Form Uc-010 - Installment Payment Agreement Page 2
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UC-010-FF (8-17)
Page 2 of 2
FINANCIAL STATEMENT
YOUR NAME (Last, First, M.I.)
SOCIAL SECURITY NUMBER
OCCUPATION
SPOUSE’S NAME (If applicable – Last, First, M.I.)
SOCIAL SECURITY NUMBER
OCCUPATION
RESIDENTIAL ADDRESS (No., Street, Apartment or Space No., City, State, ZIP Code)
HOME PHONE NUMBER
BUSINESS ADDRESS (No., Street, Suite No., City, State, ZIP Code)
PHONE NUMBER
YOUR CURRENT EMPLOYER (If different than on the front of form)
WORK PHONE NUMBER
PAY DAY(S)
GROSS MONTHLY INCOME
$
SPOUSE’S CURRENT EMPLOYER (If different than on the front of form)
WORK PHONE NUMBER
PAY DAY(S)
GROSS MONTHLY INCOME
$
OTHER INCOME (Specify)
DATE RECEIVED
GROSS MONTHLY INCOME
$
ASSETS
LIABILITIES
TOTAL DUE
MO. PAYMENTS
Cash
Notes Payable
Bank (Checking)
INCOME TAXES/OTHER TAXES
Bank (Savings)
Stocks and Bonds
Cash or Loan Value of Insurance
CURRENT TIME PAYMENTS
Accounts/Notes Receivable
Merchandise Inventory
Machinery and Equipment
Household Furniture
Real Property
Rent or Mortgage Payment
Vehicle (1)
Auto Loan (1)
Vehicle (2)
Auto Loan (2)
Other Assets (Describe)
OTHER OBLIGATIONS (Specify)
TOTAL
TOTAL
NAME OF FINANCIAL INSTITUTION AND CHECKING ACCOUNT NUMBER(S):
NAME OF FINANCIAL INSTITUTION AND SAVINGS ACCOUNT NUMBER(S):
DESCRIPTION AND LICENSE NUMBER OF EACH VEHICLE OWNED OR BEING PURCHASED:
REAL PROPERTY (Briefly describe and indicate location):
DESCRIPTION AND LOCATION OF MACHINERY, EQUIPMENT AND INVENTORY:
DESCRIPTION AND LOCATION OF ALL OTHER ASSETS:
ACCOUNTS RECEIVABLE (Names, addresses and phone numbers) – USE A SEPARATE SHEET IF NEEDED:
AFFIDAVIT
Under penalties of perjury, I/we declare that the information provided above is true and correct to the best of my/our knowledge and belief.
YOUR SIGNATURE
SPOUSE’S SIGNATURE
DATE
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