Form Ri 433 B-Collection Information Statement Businesses Page 5

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Page 5
Total Income
Total Living Expenses
Section 6
Source
Gross Monthly
Expense Items
Actual Monthly
Monthly
Gross Receipts
$______________
Materials Purchased
$______________
Income and
Gross Rental Income
______________
Inventory Purchased
______________
Expense
Interest
______________
Gross Wages & Salaries
______________
Dividends
______________
Rent
______________
Other Income (Specify)
______________
Supplies
______________
_______________________
______________
Utilities/Telephone
______________
_______________________
______________
Vehicle Gasoline & Oil
______________
_______________________
______________
Repairs/Maintenance
______________
_______________________
______________
Insurance
______________
______________
Taxes
______________
Other Expenses (Include install-
ment payments, specify)
______________________
______________
______________________
______________
______________________
______________
______________________
______________
Total Income
$ ______________
Total Expenses
$ ______________
Total Income less Expenses:
$________________
Certification: Under penalties of perjury, I declare that to the best of my knowledge and belief this statement
of assets, liabilities, and other information is true, correct and complete.
Print Name
Title
_____________________________________
____________________________________
Your Signature
Date

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