Form Cd-14a Collection Information Form - Georgia Department Of Revenue

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Georgia Department of Revenue
CD- 14A
Form
Collection Information Form
(March 2011)
Name(s) and Address
Your Social Security Number
Your Phone Number
Spouse's Social Security Number
Your Spouse's Phone Number
If address provided above is different than last return filed please check here.
Total number of dependents you will be claiming on this year's federal tax return……….
A. ACCOUNTS
(including Banking Institutions, Checking and Savings accounts, Credit Unions, Certificates of Deposit, Individual Retirement Accounts
(IRAs), Keogh Plans, Simplified Employee Pensions, 401(k) Plans, Profit Sharing Plans, Mutual Funds and Stock Brokerage Accounts)
Name and Address of Institution
Type of Account
Current Balance / Value
Total Accounts Balance/Value
(include amounts from any attachment s)
B. REAL ESTATE
(home, vacation property, timeshares and other real estate)
County/ Description
Monthly Payment(s)
Financing
Current Value
Balance Owed
Equity
Year Purchased
Purchase Price
$________
X
Year Refinanced
Refinance Amount
Personal Residence
Other
80%
Year Purchased
Purchase Price
$________
Year Refinanced
Refinance Amount
X
80%
Personal Residence
Other
Total Real Estate Equity
(include amounts from any attachments)
C. OTHER ASSETS
( cars, boats , recreational vehdicles, whole life policies, etc.)
Monthly
Year
Balance
Description
Final Payment (mo / yr)
Current Value
Equity
Payment
Purchased
Owed
Total Other Assets Equity
(include amounts from any attachments)
Page 1
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Form CD -14A

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