Form Ador 10847 - Collection Information Statement For Businesses

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COLLECTION INFORMATION STATEMENT FOR BUSINESSES
• Complete all entry spaces with the most current data available.
• Important! Write “N/A” (not applicable) in spaces that do not apply. We may
ARIZONA DEPARTMENT OF REVENUE
require additional information to support “N/A” entries.
1600 West Monroe
• Failure to complete all entry spaces may result in rejection or signifi cant delay in the
Phoenix, AZ 85007
(602) 542-5551
resolution of your account.
Section 1
1a Business Name
2c AZ Withholding No.
Business
1b Business Street Address
2d Type of Entity (Check appropriate box below):
Information
Partnership
Corporation
Other
1c City
State
ZIP Code
2e Type of Business
1d County
1e Business Phone (with area code) 3a Contact Name
Check this
box when all
2a Employer ID No. (EIN)
2b AZ Transaction Privilege Tax No.
3b Contact’s Business Phone (with area code)
spaces in
Section 1 are
Ext.
fi lled in
Section 2
4
PARTNERS, OFFICERS, MAJOR SHAREHOLDERS, ETC.
4a
Full Name __________________________ Title
Social Security No.
Business
Home Street Address
Home Phone (
)
Personnel
and
City
State
Zip
Ownership Percentage & Shares or Interest
Contacts
4b
Full Name __________________________ Title
Social Security No.
Home Street Address
Home Phone (
)
City
State
Zip
Ownership Percentage & Shares or Interest
4c
Full Name __________________________ Title
Social Security No.
Home Street Address
Home Phone (
)
City
State
Zip
Ownership Percentage & Shares or Interest
Check this
4d
Full Name __________________________ Title
Social Security No.
box when all
spaces in
Home Street Address
Home Phone (
)
Section 2 are
City
State
Zip
Ownership Percentage & Shares or Interest
fi lled in
Section 3
5
OTHER FINANCIAL INFORMATION. Respond to the following business fi nancial questions.
NO YES
5a
Does this business have other business relationships (e.g. subsidiary or parent corporation, partnership etc.)? ..............
Other
Financial
If yes, list related EIN _____________________________.
Additional EIN ______________________________
Information
5b
Does anyone (e.g. offi cer, stockholder, partner or employees) have an outstanding loan borrowed from the business? ..
MM/DD/YY
If yes, amount of loan $________________. Date of loan ________________. Current balance $_______________
5c
Are there any judgments or liens against your business? ...................................................................................................
If yes, who is the creditor? _______________________________________________________________________
MM/DD/YY
Date creditor obtained judgment/lien ________________.
Amount of debt $________________.
5d
Is your business a party in a lawsuit? ..................................................................................................................................
MM/DD/YY
If yes, amount of suit $________________. Possible completion date ________________.
Subject matter of suit ___________________________________________________________________________
5e
Has your business ever fi led bankruptcy? ...........................................................................................................................
MM/DD/YY
MM/DD/YY
If yes, date fi led ________________. Date discharged ________________. Petition No. _____________________
5f
In the past 10 years, have you transferred any assets from your business name for less than their actual value? ...........
If yes, what asset? _________________________________. Value of asset at time of transfer $_______________.
MM/DD/YY
When was it transferred? ________________. To whom or where was it transferred? _________________________
5g
Do you anticipate any increase in business income (e.g. contracts bid but not yet awarded)? ..........................................
If yes, why will the income increase? (Attach sheet if you need additional space) __________________________________
How much will it increase? $________________. When will the business income increase? ___________________
5h
Is your business a benefi ciary of a trust, an estate or a life insurance policy? ....................................................................
Check this
box when all
If yes, name of the trust, estate or policy? ___________________________________________________________
spaces in
Section 3 are
Anticipated amount to be received? $________________.
When will the amount be received? _______________
fi lled in
ADOR 10847 (4/10)
Section 4 begins on page 2
Previous ADOR 20-1020

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