Form Ador 64-1070 - Collection Information Statement For Individuals Page 2

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Section III.
General Financial Information
14. Charge cards, Lines of credit
Type of Account
Name and Address of
Monthly
Credit
Balance
Credit
or Card
Financial Institution
Payment
Limit
Due
Available
Total (Enter on line 27)
$
$
$
$
15. Safe deposit boxes rented or accessed (List all locations, box numbers, and contents)
16. Real Property (Brief description and type of ownership)
Physical Address
a.
County
b.
County
17. Life Insurance (Name of Company)
Policy Number
Type
Face Amount
Available Loan Value
$
Total (Enter on line 23)
18. Securities (stocks, bonds, mutual funds, money market funds, government securities, trust, etc.)
Kind
Quantity or Denomination
Current Value
Where Located
Owner of Record
19. Other information relating to your financial condition. If you check the yes box, please give dates and explain in Section V.
Yes
No
Yes
No
a. Court Proceedings
b. Bankruptcies
d. Recent transfer of assets for less
Yes
No
Yes
No
c. Repossessions
f. Participant or beneficiary of trust,
Yes
No
Yes
No
e. Anticipated increase in income
estate, profit sharing, etc.
ADOR 64-1070 (10/98)

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