Form Ador 64-1070 - Collection Information Statement For Individuals

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Arizona Department of Revenue
1600 W Monroe - Phoenix AZ 85007-2650
Collection Information Statement for Individuals
Note: Complete all blocks, except shaded areas. Write "N/A" (not applicable) in those blocks that do not apply.
1. Taxpayer name(s) and address
2. Home phone number
3. Marital status
(
)
4a. Taxpayer's social security
b. Spouse's social security
number
number
County
Section I.
Employment Information
5. Taxpayer's employer or business
a. How long employed
b. Business phone number
c. Occupation
(name and address)
(
)
d. Number of exemptions
e. Paydays
f. (Check appropriate box)
Wkly
Other
Wage earner
Partner
Monthly
Sole proprietor
Other
Bi-wkly
Commission
Semi-monthly
6. Spouse's employer or business
a. How long employed
b. Business phone number
c. Occupation
(name and address)
(
)
d. Number of exemptions
e. Paydays
f. (Check appropriate box)
Wkly
Other
Wage earner
Partner
Monthly
Sole proprietor
Other
Bi-wkly
Commission
Semi-monthly
Section II.
Personal Information
7. Name, address and telephone number of next of kin or other reference
8. Other names or aliases used 9. Previous address(es)
10. Age and relationship of dependents (exclude yourself and spouse)
a. Taxpayer b. Spouse
12. Latest filed income tax
a. Number of exemptions
b. Adjusted Gross Income
return (tax year)
claimed
11. Date of Birth
Section III.
General Financial Information
13. Bank accounts (Include Savings & Loans, Credit Unions, IRA and Retirement Plans, Certificates of Deposit, etc.)
Name of Institution
Address
Type of Account
Account No.
Balance
$
Total (Enter on line
ADOR 64-1070 (10/98)

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