Form Md 433-B - Collection Information Statement For Businesses Page 2
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4Form MD 433-B
Page 2
(Rev. 7-2000)
Section I (continued)
General Financial Information
12 Real Property
Brief Description and Type of Ownership
Physical Address
a
County ____________________________
b
County ____________________________
c
County ____________________________
d
County ____________________________
13 Life insurance policies owned with business as beneficiary
Name Insured
Company
Policy Number
Type
Face Amount
Available Loan Value
Total (Enter in item 19)
14a Additional information regarding financial condition (Court proceedings, bankruptcies filed or anticipated, transfers of assets for less than full
value, changes in market conditions, etc. Include information regarding company participation in trusts, estates, profit-sharing plans, etc.)
b If you know of any person or
(I) Who borrowed the funds?
organization that borrowed or
otherwise provided funds to
pay net payrolls
(ii) Who supplied the funds?
15 Accounts/notes receivable (include current contract jobs, loans to stockholders, officers, partners, etc.)
Name
Address
Amount Due
Date Due
Status
Total (Enter in item 18) ............................................................................................................................... . ........
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