Form Ri 433 A - Collection Information Statement For Wage Earners And Self-Employed Individuals - Rhode Island Division Of Taxation Page 2
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CHECKING ACCOUNTS.
List all checking accounts. ( If additional space is needed, attach a separate sheet.)
Section 5
Type of
Full Name of Bank, Savings & Loan,
Bank Account No.
Current Balance
Banking
Account
Credit Union or Financial Institution
Investment
Cash
Checking
Name_______________________________________
_________________ $ _______________
Credit
Street Address _______________________________
Life Ins-
City/State/Zip _______________________________
urance
Checking
Name_______________________________________
_________________ $ _______________
Street Address _______________________________
City/State/Zip _______________________________
Total Checking Account Balances
$ _______________
OTHER ACCOUNTS.
List all accounts,including brokerage, savings, and money market, not listed previously.
Type of
Full Name of Bank, Savings & Loan,
Bank Account No.
Current Balance
Account
Credit Union or Financial Institution
Name_______________________________________
_________________ $ _______________
Street Address _______________________________
City/State/Zip _______________________________
Name_______________________________________
_________________ $ _______________
Street Address _______________________________
City/State/Zip _______________________________
Total Other Account Balances
$ _______________
INVESTMENTS.
Name of Company
Number of
Current
Loan
Used as collateral
Shares/Units
Value
Amount
on loan
Current
____________
$
$
( ) No
( ) Yes
Value:
Indicate
____________
$
$
( ) No
( ) Yes
the amount
you could
____________
$
$
( ) No
( ) Yes
sell the
asset for
today.
Total Investments
$ _______________
CASH ON HAND.
Include any money that you have that is not in the bank.
Total Cash on Hand
$ _______________
AVAILABLE CREDIT.
List all lines of credit, including credit cards.
Full Name of
Credit Institution
Credit Limit
Amount Owed
Available Credit
Name_______________________________________
$ _______________ $ _______________ $ _______________
Street Address _______________________________
City/State/Zip _______________________________
Name_______________________________________
$ _______________ $ _______________ $ _______________
Street Address _______________________________
City/State/Zip _______________________________
Total Credit Available
$ _______________
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Parent category: Legal