Form Ador 10896 - Collection Information Statement (Personal) Page 2
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5Arizona Department of Revenue
Collection Information Statement (Personal)
Name
SSN
Section 5
12 OTHER ACCOUNTS. List all accounts including brokerage accounts, savings and money market accounts not listed on line 11.
Type of
Full Name of Bank, Savings & Loan,
Bank
Bank
Current
continued
Account
Credit Union or Financial Institution
Routing No.
Account No.
Account Balance
Banking,
12a
Investment,
Name of Institution
$
Cash, Credit,
Street Address
and Life
City, State, Zip
Insurance
12b
Information
Name of Institution
$
Street Address
City, State, Zip
Complete all
You must calculate and enter line 12c amount.
12c Subtotal from supplemental page ................................................................................................................. 12c $
entry spaces
12d Total Other Account Balances ................................................................................................................... 12d $
with the most
current data
ATTACHMENTS REQUIRED: Please include your current bank statements (checking, savings, money market, and
available.
brokerage accounts) for the past three months for all accounts.
Supplement
13
INVESTMENTS. List all investment assets below. Include stocks, bonds, mutual funds, stock options, certifi cates of deposits,
and retirement assets such as IRAs, Keogh, and 401(k) plans. (If you need additional space, attach supplemental page.)
Current Value:
Number of
Current
Used as collateral
Loan
Net Value
Indicate the
Company Name
Shares/Units
Value
(a)
on loan?
Amount
(b)
(a - b)
amount you could
13a
$
No
Yes $
$
sell the asset for
13b
$
No
Yes $
$
today.
You must calculate and enter line 13c amount.
13c Subtotal from supplemental page ................................................................................................................. 13c $
13d Total Net Investments ................................................................................................................................. 13d $
14 CASH ON HAND. Enter the total of any cash you have that is not currently in a bank .............................. 14 $
15 AVAILABLE CREDIT. List all lines of credit, including credit cards. (If you need additional space, attach supplemental page.)
Full Name of Credit Institution
Credit Limit
Amount Owed
Available Credit
15a Name
$
$
$
Street Address
City, State, Zip
15b Name
$
$
$
Street Address
City, State, Zip
You must calculate and enter line 15c amount.
15c Subtotal from supplemental page ................................................................................................................. 15c $
15d Total Credit Available .................................................................................................................................. 15d $
16
LIFE INSURANCE. Do you have life insurance with a cash value? .....................................................................
No
Yes
You must click the Yes checkbox to enter insurance information.
(Term life insurance does not have a cash value.) If “Yes”:
16a Name of Insurance Company:
16b Policy Number(s):
Check this box
16c Owner of Policy:
when all spaces in
Section 5 are fi lled
16d Current Cash Value .................................................................................................... 16d $
in and attachments
16e Outstanding Loan Balance ......................................................................................... 16e $
are provided
16f Total Cash Value: Subtract line 16e from line 16d; enter the difference .................................................... 16f $
ATTACHMENTS REQUIRED: Please include a statement from the life insurance companies that includes type and
cash/loan value amounts. If currently borrowed against, include loan amount and date of loan.
Section 6
You must click the Yes checkbox to enter detailed information.
17
Do you owe any federal taxes? ..............................................................................................................................
No
Yes
Federal and
If “Yes”, how much? $_____________________
Amount of payment: $_____________________
Other Taxes
17a Do you owe any other government agency? ..........................................................................................................
No
Yes
Owed
If “Yes”, who?
How much is owed? $_____________________
Amount of payment: $_____________________
Section 7
18
OTHER INFORMATION. Respond to the following questions related to your fi nancial condition. (Attach a sheet if
You must click the Yes checkbox to enter detailed information.
you need more space).
Other
18a Are there any garnishments against your wages? .................................................................................................
No
Yes
Information
MM/DD/YY
If yes, who is the creditor? ____________________________ Date creditor obtained judgement: ______________
Amount of debt $_________________
Check this box
18b Are there any judgments against you? ...................................................................................................................
No
Yes
when all spaces in
MM/DD/YY
Sections 6 and 7
If yes, who is the creditor? ____________________________ Date creditor obtained judgement: ______________
are fi lled in
Amount of debt $_________________
ADOR 10896 (10/10)
Page 2 of 4
Section 7 continues on page 3
Previous ADOR 20-1070
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Parent category: Financial