Form Ri 433 A - Collection Information Statement For Wage Earners And Self-Employed Individuals - Rhode Island Division Of Taxation Page 4
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LEASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS.
Include boats, RV's motorcycles,
Section 7
(If you need additional space, attach a separate sheet.)
trailers, etc.
Continued
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_____________________ $
$
_______ $
REAL ESTATE.
List all real estate you own. (If you need additional space, attach a separate sheeet.)
Street Address, City,
Date
Purchase Current
Loan
Name of Lender
Amount of Date of
State, Zip and County Purchased Price
Value
Balance
or Lien Holder
Monthly
Final
Payment
Payment
_______ $_______ $_______ $_______
$_______
_______ $_______ $_______ $_______
$_______
PERSONAL ASSETS. List all personal assets below. (If you need additional space, attach a separate sheet.)
Furniture/Personal Effects includes the total current market value of your household such as furniture and
appliances. Other personal assets includes all artwork, jewelry, collections (coin, gun, etc.), antiques or
other assets.
Description
Current
Loan
Name of Lender
Amount
Date of
Value
Balance
of Monthly Final
Payment
Payment
Furniture/Personal Effects
Other:
Artwork
$_______ $_______ ___________________________ $_______ ________
Jewelry
$_______ $_______ ___________________________ $_______ ________
$_______ $_______ ___________________________ $_______ ________
$_______ $_______ ___________________________ $_______ ________
BUSINESS ASSETS. List all business assets and encumbrances below.
Description
Current
Loan
Name of Lender
Amount
Date of
Value
Balance
of Monthly Final
Tools used in Trade/Business
$_______ $_______ ___________________________ $_______ ________
Other:
Machinery
$_______ $_______ ___________________________ $_______ ________
Equipment
$_______ $_______ ___________________________ $_______ ________
$_______ $_______ ___________________________ $_______ ________
$_______ $_______ ___________________________ $_______ ________
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