) through (8c) for total bank account(s) =

(8)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of asset:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Market Value

 

 

 

 

 

 

 

 

 

Less Loan Balance

 

 

$

 

 

 

 

 

 

 

 

 

X .8 = $

 

 

 

 

 

 

– $

=

(9a)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of asset:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Market Value

 

 

 

 

 

 

 

 

 

Less Loan Balance

 

 

$

 

 

 

 

 

 

 

 

 

X .8 = $

 

 

 

 

 

 

– $

=

(9b)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total value of assets listed from attachment [current market value X .8 less any loan balance(s)]

(9c)

$

Add lines (9a) through (9c) for tools, books, machinery, equipment, etc... that is owned/leased/rented =

(9)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes Receivable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have notes receivable?

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

If yes, attach current listing which includes name and amount of note(s) receivable.

 

 

 

 

 

 

(10)

$

 

 

 

 

 

 

 

 

 

 

 

Enter the total value of notes receivable from attached listing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do not include amount on the lines with a letter beside the number.

Box 1 Total Available Assets

Add lines (1) through line (10) and enter the amount in Box 1 = $

www.dor.ga.gov

Form CD-14C (3-2012)

Page 5 of 7

Section 5

Business Income and Expense Information (for Self-Employed)

 

 

Note: If you provide a current profit and loss (P&L) statement for the information below, enter the total gross monthly income on line 18 and your monthly expenses on line 29 below. Do not complete lines (13) - (17) and (19) - (29). You may use the amounts claimed for income and expenses on your most recent Schedule C; however, if the amount has changed significantly within the past year, a current P&L should be submitted to substantiate the claim.

Business Income (You may average 6-12 months income/receipts to determine your Gross monthly income/receipts.)

Gross receipts

 

(13)

$

 

 

 

 

Gross rental income

 

(14)

$

 

 

 

 

Interest income

 

(15)

$

 

 

 

 

Dividends

 

(16)

$

 

 

 

 

Other income

 

(17)

$

 

 

 

 

 

Gross Monthly Business Income - Add lines (13) through (17) =

(18)

$

 

 

 

Business Expenses (You may average 6-12 months expenses to determine your average expenses.)

 

 

 

 

 

Materials purchased (e.g., items directly related to the production of a product or service)

(19)

$

 

 

 

Inventory purchased (e.g., goods bought for resale)

(20)

$

 

 

 

 

Gross wages and salaries

 

(21)

$

 

 

 

 

Rent

 

(22)

$

 

 

 

Supplies (items used to conduct business and used up within one year, e.g., books, office supplies, professional equipment,

(23)

$

etc.)

 

 

 

 

 

Utilities/telephones

 

(24)

$

 

 

 

 

Vehicle costs (gas, oil, repairs, maintenance)

 

(25)

$

 

 

 

 

Business Insurance

 

(26)

$

 

 

 

 

Current Business Taxes (e.g., Real estate,

excise, franchise, occupational, personal property, sales and employer's portion

(27)

$

of employment taxes)

 

 

 

 

 

Other secured debts (not credit cards)

 

(28)

$

 

 

 

 

Other business expenses (include a list)

 

(29)

$

 

 

 

 

 

Total Monthly Business Expenses - Add lines (19) through (29) =

(30)

$

 

 

 

 

 

Box 2 Net Business Income

Subtract line (30) from line (18) and enter the amount in Box 2 =

$

 

 

 

 

 

Section 6

Monthly Household Income and Expense Information

 

 

 

 

 

 

Enter your household's gross monthly income. The information below is for yourself, your spouse, and anyone else who contributes to your household's income. The entire household includes spouse, significant other, children, and others who contribute to the household. This is necessary for the GA DOR to accurately evaluate your offer.

Monthly household income

Primary taxpayer

 

 

 

 

 

 

 

 

 

 

 

 

Wages

Social Security

Pension(s)

 

Total primary taxpayer

 

 

$

 

 

 

+ $

 

 

 

+ $

 

 

=

 

 

 

 

 

 

 

 

 

 

income

(31)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse/Other contributors to the household

 

 

 

 

 

 

 

 

Wages

Social Security

Pension(s)

 

Total spouse/other

 

 

$

 

 

+ $

 

 

+ $

 

=

(32)

$

 

 

 

 

 

contributors income

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Interest and dividends

 

 

 

 

 

 

 

 

 

 

(33)

$

 

 

 

 

 

Distributions (such as, income from partnerships, sub-S Corporations, etc.)

