Form Ro-1062 - Collection Information Statement For Individuals Page 2
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615. Life Insurance (Name of Company)
Policy Number
Type
Face Amount
Available Cash Value
15a.
15b.
15c. Total
Section 4
Real Property
16. Real property owned, rented, and leased. Include all real property and land contracts. (For personal and business use if sole proprietor)
16a. Primary Residence
Purchase/Lease Date
County
Current Fair Market
Current Loan
Amount of Monthly
Date of Final
Equity
(mm/dd/yy)
Tax Value
Value (FMV)
Balance
Payment
Payment
FMV minus loan
Property Location (Street, Address, State, ZIP code)
Lender/Lessor/Landlord Name, Address, (Street, Address, State, ZIP code)
Property County
Landlord/Lessor Phone Number
First Mortgage Holder
Second Mortgage/Home Equity Line
16b. Property Description
Purchase/Lease Date
County
Current Fair Market
Current Loan
Amount of Monthly
Date of Final
Equity
(mm/dd/yy)
Tax Value
Value (FMV)
Balance
Payment
Payment
FMV minus loan
Property Location (Street, Address, State, ZIP code)
Lender/Lessor/Landlord Name, Address, (Street, Address, State, ZIP code)
Property County
Landlord/Lessor Phone Number
16c. Total Fair Market Value
16d. Total Current Loan Balance
16e. Net Equity
Attach additional sheets as needed
Section 5.
Licensed Assets/Vehicles
Vehicles Purchased Include boats, RVs, motorcycles, trailers, etc. (For personal and business use if sole proprietor)
17.
17a. Description
Purchase Date
Current Fair Market
Current Loan
Amount of Monthly
Date of Final
Equity
(Make, Model,
(mm/dd/yy)
Value (FMV)
Balance
Payment
Payment
FMV minus loan
Year, Mileage)
Lender/Lessor Name, Address, (Street, Address, State, ZIP code)
Make
Model
Year
Mileage
17b. Description
Purchase Date
Current Fair Market
Current Loan
Amount of Monthly
Date of Final
Equity
(Make, Model,
(mm/dd/yy)
Value (FMV)
Balance
Payment
Payment
FMV minus loan
Year, Mileage)
Lender/Lessor Name, Address, (Street, Address, State, ZIP code)
Make
Model
Year
Mileage
17c. Description
Lease Date
Current Fair Market
Current Loan
Amount of Monthly
Date of Final
Equity
(Make, Model,
(mm/dd/yy)
Value (FMV)
Balance
Payment
Payment
FMV minus loan
Year, Mileage)
Lender/Lessor Name, Address, (Street, Address, State, ZIP code)
Make
Model
Year
Mileage
17d. Total Current Fair Market Value
17e. Total Current Loan Balance
17f. Net Equity
Form RO-1062 page 2 (Rev. 4-10)
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