Form Ador 10847 - Collection Information Statement For Businesses Page 3
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10YELLOW fields are Read-Only. You cannot enter data in yellow fields; they are calculated as you fill in the form.
Arizona Department of Revenue
Collection Information Statement for Businesses
Business Name
9
BUSINESS ASSETS. List all business assets and encumbrances below. Include Uniform Commercial Code (UCC) fi lings. (If
Section 4
you need additional space, attach a separate sheet.) Note: If attaching a depreciation schedule, the attachment must include all
continued
of the information requested below.
Check this
Current
Loan
Monthly
Date of
box if you
Description
Value
Balance
Name of Lender
Payment
Final Payment
are attaching
a depreciation
9a
Machinery:
schedule for
machinery/
$
$
$
MM DD YY
equipment in
lieu of
$
$
$
completing
MM DD YY
line 9.
$
$
$
MM DD YY
Current
Equipment:
Value:
$
$
$
MM DD YY
Indicate the
amount you
$
$
$
MM DD YY
could sell
$
$
$
MM DD YY
the asset
for today.
Merchandise:
$
$
$
MM DD YY
Date of Final
Payment:
$
$
$
MM DD YY
Enter the date
Other Assets: (List below)
the loan or
lease will be
9b
$
$
$
MM DD YY
fully paid.
9c
$
$
$
MM DD YY
Check this
box when all
spaces in
ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly payment amount and
Section 4 are
fi lled in and
current loan balance for assets listed which have an encumbrance.
attachments
are provided
Section 5
NO YES
10
Do you owe any federal taxes? .........................................................................................................................................
Federal and
If “Yes”, how much? $_____________________
Amount of payment: $_____________________
Other
Taxes Owed
10a Do you owe any other government agency? .....................................................................................................................
If “Yes”, who?
How much is owed? $_____________________
Amount of payment: $_____________________
Section 6
11
INVESTMENTS. List all investment assets below. Include stocks, bonds, mutual funds, stock options and certifi cates of
deposits. If you need additional space, attach supplemental page.
Investment,
Banking and
Number of
Current
Used as collateral
Loan
Net Value
Cash
(a)
(b)
Company Name
Shares/Units
Value
on loan?
Amount
(a - b)
Information
11a
$
No
Yes $
$
11b
$
No
Yes $
$
11c
$
No
Yes $
$
11d
$
No
Yes $
$
Check this
11e
$
No
Yes $
$
box when all
spaces in
You must calculate and enter line 11f amount.
11f Subtotal from supplemental pages ............................................................................................................... 11f $
Sections 5 and
6 are fi lled in
11g Total Net Investments: Sum of the Net Values for lines 11a thru 11e plus line 11f ................................... 11g $
Section 6 continues on page 4
Supplement
ADOR 10847 (4/10)
Page 3 of 8
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