Form Ro-1062 - Collection Information Statement For Individuals Page 6
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6Business Assets. Include all tools, books, machinery, equipment, inventory or other assets used in trade or business. Include Uniform
Commercial Code (UCC) filings. Include Vehicles and Real Property owned/leased/rented by the business, if not shown in Section 10.
Current Fair
Amount of
Date of Final
Purchase/Lease/Rental
Market Value
Current Loan
Monthly
Payment
Equity
Date (mm/dd/yyyy)
(FMV)
Balance
Payment
(mm/dd/yyyy)
FMV Minus Loan
61a. Property Description
$
Location (Street, City, State, ZIP code) and County
Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code) and Phone
61b. Property Description
$
Location (Street, City, State, ZIP code) and County
Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code) and Phone
61c. Total Equity (Add lines 61a, 61b and amounts from any attachments
$
Section 12 must be completed only if the taxpayer is SELF-EMPLOYED
Section 12.
Sole Proprietorship Information
(lines 62 through 83 should reconcile with business Profit and Loss Statement)
Accounting Method Used:
Cash
Accrual
Income and Expenses during the period (mm/dd/yyyy)
to (mm/dd/yyyy)
Total Monthly Business Income
Source
Gross Monthly
Expense Items
Actual Monthly
62. Gross Receipts
72. Materials Purchased
63. Gross Rental Income
73. Inventory Purchased
64. Interest
74. Gross Wages & Salaries
65. Dividends
75. Rent
66. Cash
76. Supplies
Other Income (Specify Below)
77. Utilities/Telephone
67
78. Vehicle Gasoline/Oil
68
79. Repairs & Maintenance
69
80. Insurance
70
81. Current Taxes
82. Other Expenses,
including installment payments
71. Total Income
83. Total Expenses (Add lines 72 through 82)
Add lines 62 through 70
84. Net Business Income (line 71 minus 83)
Enter the amount from line 84 on line 32, Section 10. If line 84 is a loss, enter "0" on line 32, Section 10.
Self-employed taxpayers must return to page 4 to sign the certification and include all applicable attachments.
Materials Purchased: Materials are items directly related to the
Current Taxes: Real estate, state, and local income tax, excise,
production of a product or service.
franchise, occupational, personal property, sales and the employer's
portion of the employment taxes.
Inventory Purchased: Goods bought for resale.
Net Business Income: Net profit from Form 1040, Schedule C may
Supplies: Supplies are items used to conduct business and are consumed
be used if duplicated deductions are eliminated (e.g., expenses for
or used up within one year. This could be the cost of books, office
business use of home already included in housing and utility expenses
supplies, professional equipment, etc.
on page 4). Deductions for depreciation and depletion on Schedule C
are not cash expenses and must be added back to the net income
Utilities/Telephone: Utilities include gas, electricity, water, oil,
figure. In addition, interest cannot be deducted if it is already included
other fuels, trash collection, telephone and cell phone.
in any other installment payments allowed.
FINANCIAL ANALYSIS OF COLLECTION POTENTIAL
FOR INDIVIDUAL WAGE EARNERS AND SELF-EMPLOYED INDIVIDUALS
(DOR USE ONLY)
Cash Available
(Lines 12, 13e, 14d, 15c, 20e, 58, 59c, 60e)
Total Cash
$
Distrainable Asset Summary
(Lines 16e, 17e, 18f, 61c)
Total Equity
$
Monthly Total Positive Income minus Expenses
(Line 35 minus Line 47)
Monthly Available Cash
$
Form RO-1062 page 6 (Rev. 4-10)
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