Form Rev-488 Fo - Collection Information Statement For Individuals Page 3

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Assets and Liabilities
SECTION IV.
Current
Current
Equity
Amount of
Name and Address
Date of
Description
Market
Amount
in
Monthly
of
Date
Final
Value
Owed
Asset
Payments
Lien/Note Holder/Lender
Pledged
Payment
20. Cash
21. Bank accounts (from Item 13)
22. Securities (from Item 18)
23. Cash or loan value of insurance
24. Vehicles (model, year, license tag #)
a.
b.
c.
25. Real Property
a.
(from Section III.
b.
Item 16)
c.
26. Other Assets
a.
b.
c.
d.
e.
27. Bank revolving credit (from Item 14)
28. Other Liabilities
a.
(including bank
b.
loans, judgments, c.
notes, and
d.
charge accounts
e.
not entered in
f.
Item 14.)
g.
29. State/Federal taxes owed (prior years)
30. Totals
$
$
Official Use Only Below This Line
Financial Verification/Analysis
Date Information
Date Property
Estimated Forced
Item
or Encumbrance Verified
Inspected
Sale Equity
Personal Residence
Other Real Property
Vehicles
Other Personal Property
Employment (Husband and Wife)
Income Tax Return
Wage Statements (Husband and Wife)
Sources of Income/Credit
Expenses
Other Assets/Liabilities
Page 3

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