Form Ri 433 B-Collection Information Statement Businesses Page 3
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Section 4 REAL ESTATE.
List all real estate you owned by business. (If you need additional space, attach a
separate sheet.)
Continued
Street Address, City,
Date
Purchase Current
Loan
Name of Lender
Amount of Date of
State, Zip and County Purchased Price
Value
Balance
or Lien Holder
Monthly
Final
Payment
Payment
_______ $_______ $_______ $_______
$_______
_______ $_______ $_______ $_______
$_______
_______ $_______ $_______ $_______
$_______
Section 4 BUSINESS ASSETS. List all business assets and encumbrances below.
Continued Description
Current
Loan
Name of Lender
Amount
Date of
Value
Balance
of Monthly Final
Payment
Tools used in Trade/Business
$_______ $_______ ___________________________ $_______ ________
Other:
Machinery
$_______ $_______ ___________________________ $_______ ________
Equipment
$_______ $_______ ___________________________ $_______ ________
$_______ $_______ ___________________________ $_______ ________
$_______ $_______ ___________________________ $_______ ________
$_______ $_______
$_______ $_______
$_______ $_______
Section 5 INVESTMENTS.
List all investment assets below. Include stocks, bonds, mutual funds, stock options and
certificates of deposits.
Name of Company
Number of
Current
Loan
Used as collateral
Invest-
Shares/Units
Value
Amount
on loan
ment,
Banking
____________
$
$
( ) No
( ) Yes
and Cash
Information
____________
$
$
( ) No
( ) Yes
____________
$
$
( ) No
( ) Yes
Total Investments
$ _______________
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