Form Ador 20-1020 - Collection Information Statement For Business Page 4
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4Section IV.
Income and Expense Analysis
The following information applies to income and expenses during the period
Accounting method used
_______________________________ to ______________________________
Income
Expenses
$
$
28. Gross receipts from sales, services, etc.
34. Materials purchased
29. Gross rental income
35. Net wages and salaries
30. Interest
36. Rent
31. Dividends
37. Installment payments
32. Other income (Specify)
38. Supplies
39. Utilities/Telephone
40. Gasoline/Oil
41. Repairs and maintenance
42. Insurance
43. Current taxes
44. Other (Specify)
$
33. Total Income
45. Total Expenses
$
$
46. Net difference
Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities, and
Certification
other information is true, correct, and complete.
47. Signature
Title
48. Date
Department of Revenue Use Only Below This Line
Financial Verification/Analysis
Date Information or
Item
Date Property Inspected
Estimated Forced Sale Equity
Encumbrance Verified
Sources of Income/Credit
Expenses
Real Property
Vehicles
Machinery and Equipment
Merchandise
Accounts/Notes Receivable
Corporate Information, if Applicable
U.C.C.: Senior/Junior Lienholder
Other Assets/Liabilities:
Explain any difference between line 46 (or P&L) and the installment agreement payment amount:
Reviewing Agent
Date
ADOR 20-1020 (10/01)
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Parent category: Financial