Form Ador 10896 - Collection Information Statement (Personal) Page 5
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5Arizona Department of Revenue
Collection Information Statement (Personal)
Name
SSN
SUPPLEMENTAL PAGE:
Investment, Bank, Credit, Other Accounts
List additional accounts not listed on page 2.
Show the full name of the investment company, bank, savings and loan, credit, or other fi nancial institution.
Company Name
Street Address
City, State, Zip Code
A
Select only one account type below; enter information for that account.
Used as collateral
Net Value
Indicate type of account:
No. Shares/Units
Current Value
(a)
on loan?
Loan Amount
(b)
(a - b)
Investment Account
$
No
Yes
$
Other Account Type:
Bank Routing No.
Bank Account No.
Current Balance
$
Credit Limit
Amount Owed
Available Credit
Credit Account
$
$
$
Company Name
Street Address
City, State, Zip Code
B
Select only one account type below; enter information for that account.
Used as collateral
Net Value
(a)
(b)
Indicate type of account:
No. Shares/Units
Current Value
on loan?
Loan Amount
(a - b)
Investment Account
$
No
Yes
$
Other Account Type:
Bank Routing No.
Bank Account No.
Current Balance
$
Credit Limit
Amount Owed
Available Credit
Credit Account
$
$
$
Company Name
Street Address
City, State, Zip Code
C
Select only one account type below; enter information for that account.
Used as collateral
Net Value
(a)
(b)
Indicate type of account:
No. Shares/Units
Current Value
on loan?
Loan Amount
(a - b)
Investment Account
$
No
Yes
$
Other Account Type:
Bank Routing No.
Bank Account No.
Current Balance
$
Credit Limit
Amount Owed
Available Credit
Credit Account
$
$
$
Company Name
Street Address
City, State, Zip Code
D
Select only one account type below; enter information for that account.
Used as collateral
Net Value
Indicate type of account:
No. Shares/Units
Current Value
(a)
on loan?
Loan Amount
(b)
(a - b)
Investment Account
$
No
Yes
$
Other Account Type:
Bank Routing No.
Bank Account No.
Current Balance
$
Credit Limit
Amount Owed
Available Credit
Credit Account
$
$
$
a) Subtotal Investment Account Net Values: List here and on page 2, line 13c .............................................................a)
$
b) Subtotal Other Account Current Balances: List here and on page 2, line 12c ...........................................................b)
$
Page 2
c) Subtotal Credit Available: List here and on page 2, line 15c .......................................................................................c)
$
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Parent category: Financial