Collection Information Statement - State Of Delaware

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STATE OF DELAWARE
DEPARTMENT OF FINANCE
COLLECTION INFORMATION STATEMENT
[If you need additional space, please attach a separate sheet with your
DIVISION OF REVENUE
820 N. FRENCH STREET
name(s) and social secuirty number(s).]
WILMINGTON, DE 19801
YOUR NAME & ADDRESS [INCLUDING COUNTY]:
PHONE NUMBERS: [CIRCLE BEST DAYTIME NUMBER]
HOME:
YOUR WORK:
YOUR SPOUSE’S WORK:
SOCIAL SECURITY NUMBER[S]:
YOURS:
YOUR SPOUSE’S: _
______
__
_ YOUR SPOUSE’S: __
_ __
DATES OF BIRTH: YOURS: __
_
YOUR EMPLOYER OR BUSINESS [NAME & ADDRESS]:
YOUR SPOUSE’S EMPLOYER OR BUSINESS [NAME & ADDRESS]:
AGE & RELATIONSHIP OF PEOPLE WHO LIVE WITH YOU [DEPENDENTS ONLY]:
BANK ACCOUNTS [INCLUDE SAVINGS & LOANS, CREDIT UNIONS, CERTIFICATES OF DEPOSIT, INDIVIDUAL RETIREMENT ACCOUNTS]:
TYPE OF ACCOUNT
NAME OF INSTITUTION
[CHECKING, SAVINGS]
ACCOUNT NO.
BALANCE
ADDRESS
CREDIT CARDS, CHECKING OVERDRAFT PROTECTION, LINE OF CREDIT:
NAME OF CREDIT CARD, BANK, ETC.
MIN. MONTHLY PAYMENT
CREDIT LIMIT
AMOUNT OWED
DATE OF FINAL PAYMENT
LIFE INSURANCE:
NAME OF COMPANY
POLICY NUMBER
AMOUNT YOU CAN BORROW ON THE POLICY
REAL ESTATE:
ADDRESS [INCLUDING COUNTY]
MORTGAGE BALANCE
PAID TO [NAME OF PERSON OR BANK]
CURRENT VALUE
MOTOR VEHICLES:
YEAR, MAKE & LICENSE NO.
CURRENT VALUE
LOAN BALANCE
DATE LOAN WILL BE PAID OFF
OTHER THINGS YOU OWN OR ARE CURRENTLY BUYING [STOCKS, BONDS, BOAT, ETC]:
DESCRIPTION
CURRENT VALUE
LOAN BALANCE
DATE LOAN WILL BE PAID OFF

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