Form Ador 10847 - Collection Information Statement For Businesses Page 7
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10Arizona Department of Revenue
Collection Information Statement for Businesses
DATE FIELDS:
Type only the MMDDYY digits. Acrobat will enter
Business Name
the slashes for you.
Current
Liabilities
Equity in
Monthly
Date of
Section 9
Market Value Balance Due
Asset
Payment
Name and Address of
Date
Final
Description
$
$
$
$
Lien/Note Holder/Obligee
Pledged
Payment
Asset and
Liability
39 Cash on hand
MM DD YY MM DD YY
Analysis
40 Bank accounts
MM DD YY MM DD YY
41 Accounts/Notes received
MM DD YY MM DD YY
Complete all
42 Life insurance loan value
MM DD YY MM DD YY
entry spaces
with the most
a.
43 Real
MM DD YY MM DD YY
current data
Property
b.
MM/DD/YY MM DD YY
available not
to exceed 60
c.
MM DD YY MM DD YY
days in age.
d.
MM/DD/YY MM/DD/YY
44 Vehicles
a.
MM DD YY MM DD YY
(model,
b.
year,
MM DD YY MM DD YY
license)
c.
MM DD YY MM DD YY
45 Merchan-
a.
MM DD YY MM DD YY
dise and
Equip-
b.
MM DD YY MM DD YY
ment
c.
(specify)
MM DD YY MM DD YY
46 Merchan-
a.
dise
MM DD YY MM DD YY
Inventory
b.
(specify)
MM DD YY MM DD YY
47 Other
a.
MM DD YY MM DD YY
Assets
b.
(specify)
MM DD YY MM DD YY
48 Other
a.
MM DD YY MM DD YY
Liabilities
b.
MM DD YY MM DD YY
(include
c.
notes
MM DD YY MM DD YY
and
d.
judg-
MM DD YY MM DD YY
ments)
e.
MM DD YY MM DD YY
f.
MM DD YY MM DD YY
g.
MM DD YY MM DD YY
Check this
State taxes owed
MM DD YY MM DD YY
box when all
spaces in
49 Federal taxes owed
MM DD YY MM DD YY
Section 9 are
fi lled in
50 TOTALS
Section 10
Additional information regarding fi nancial condition: (Court proceedings, bankruptcies fi led or anticipated, transfers of assets for less than full value,
Additional
changes in market conditions, etc.. Include information regarding company participation in trusts, estates, profi t-sharing plans, etc.)
Information
or
Comments
Signature required on page 8
ADOR 10847 (4/10)
Page 7 of 8
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Parent category: Financial