Financial and Other Information Statement

Document Number:  UCT-9906

Description:  This form is used to determine a compromise settlement offer from an employer or individual who owes unemployment insurance tax debt.  This form is completed by the employer or individual to list income, assets, liabilities and monthly expenses.

Comments:  This form is not fill enabled.  It can be printed and completed by hand.

Content Contact:  Shashank Partha

Document Attachment:  UCT-9906 (pdf/99 KB)

*** If you need to access this form in an alternate format, please send an email to the Content Contact listed above.

*** Should you require the necessary software to view the above attachment, please go to the DWD Viewers Download Page.  Links to each specific vendor's site have been provided for you.  Thank you.


Updated February 08, 2011