 

 

(34)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

Net rental income

 

 

 

 

 

 

 

 

 

 

(35)

$

 

 

 

 

 

 

 

 

 

Net business income from Box 2

 

 

 

 

 

 

(36)

$

 

 

 

 

 

 

 

 

 

Child support received by the household

 

 

 

 

 

 

(37)

$

 

 

 

 

 

 

 

 

 

Alimony received by the household

 

 

 

 

 

 

(38)

$

 

 

 

 

 

 

 

 

 

Additional household income

 

 

 

 

 

 

(39)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Box 3 Total Household Income

 

 

 

 

 

 

Add lines (31) through (39) and enter the amount in Box 3 =

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

www.dor.ga.gov

Form CD-14C (3-2012)

Page 6 of 7

Section 6Monthly Household Income and Expense Information

Monthly Household Expenses

Enter your average monthly expenses. Note: Expenses may be adjusted based on IRS Collection Financial Standards.

Food, clothing, and miscellaneous (e.g., housekeeping supplies, personal care products). A reasonable estimate of

(41)

$

these expenses may be used.

 

 

 

 

Housing and utilities (e.g., rent or mortgage payment and average monthly cost of property taxes, home insurance,

 

 

maintenance, dues, fees and utilities including electricity, gas, other fuels, trash collection, water, cable, telephone, and cell

(42)

$

phone).

 

 

 

 

 

Vehicle loan and/or lease payment(s)

 

(43)

$

 

 

 

Vehicle operating costs (e.g., average monthly cost of maintenance, repairs, insurance, fuel, registrations, licenses,

(44)

$

inspections, parking, tolls, etc.). A reasonable estimate of these expenses may be used.

 

 

 

Public transportation costs (e.g., average monthly cost of fares for mass transit such as bus, train, ferry, taxi, etc.). A

(45)

$

reasonable estimate of these expenses may be used.

 

 

 

 

Health insurance premiums

 

(46)

$

 

 

 

Out-of-pocket heath care costs (e.g. average monthly cost of prescription drugs, medical services, and medical supplies like

(47)

$

eyeglasses, hearing aids, etc.)

 

 

 

 

Court-ordered payments (e.g., monthly cost of any alimony, child support, etc.)

(48)

$

 

 

 

Child/dependent care payments (e.g., daycare, etc.)

(49)

$

 

 

 

 

Life insurance premiums

 

(50)

$

 

 

 

Taxes (e.g., monthly cost of federal, state, and local tax, personal property tax, etc.)

(51)

$

 

 

 

Other secured debts (e.g., any loan where you pledged an asset as collateral not previously listed). Do not include

 

 

unsecured debt such as credit cards.

 

(52)

$

 

 

 

 

 

Box 4 Household Expenses

 

Add lines (41) through (52) and enter the amount in Box 4 =

$

 

 

 

 

 

 

Box 5 Remaining Monthly Income

 

Subtract Box 4 from Box 3 and enter the amount in Box 5 =

$

 

 

 

 

 

Section 7

Calculate Your Minimum Offer Amount

 

 

 

 

 

 

The next steps calculate your minimum offer amount. The amount of time you take to pay your offer in full will affect your minimum offer amount. Paying over a shorter period of time will result in a smaller minimum offer amount.

If you will pay your offer within 60 days from written acceptance of the offer (Payment Option 1), multiply "Remaining Monthly Income" (Box 5) by 48 to get "Future Remaining Income" (Box 6).

Enter the total from Box 5 here

$

X 48 =

Box 6 Future Remaining Income

$

If you will pay your offer in more than 60 days and in less than or equal to 60 months and pay in monthly installments (Payment Option 2), multiply "Remaining Monthly Income" (Box 5) by 60 to get "Future Remaining Income" (Box 7).

Enter the total from Box 5 here

$

X 60 =

Box 7 Future Remaining Income

$

Determine your minimum offer amount by adding the total available assets from Box 1 to amount in either Box 6 or Box 7.

