Form Ador 10847 - Collection Information Statement For Businesses Page 4

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Arizona Department of Revenue

Collection Information Statement for Businesses

Business Name

Supplement

BANK ACCOUNTS. List all checking and savings accounts.

Section 6

Type of

Full Name of Bank, Savings & Loan,

Bank

Current

continued

Account

Credit Union or Financial Institution

Routing No.

Account No.

Account Balance

12a

Name

Complete all

Street Address

entry spaces

City, State, Zip

with the most

current data

12b

Name

available.

Street Address

City, State, Zip

12c

Name

Street Address

City, State, Zip

12d Total Bank Account Balances .................................................................................................................... 12d $

ATTACHMENTS REQUIRED: Please include your current bank statements (checking and savings) for the past three

months for all accounts.

13 OTHER ACCOUNTS. List all accounts including brokerage accounts, money market, additional checking and savings accounts

not listed on line 12 and any other accounts not listed in this section. If you need additional space, attach supplemental page.

Type of

Full Name of Bank, Savings & Loan,

Bank

Current

Account

Credit Union or Financial Institution

Routing No.

Account No.

Account Balance

13a

Name of Institution

Street Address

City, State, Zip

13b

Name of Institution

Street Address

City, State, Zip

You must calculate and enter line 13c amount.

13c Subtotal from supplemental pages ............................................................................................................... 13c $

13d Total Bank Account Balances .................................................................................................................... 13d $

ATTACHMENTS REQUIRED: Please include your current bank statements (checking, savings, money market, and

brokerage accounts) for the past three months for all accounts.

14 CASH ON HAND. Include any money that you have that is not in the bank.

14a Total Cash on Hand .................................................................................................................................... 14a $

15 AVAILABLE CREDIT. List all lines of credit, including credit cards. If you need additional space, attach supplemental page.

Full Name of Credit Institution

Credit Limit

Amount Owed

Available Credit

15a Name

Street Address

City, State, Zip

15b Name

Check this

box when all

Street Address

spaces in

Section 6 are

City, State, Zip

ﬁ lled in and

attachments

You must calculate and enter line 15c amount.

15c Subtotal from supplemental pages ............................................................................................................... 15c $

are provided

15d Total Credit Available .................................................................................................................................. 15d $

ADOR 10847 (4/10)

Page 4 of 8

Section 7 begins on page 5.

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