Form Ador 10847 - Collection Information Statement For Businesses Page 8
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10Arizona Department of Revenue
Collection Information Statement for Businesses
Business Name
!
Failure to complete all entry spaces may result in rejection or signifi cant delay in the
resolution of your account.
CAUTION
Certifi cation: Under penalties of perjury, I declare that to the best of my knowledge and belief,
this statement of assets, liabilities, and other information is true, correct and complete.
Print Name
Title
TYPE YOUR NAME
TYPE YOUR TITLE
Your Signature
Date
Print Form
Reset Form
Check this box when all spaces in all sections are fi lled in and
all attachments are provided.
ADOR 10847 (4/10)
Page 8 of 8
Previous ADOR 20-1020
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Parent category: Financial