Form Md 433-A - Collection Information Statement For Individuals

Form Md 433-A - Collection Information Statement For Individuals - 2000 Page 2

Form MD 433-A

Page 2

(Rev. 7-2000)

Section III (continued) General Financial Information

14 Charge cards and lines of credit from banks, credit unions, and savings and loans.

Type of Account

Name and Address of

Monthly

Credit

Amount

Credit

or Card

Financial institution

Payment

Limit

Owed

Available

Total (Enter in Item 27) ..........................................................................................

15 Safe deposit boxes rented or accessed (List all locations, box numbers, and contents)

16 Real Property (Brief description and type of ownership)

Physical Address

County _________________________________

17 Life Insurance (Name and Company)

Policy Number

Type

Face Amount

Available Loan Value

! Whole

! Term

! Whole

! Term

! Whole

! Term

Total (Enter in Item 23)

18 Securities (stocks, bonds, mutual funds, money market funds, government securities, etc.):

Kind

Quantity or

Current

Where

Owner

Denomination

Value

Located

of Record

19 Other information relating to your financial condition. If you check the “Yes” box, please give dates and explain on page 4, Additional

Information or Comments:

! Yes

! No

! Yes

! No

a Court proceedings

b Bankruptcies

! Yes

! No

! Yes

! No

c Repossessions

d Recent sale or other transfer of

assets for less than full value

! Yes

! No

! Yes

! No

e Anticipated increase

f Participant or beneficiary

in income

to trust, estate, profit sharing, etc.

Form Md 433-A - Collection Information Statement For Individuals - 2000 Page 2

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