Enter the amount from Box 1 here

$

+

Enter the amount from either Box 6 or Box 7

$

=

Minimum Offer Amount

Must be more than zero

$

If you have special circumstances that would hinder you from paying this amount, explain them on Form OIC-1 (Offer in Compromise) page 2, section 3 ("Explanation of Circumstances").

www.dor.ga.gov

Form CD-14C (3-2012)

Page 7 of 7

Section 7

Additional information GA DOR needs to consider settlement of your tax debt. If you or your business are currently in a bankruptcy proceeding, you are not eligible to apply for an offer.

Other Information

Are you the beneficiary of a trust, estate, or life insurance policy?

Yes

No

 

 

 

 

 

Are you currently in bankruptcy?

Have you filed bankruptcy in the past 10 years?

 

Yes

No

Yes

No

 

 

 

Discharge/Dismissal Date (mm/dd/yyyy)

County Filed

 

 

 

 

 

Have you been party to a lawsuit?

Yes No

If yes, date the lawsuit was resolved: (mm/dd/yyyy)

In the past 10 years, have you transferred any assets for less than their full value?

Yes No

Have you lived outside the U.S. for 6 months or longer in the past 10 years?

Yes No

Do you have any funds being held in trust by a third party?

Yes

No If yes, how much $

Where:

Section 8

Signatures

 

 

Under penalties of perjury, I declare that I have examined this offer, including accompanying documents, and to the best of my knowledge it is true, correct, and complete.

Signature of Taxpayer

Date (mm/dd/yyyy)

Signature of Taxpayer

Date (mm/dd/yyyy)

Remember to include all applicable attachments listed below.

Copies of the most recent pay stub, earnings statement, etc., from each employer

Copies of bank statements for the three most recent months

Copies of the most recent statement, etc., from all other sources of income such as pensions, Social Security, rental income, interest and dividends, court order for child support, alimony, and rent subsidies

Copies of the most recent statement for each investment and retirement account

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

List of Notes Receivable, if applicable

Accountant's depreciation schedules, if applicable

Documentation to support any special circumstances described in section 3 "Explaintion of Circumstances" on page 2 of Form OIC-1, if applicable

Attach a Form RD-1061, Power of Attorney, if you would like your attorney, CPA, or other party to represent you and you do not have a current form on file with the GA DOR.

www.dor.ga.gov

Form CD-14C (3-2012)

How to Edit Form Cd 14C Online for Free

When using the online tool for PDF editing by FormsPal, you can fill out or alter ga cd14c right here and now. To make our editor better and easier to work with, we continuously come up with new features, taking into account feedback from our users. All it requires is just a few easy steps:

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With regards to the blank fields of this specific PDF, this is what you should consider:

1. Start completing your ga cd14c with a selection of essential blanks. Collect all the important information and make sure not a single thing forgotten!

How one can complete cd 14b form part 1

2. Once your current task is complete, take the next step – fill out all of these fields - Name, Age, Relationship, Claimed as a dependent, Contributes to, on your Form, household income, Yes, Yes, Yes, Yes, Yes, Yes, Yes, and Yes with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Yes, on your Form, and Yes in cd 14b form

3. This third part is straightforward - fill in all the blanks in Section Do you or your spouse, Yes Percentage of ownership, Business Address Street City State, Business Name, Business Telephone Number Type of, Business Identification Number, Partnership, Single member LLC, LLC, Corporation, Other, Section, Personal Asset Information, If any total below results in a, and Cash and Investments domestic and in order to complete this part.

Section, If any total below results in a, and Personal Asset Information in cd 14b form

Be extremely careful while filling out Section and If any total below results in a, as this is where a lot of people make mistakes.

4. This specific section arrives with the next few blanks to complete: Account Number, Bank Account Bank Name, Total value of bank accounts from, Investment Account Name of, Stocks Bonds Other, Account Number, Current Market Value, Less Loan Balance, Add lines a through c, Investment Account Name of, Stocks, Bonds, Other, Account Number, and Current Market Value.

Tips to complete cd 14b form portion 4

5. As a final point, the following last section is precisely what you'll have to finish prior to finalizing the document. The fields under consideration are the next: Retirement Account Name of, IRA, Other, Account Number, Current Market Value, Less Loan Balance, Total of investment accounts from, wwwdorgagov, Form CDC, and Add lines a through c.

cd 14b form writing process clarified (stage 5)

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