Form Ro-1063 - Collection Information Statement For Businesses
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4Form RO-1063
N.C. Department of Revenue
(4-90)
Collection Information Statement for Businesses
(If you need additional space, please attach a separate sheet)
(
)
1. Name and address of business
2. Business phone number
3. (Check appropriate box)
Sole proprietor
Other (specify)
Partnership
Corporation
County
4. Name and title of person being interviewed
5. Employer Identification
6. Type of business
Number
7. Information about owner, partners, officers, major shareholder, etc.
Total
Name and Title
Effective
Home Address
Phone
Social Security
Shares or
Date
Number
Number
Interest
Section I.
General Financial Information
Form
Tax Year ended
Net income before taxes
8. Latest filed income tax return
9. Bank accounts (List all types of accounts including payroll and general, savings, certificates of deposit, etc.)
Name of Institution
Address
Type of Account
Account Number
Balance
Total
( Enter in Item 17)
10. Bank credit available (Lines of credit, etc. )
Credit
Amount
Credit
Monthly
Name of Institution
Address
Limit
Owed
Available Payments
Totals
(Enter in Items 24 or 25 as appropriate)
11. Location, box number, and contents of all safe deposit boxes rented or accessed
Page 1
Form RO-1063 (4-90)
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Parent category: Financial