Form Ro-1062 - Collection Information Statement For Individuals Page 5

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Sections 11 and 12 must be completed only if the taxpayer is SELF-EMPLOYED
Section 11.
Business Information
48. Is the business a sole proprietorship (filing Schedule C)
Yes, Continue with Sections 11 and 12.
No, Complete Business Financial Statement
All other business entities, including limited liability companies, partnerships or corporations, must complete business financial statement.
49. Business Name
50. Employer Identification Number
51. Type of Business
Federal or State Contractor
52. Business Website
53. Total Number of Employees
54a. Average Gross Monthly Payroll
54b. Frequency of Tax Deposits
55. Does business engage in e-Commerce (Internet sales)
Payment Processor (e.g., PayPal,, Google Checkout, etc.) Name and Address (Street, City, State, Zip code)
Payment Processor Account Number
Credit Cards Accepted by the Business
Merchant Account Provider, Name & Address
(Street, City, State, ZIP code)
Credit Card
Merchant Account Number
58. Business Cash on Hand. Include cash that is not in a bank
Total Cash on Hand
Business Bank Accounts. Include checking accounts, online bank accounts, money market accounts, savings accounts, and stored value
cards (e.g. payroll cards, government benefit cards, etc.) Report Personal Accounts in Section 3.
Type of
Full Name & Address (Street, City, State, ZIP code) of Bank,
Account Number
Account Balance
Savings & Loan, Credit Union or Financial Institution.
As of
59c. Total Cash in Banks (Add lines 59a, 59b, and amounts from any attachments)
Accounts/Notes Receivable. Include e-payment accounts receivable and factoring companies, and any bartering or online auction accounts.
(List all contracts separately, including contracts awarded, but not started.) Include Federal and State Government Contracts.
Status (e.g., age,
Date Due
Invoice Number or Federal
Accounts/Notes Receivable & Address (Street, City, State, ZIP Code)
factored, other)
or State Government Contract
Amount Due
60e. Total Outstanding Balance (Add lines 60a through 60d and amounts from any attachments)
Form RO-1062 page 5 (Rev. 4-10)


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