Form Ro-1062 - Collection Information Statement For Individuals Page 3
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6Section 6.
Other Personal Assets
18. Other Assets (Include all assets listed on homeowners insurance policy)
Current
Liabilities
Equity
Amount of
Date of
Description
Market
Balance
In
Monthly
Name and Address of
Date
Final
Value
Due
Asset
Payment
Lien/Note Holder/Obligee
Pledged
Payment
18a.
18b.
18c .
18d. Total Current Fair Market Value
18e. Total Current Loan Balance
18f. Net Equity
Section 7.
Judgments & Secured Liens (other secured debts)
19. Other Liabilities (Include judgments and any secured debt)
Liabilities
Amount of
Date of
Description
Balance
Monthly
Name and Address of
Date
Final
Due
Payment
Lien/Note Holder/Obligee
Pledged
Payment
19a. IRS
19b.
19c.
19d.
Total Liabilities
Balance Due
Section 8.
Notes, Charge Accounts and Medical Expenses
20. Available Credit (list bank charge cards, credit unions, lines of credit, medical expenses)
Type of Account
Name and Address of
Monthly
Credit
Amount
Credit
or Card
Financial Institution
Payment
Limit
Owed
Available
20a.
20b.
20c.
20d.
20e. Total Credit Available
Section 9.
Other Financial Information
21. Other information relating to your financial condition. If you check the yes box, please give dates and explain under remarks.
a. Court proceedings
Yes
No
b. Bankruptcies
Yes
No
Remarks:
Remarks:
c. Repossessions
Yes
No
d. Recent transfer of assets
Yes
No
for less than full value
Remarks:
Remarks:
e. Anticipated increase in income
Yes
No
f. Participant or beneficiary to trust,
Yes
No
estate, profit sharing, etc.
Remarks:
Remarks:
g. Do you receive government assistance
h. Are all required state tax returns filed?
based on disability and/or financial need?
Yes
No
Yes
No
Remarks:
Remarks:
Form RO-1062 page 3 (Rev. 4-10)
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