Form Md 433-A - Collection Information Statement For Individuals - 2000 Page 3

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Form MD 433-A
Page 3
(Rev. 7-2000)
Section IV
Assets and Liabilities
Current
Current
Equity
Amount of
Name and Address of
Date
Date of
Description
Market
Amount
in
Monthly
Lien/Note Holder/Lender
Pledged
Final
Value
Owed
Asset
Payment
Payment
20 Cash
21 Bank accounts (from item 13)
22 Securities (from item 18)
23 Cash or loan value of insurance
24 Vehicles leased or owned
(model, year, license, tag #)
a
b
c
25 Real property
a
(from Section III,
item 16)
b
c
26 Other assets
a
b
c
d
e
27 Bank revolving credit (from item 14)
28 Other liabilities
a
(including bank
loans, judgements b
notes, and
charge accounts
c
not entered in
item 13)
d
e
f
g
29 Federal taxes owed (prior years)
29 Totals
$
$
Comptroller of Maryland Use Only Below This Line
Financial Verification/Analysis
Date Information or
Date Property
Estimated Forced
Item
Encumbrance Verified
Inspected
Sale Equity
Personal Residence
Other real property
Vehicles
Other personal property
State employment (husband and wife)
Income tax return
Wage statements (husband and wife)
Sources of income/credit (D&B report)
Expenses
Other assets/liabilities

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