Form Ador 10847 - Collection Information Statement For Businesses Page 2
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10Arizona Department of Revenue
Collection Information Statement for Businesses
Business Name
6
PURCHASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s, motorcycles, trailers, etc. (If
Section 4
Section 4
you need additional space, attach a separate sheet.)
Business
Business
Description
Current
Loan
Name of
Purchase
Monthly
Assets
Assets
(Year, Make, Model, Mileage)
Value
Balance
Lender
Date
Payment
6a
Year
Make/Model
Current
Current
MM DD YY
Mileage
$
$
$
Value:
Value:
Indicate the
Indicate the
6b
Year
amount you
amount you
Make/Model
could sell
could sell
MM DD YY
Mileage
$
$
$
the asset
the asset
6c
Year
for today.
for today.
Make/Model
MM DD YY
Mileage
$
$
$
7
LEASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s, motorcycles, trailers, etc. (If you
need additional space, attach a separate sheet.)
Description
Lease
Lease
Monthly
(Year, Make, Model)
Balance
Name of Lessor
Date
Payment
7a
Year
MM DD YY
Make/Model
$
$
7b
Year
MM DD YY
Make/Model
$
$
7c
Year
MM DD YY
Make/Model
$
$
ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly car payment amount
and current balance of the loan for each vehicle purchased or leased.
8
REAL ESTATE. List all real estate owned by the business. (If you need additional space, attach a separate sheet.)
Date
Date of Final
Date of Final
Street Address
Date
Purchase
Current
Loan
Name of Lender
Monthly
of Final
Payment:
Payment:
City, State, Zip
Purchased
Price
Value
Balance
or Lien Holder
Payment
Payment
Enter the date
Enter the date
8a
the loan or
the loan or
lease will be
lease will be
fully paid.
fully paid.
MM DD YY
MM DD YY
County
$
$
$
$
8b
MM DD YY
MM DD YY
County
$
$
$
$
8c
Check this
Check this
MM DD YY
MM DD YY
County
$
$
$
$
box when all
box when all
spaces on
spaces on
this page of
this page of
Section 4 are
Section 4 are
ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly payment amount and
fi lled in and
fi lled in and
current balance for each piece of real estate owned.
attachments
attachments
are provided
are provided
Section 4 continues on page 3
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