Form Ri 433 A - Collection Information Statement For Wage Earners And Self-Employed Individuals - Rhode Island Division Of Taxation Page 3
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LIFE INSURANCE.
Do you have life insurance with a cash value?
( ) No
( ) Yes
Section 5
(Term Life Insurance does not have a cash value.)
Continued
If yes:
Name of Insurance Company
Policy Number(s)
Owner of Policy
Current Cash Value
Outstanding Loan Balance
$
$
Net Difference of Current Cash Value and Outstanding Loan Balance
$
OTHER INFORMATION.
Section 6
Are there any garnishments against your wages?
( ) No ( ) Yes
Other
If yes, who is the creditor?"
Date of Judgement
Amt Owed $
Information
Are there any other judgements against you?
( ) No ( ) Yes
If yes, who is the creditor?"
Date of Judgement
Amt Owed $
Are you a party in a lawsuit?
( ) No ( ) Yes
If yes, amount of suit $_______________ Possible completion date________ Subject matter of suit________________
Did you ever file bankruptcy?
( ) No ( ) Yes
If yes, date filed_____________________ Date discharged_______________________
Are you a beneficiary of a trust or an estate?
( ) No ( ) Yes
If yes, name of trust or estate____________________________
Anticipated amount to be received $_______________
Are you a participant in a profit sharing plan?
( ) No ( ) Yes
If yes, name of plan____________________________________ Value in plan $________________________
PURCHASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS:
Include boats, RV's motorcycles,
Section 7
(If you need additional space, attach a separate sheet.)
trailers, etc.
Assets and
Description
Current
Current
Name of
Purchase Amount of
Liabilities
Value
Loan
Lender
Date
Monthly
Balance
Payment
Year
__________________
Make/Model_________________
Mileage_____________________ $________________
_______ $ _______
Description
Current
Current
Name of
Purchase Amount of
Value
Loan
Lender
Date
Monthly
Balance
Payment
Year
__________________
Make/Model_________________
Mileage_____________________ $
$
_______ $ _______
Description
Current
Current
Name of
Purchase Amount of
Value
Loan
Lender
Date
Monthly
Balance
Payment
Year
__________________
Make/Model_________________
Mileage_____________________ $
$
_______ $ _______
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