Form Ro-1062 - Collection Information Statement For Individuals

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Form RO-1062
N.C Department of Revenue
Collection Information Statement for Individuals
Web-fill (Rev. 4-10)
Note: Complete all blocks, except shaded areas. Write "N/A" (not applicable) in those blocks that do not apply.
1. Taxpayers' names and address (including County)
2a. Home phone number
3a. Taxpayer's social security number
3b. Spouse's social security number
2b. Cell phone number
4a. Taxpayer's date of birth
# of years at this address
2c. Business phone number
4b. Spouse's date of birth
Own
Rent
Section 1.
Personal Information
5. Do you have a power of attorney for tax matters? If yes, please attach a copy.
Marital Status:
yes
no
married
unmarried (single, divorced, widowed)
6. Age and relationship of dependents (exclude yourself and spouse) living in your household.
Section 2.
Employment Information
7. Taxpayer's employer or business
7a. How long employed
7c. Occupation
7e. (Check appropriate box)
(name and address)
Wage earner
7b. Number of exemptions
7d. Paydays
Sole proprietor
claimed on Form NC-4
Partner/Member
8. Spouse's employer or business
8a. How long employed
8c. Occupation
8e. (Check appropriate box)
(name and address)
Wage earner
8b. Number of exemptions
8d. Paydays
Sole proprietor
claimed on Form NC-4
Partner/Member
Business phone #
9. Latest filed income tax
10. Number of exemptions
11. Adjusted Gross Income
return (tax year)
claimed
Section 3
Liquid Assets
Section 3
Liquid Assets
12. Cash on hand
13. Bank accounts (Include Savings & Loans, Credit Unions, Certificates of Deposit, etc.)
Name of Institution
Address
Type of Account
Account No.
3 month average
ending balance
13a.
13b.
13c.
13d.
13e. Total
14. Investment Accounts
Include stocks, bonds, mutual funds, stock options, certificates of deposit, and retirement assets such as IRAs, Keogh, and 401(k) plans.
Include all corporations, partnerships, limited liability companies or other business entities in which the individual is an officer,
director, owner, member, or otherwise has a financial interest.
Loan Balance
(if applicable)
Type of Investment
Full Name & Address(City, State, Zip Code)
Current
As of
Equity
or Financial Interest
of Company
Market Value
mm/dd/yyyy
Value Minus Loan
14a.
14b.
14c.
14d. Total Equity (Add lines 14a through 14c and amounts from any attachments)
Form RO-1062 page 1 (Rev. 4-10)

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