Form 433a - Collection Information Statement For Individuals - West Virginia State Tax Department Page 2

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Section III. - continued
General Financial Information
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 Available
or Card
Financial Institution
Payment
Limit
Owed
0.00
0.00
0.00
0.00
Totals (Enter in Items 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
a.
County _________
b.
County _________
c.
County _________
17
.Life insurance (Name of Company)
Policy
Type
Face
Available Loan
Number
Amount
Value
Whole
Term
Whole
Term
Whole
Term
Total
$
0.00
(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 conditions. If you check the yes box below , please give dates and explain on page 4,
Additional information or Comments:
a
. Court proceedings
Yes
No
b. Bankruptcies
Yes
No
c. Repossessions
Yes
No
d. Recent sale or other transfer
Yes
No
of assets for less than full value

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