Form Ro-1063 - Collection Information Statement For Businesses Page 3
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1
2
3
4Asset and Liability Analysis
Section II.
Description
Cur. Mkt.
Liabilities
Equity in
Amt. Of
Name and Address of
Date
Date of
Value
Bal. Due
Asset
Mo. Pymt
Lien / Note Holder / Obligee
Pledged
Final Pymt.
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
16. Cash on hand
17. Bank accounts
18. Accounts / Notes
receivable
19. Life insurance
loan value
a.
b.
20. Real
property
c.
(from
Item 12)
d.
a.
21. Vehicles
b.
(Model,
year, and
c.
license)
a.
22. Machin-
b.
ery and
equip-
c.
ment
(specify)
a.
23. Mer-
chandise
b.
inventory
(specify)
a.
24. Other
b.
Assets
(specify)
a.
b.
25. Other
c.
liabili-
ties
d.
(Include
notes
e.
and
judg-
f.
ments
g.
h.
26. State taxes owed
Total
27.
Page 3
Form RO-1063 (4-90)
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