Pa2 Collection Information Statement For Businesses Page 4
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4Income and Expense Analysis
Income
Expenses
Gross receipts from sales, services, etc.
$
Materials purchased
$
Gross rental income
Net wages and salaries
Number of employees
Interest
Rent
Dividends
Installment payments
Other income (specify)
Supplies
Utilities / Telephone
Gasoline / Oil
Repairs and maintenance
Insurance
Current taxes
Other (Specify)
Total income
$
Total Expenses
$
Net difference
$
Certification: 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.
Signature
Date
Financial Verification / Analysis (to be completed by The Collection Division)
Item
Date Information or
Date Property
Estimated Forced
Sale Equity
Encumbrance Verified
Inspected
Sources of Income/Credit (D&B Report)
Expenses
Real Property
Vehicles
Machinery and Equipment
Merchandise
Accounts/Notes Receivable
Corporate Information, If Applicable
U.C.C.: Senior/Junior Lienholder
Other Assets/Liabilities
Explain any differences “Net Difference” (or P&L ) and the installment agreement payment amount:
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