Business Collection Informaton Statement - State Of Delaware

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STATE OF DELAWARE
BUSINESS COLLECTION INFORMATON STATEMENT
DEPARTMENT OF FINANCE
[If you need additional space, please attach a separate sheet
DIVISION OF REVENUE
with your Business Name & Federal Employer Identification No.
820 N. FRENCH STREET
or Social Security No., if applicable]
WILMINGTON, DE 19801
1) NAME & ADDRESS OF BUSINESS:
2) BUSINESS PHONE NUMBER:
3) CHECK APPROPRIATE BOX:
SOLE PROPRIETOR
OTHER (SPECIFY):
PARTNERSHIP
CORPORATION
5) FEDERAL EMPLOYER ID
4) NAME & TITLE OF PERSON COMPLETING THIS
6) TYPE OF BUSINESS:
NO. OR SOCIAL SECURITY
FORM:
NO. [IF APPLICABLE]
:
7) INFORMATION ABOUT OWNER, PARTNERS, OFFICERS, MAJOR SHAREHOLDERS, ETC.:
EFFECTIVE
PHONE
SOCIAL SECURITY
TOTAL SHARES
NAME & TITLE
HOME ADDRESS
NUMBER
NUMBER
OF INTEREST
DATE
SECTION 1.
GENERAL FINANCIAL INFORMATION
8) LATEST FILED INCOME TAX
FROM:
TAX YEAR ENDED:
NET INCOME BEFORE TAXES:
RETURN
9) BANK ACCOUNTS: (List all types of accounts, including Payroll and General, Savings,
Certificates of Deposits, etc.)
TYPE OF
ACCOUNT
BALANCE
NAME OF INSTITUTION
ADDRESS
ACCOUNT
NUMBER
10)
BANK CREDIT AVAILABLE: (Lines of Credit, etc.)
CREDIT
AMOUNT
MONTHLY
CREDIT
NAME OF INSTITUTION
LIMIT
OWED
AVAILABLE
PAYMENTS
ADDRESS
11) LOCATION, BOX NUMBER AND CONTENTS OF ALL SAFE DEPOSIT BOXES RENTED OR ACCESSED:

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