Pa2 Collection Information Statement For Businesses
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4PA-2 (Rev. 1/06)
Government of the District of Columbia • Office of Tax and Revenue • Collection Division
Collection Information Statement for Businesses
Note: Complete all blocks. Write “N/A” (not applicable) in blocks that do not apply.
Name and address of business (list other locations or other businesses that you own on
Business phone number
(
)
a separate sheet & attach)
Check appropriate box
Sole Proprietor
Corporation
Partnership
LLC
Other
Name and title of person being interviewed
Employer Identification #
Type of business
Information about owner, partners, officers, major shareholder, etc.
Name and Title
Effective Date
Home Address
Phone Number
SSN
Total Shares
(
)
(
)
(
)
(
)
(
)
General Financial Information
Latest filed federal individual and/or
Form
Tax Year ended
Net Income before taxes
business income tax return (please
)
attach a copy
Bank accounts (List all types of accounts including payroll, general, savings, certificates of deposit, etc.)
Name of Institution
Address
Type of Account
Account Number
Balance
Total
Bank credit available (Lines of credit, etc.)
Name of Institution
Address
Credit Limit
Amount Owed
Credit Available
Monthly Payments
Totals
Location, box number and contents of all safe deposit boxes rented or accessed:
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