Form Ador 10896 - Collection Information Statement (Personal)

Download a blank fillable Form Ador 10896 - Collection Information Statement (Personal) in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Ador 10896 - Collection Information Statement (Personal) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Acrobat Reader 8 and 9 users: You may fill in and save this form with the data. Once you save the form, you cannot edit your data.
COLLECTION INFORMATION STATEMENT (PERSONAL)
• Complete all entry spaces with the most current data available.
• Important! Write “N/A” (not applicable) in spaces that do not apply. We may
ARIZONA DEPARTMENT OF REVENUE
require additional information to support “N/A” entries.
1600 West Monroe
• Failure to complete all entry spaces may result in rejection or signifi cant delay in the
Phoenix, AZ 85007
(602) 542-5551
resolution of your account.
YELLOW fields are Read-Only. You cannot enter data in yellow fields; they are calculated as you fill in the form.
Section 1
1a Your Full Name
1b Your Social Security No.
1c Your Date of Birth
MM/DD/YYYY
Personal
1d Spouse’s Full Name
1e Spouse’s Social Security No.
1f Spouse’s Date of Birth
Information
MM/DD/YYYY
2 Marital Status (check one box):
3 Check one box:
Married
Separated
Own Home
Rent
Unmarried (single, divorced, widowed)
Other (specify, i.e. share rent, live with relative):
4a Street Address
4b City
State
ZIP Code
4c County of Residence
4d How long at this address?
5 Home Phone (with area code)
6
List the dependents you can claim on your tax return (attach sheet if more space is needed):
Does this person
Does this person
First Name
Relationship
Age
live with you?
First Name
Relationship
Age
live with you?
Check this box
No
Yes
No
Yes
when all spaces in
No
Yes
No
Yes
Section 1 are fi lled in
Section 2
7
Are you or your spouse self-employed or operate a business? Check “Yes” if either applies.
No
Yes (If “Yes”, provide the following information)
Your
7a
Name of Business
7d
Employer I.D. No.
Business
7b
Street Address
7e
Do you have employees?
No
Yes
Information
7c
City, State, Zip
Check this box
ATTACHMENTS REQUIRED: You must complete a Collection Information Statement for Businesses,
when all spaces in
ADOR 20-1020.
Section 2 are fi lled in
Section 3
8a
Your Employer
9a
Spouse’s Employer
8b
Street Address
9b
Street Address
Employment
8c
City, State, Zip
9c
City, State, Zip
Information
8d
Work Phone (with area code)
9d
Work Phone: (with area code)
8e
How long with this employer?
9e
How long with this employer?
8f
Occupation
9f
Occupation
ATTACHMENTS REQUIRED: Please include proof of gross earnings and deductions for the past 3 months from
Check this box
each employer (e.g., pay stubs, earnings statements). If year-to-date information is available, send only 1 such
when all spaces in
statement as long as a minimum of 3 months is represented.
Section 3 are fi lled in
Section 4
10
Do you receive income from sources other than your own business or your employer? Check all that apply:
Pension
Social Security
Other (Specify, i.e. child support, alimony, rental)
Other
Income
ATTACHMENTS REQUIRED: Please include proof of pension/social security/other income for the past 3 months
Information
from each payor including any statements showing deductions. If year-to-date information is available, send only
1 such statement as long as a minimum of 3 months is represented.
Section 5
11
CHECKING ACCOUNTS. List all checking accounts. (If you need additional space, attach a separate sheet.)
Type of
Full Name of Bank, Savings & Loan,
Bank
Bank
Current
Banking,
Account
Credit Union or Financial Institution
Routing No.
Account No.
Account Balance
Investment,
11a Checking
Name
$
Cash, etc.
Street Address
City, State, Zip
Check this box
when all spaces in
11b Checking
Name
$
Sections 4 and 5,
Street Address
lines 11 thru 11c, are
fi lled in and attach-
City, State, Zip
ments are provided
11c Total Checking Account Balances ............................................................................................................ 11c $ ______________
ADOR 10896 (10/10)
Section 5 continues on page 2
Previous ADOR 20-1070

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go
Page of 5