Form Ador 10847 - Collection Information Statement For Businesses Page 9
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10Arizona Department of Revenue
Collection Information Statement for Businesses
Business Name
SUPPLEMENTAL PAGE:
Investment, Bank, Credit, Other Accounts
List additional accounts not listed on pages 3 or 4.
Show the full name of the investment company, bank, savings and loan, credit, or other fi nancial institution.
Company Name
Street Address
City, State, Zip Code
A
Select only one account type below; enter information for that account.
Used as collateral
Net Value
Indicate type of account:
No. Shares/Units
Current Value
(a)
on loan?
Loan Amount
(b)
(a - b)
Investment Account
$
No
Yes
$
Other Account Type:
Bank Routing No.
Bank Account No.
Current Balance
$
Credit Limit
Amount Owed
Available Credit
Credit Account
$
$
$
Company Name
Street Address
City, State, Zip Code
B
Select only one account type below; enter information for that account.
Used as collateral
Net Value
(a)
(b)
Indicate type of account:
No. Shares/Units
Current Value
on loan?
Loan Amount
(a - b)
Investment Account
$
No
Yes
$
Other Account Type:
Bank Routing No.
Bank Account No.
Current Balance
$
Credit Limit
Amount Owed
Available Credit
Credit Account
$
$
$
Company Name
Street Address
City, State, Zip Code
C
Select only one account type below; enter information for that account.
Used as collateral
Net Value
(a)
(b)
Indicate type of account:
No. Shares/Units
Current Value
on loan?
Loan Amount
(a - b)
Investment Account
$
No
Yes
$
Other Account Type:
Bank Routing No.
Bank Account No.
Current Balance
$
Credit Limit
Amount Owed
Available Credit
Credit Account
$
$
$
Company Name
Street Address
City, State, Zip Code
D
Select only one account type below; enter information for that account.
Used as collateral
Net Value
Indicate type of account:
No. Shares/Units
Current Value
(a)
on loan?
Loan Amount
(b)
(a - b)
Investment Account
$
No
Yes
$
Other Account Type:
Bank Routing No.
Bank Account No.
Current Balance
$
Credit Limit
Amount Owed
Available Credit
Credit Account
$
$
$
Page 3
a) Subtotal Investment Account Net Values: List here and on page 3, line 11f ..............................................................a)
$
b) Subtotal Bank Account Current Balances: List here and on page 4, line 13c ...........................................................b)
$
Page 4
c) Subtotal Credit Available: List here and on page 4, line 15c .......................................................................................c)
$
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Parent category: Financial