Form Rev-488 Fo - Collection Information Statement For Individuals Page 2

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General Financial Information
SECTION III.
continued –
14. Charge cards and lines of credit from banks, credit unions, and savings and loans. List all other charge accounts in Item 28.
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)
Physical Address
16. Real Property (Brief description and type of ownership)
a.
County
b.
County
c.
County
17. Life Insurance (Name of 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 Denomination
Current Value
Where Located
Owner 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.
❏
❏
❏
❏
a. Court proceedings
Yes
No
b. Bankruptcies – Cause Nos.
Yes
No
d. Recent sale or other transfer of
❏
❏
❏
❏
c. Repossessions
Yes
No
assets for less than full value
Yes
No
f. Participant or beneficiary to
❏
❏
❏
❏
e. Anticipated increase in income
Yes
No
trust, estate, profit sharing, etc.
Yes
No
Page 2

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