Form Ador 10896 - Collection Information Statement (Personal) Page 4
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5Some fields on this page are Read-Only. You cannot enter data in these fields; they are calculated as you fill in the form.
Arizona Department of Revenue
Collection Information Statement (Personal)
Name
SSN
Total Monthly Income
Total Monthly Expenses
Section 9
Source
Gross
Net
Expense Items
Actual
DOR Use
Monthly
22 Wages (Yourself)
$
$
33 Rent/Mortgage
$
Income and
23 Wages (Spouse)
34 Groceries (no. of people
)
Expense
24 Interest - Dividends
35 Installment Payments
Analysis
25 Net Income from Business
36 Utilities:
26 Net Rental Income
36a Gas
$
27 Pension/Social Security (Yourself)
36b Water
$
If only one
28 Pension/Social Security (Spouse)
36c Electric
$
spouse has a
29 Child Support
36d Phone
$
tax liability, but
30 Alimony
36e Total Utilities Expense
both have
31 Other Income
37 Transportation
income, list the
38 Insurance:
total household
32 TOTAL INCOME
$
$
38a Life
$
income and
38b Health
$
expenses.
38c Car
$
38d Total Insurance Expense
39 Medical expenses
40 Estimated tax payments
41 Court-ordered/Child support payment
42 Child/Dependent care
43 Other Expenses
44
TOTAL LIVING EXPENSES $
0
45 NET DIFFERENCE: Subtract Total Living Expenses (line 44) from Total Net Income (line 32). . . . . . . . $
Wages, salaries, pensions, and social security: Enter your gross monthly wages and/or salaries. Enter your net income and
deduct withholding or allotments you elect to take out of your pay, such as insurance payments, credit union deductions, car payments,
etc. To calculate your gross monthly wages and/or salaries:
• If paid weekly: Multiply weekly gross wages by 4.3. Example: $425.89 x 4.3 = $1,831.33
• If paid bi-weekly (every 2 weeks): Multiply bi-weekly gross wages by 2.17. Example: $972.45 x 2.17 = $2,110.22
• If paid semi-monthly (twice each month): Multiply semi-monthly gross wages by 2. Example: $856.23 x 2 = $1,712.46
Net Income from Business: Enter your monthly net business income. This is the amount you earn after you pay ordinary and
necessary monthly business expenses. If your net business income is a loss, enter “0”. Do not enter a negative number.
Net Rental Income: Enter your monthly net rental income. This is the amount you earn after you pay ordinary and necessary monthly
rental expenses. If your net rental income is a loss, enter “0”. Do not enter a negative number.
Rent/Mortgage: For your principal residence: Total of rent or mortgage payment. Add the average monthly expenses for the
following: property taxes, homeowner’s or renter’s insurance, maintenance, dues, and fees.
Groceries: Total of food expenses for one month.
Transportation: Total of lease or purchase payments, registration fees, normal maintenance, fuel, public transportation, parking and
tolls for one month.
Medical Expenses: List medical expenses not covered by insurance.
ATTACHMENTS REQUIRED. Please include the following:
• Proof of all current expenses that you paid for the past 3 months, including utilities, rent, insurance,
property taxes, etc.
• Proof of all non-business transportation expenses (e.g., car payments, lease payments, fuel, oil,
insurance, parking, registration).
Check this box
when all spaces in
• Proof of all payments for health care, including health insurance premiums, co-payments, and other
Section 9 are fi lled in
out-of-pocket expenses, for the past 3 months.
and attachments
• Copies of any court order requiring payment and proof of such payments (e.g., cancelled checks, money
are provided.
orders, earning statements showing such deductions) for the past 3 months.
Failure to complete all entry spaces may result in rejection or signifi cant delay in the
!
resolution of your account.
CAUTION
Certifi cation: Under penalties of perjury, I declare that to the best of my knowledge and belief,
this statement of assets, liabilities, and other information is true, correct and complete.
Check this box
Your Signature
Date
when all spaces in all
sections are fi lled in
and all attachments
Spouse’s Signature
Date
are provided
ADOR 10896 (10/10)
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