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Form 10896 Fillable Collection Information Statement - Personal
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)Check this box Check this box Check this box Check this box Check this box Complete all entry spaces with the most current data available Copies of any court order requiring payment and proof of such payments (e g cancelled checks money Credit Account Credit Account Current Loan Current Value: Current Value: Mileage Date of Final If paid bi weekly (every 2 weeks): Multiply bi weekly gross wages by 2 17 Example: $972 45 x 2 17 = $2 110 22 If paid semi monthly (twice each month): Multiply semi monthly gross wages by 2 Example: $856 23 x 2 = $1 712 46 If paid weekly: Multiply weekly gross wages by 4 3 Example: $425 89 x 4 3 = $1 831 33 Important! Write N/A (not applicable) in spaces that do not apply We may Investment Account Investment Account Married Separated Own Home Rent No Yes No Yes No Yes $ $ No Yes (If Yes provide the following information) No Yes No Yes Pension Social Security Other (Specify i e child support alimony rental) Proof of all current expenses that you paid for the past 3 months including utilities rent insurance Proof of all non business transportation expenses (e g car payments lease payments fuel oil Proof of all payments for health care including health insurance premiums co payments and other Unmarried (single divorced widowed) Other (specify i e share rent live with relative): (: Month) Unchecked (: No) Unchecked (: No) Unchecked (: No) Unchecked (: No) Unchecked (: No) Unchecked (: No) Unchecked (: Year) Unchecked (: Yes) Unchecked (: Yes) Unchecked (: Yes) Unchecked (: Yes) Unchecked (: Yes) Unchecked (: Yes) Unchecked (602) 542 5551 (a b) (a b) (a b)Indicate type of account: (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (Click on an option to select or type your own) (Click on an option to select or type your own) (Click on an option to select or type your own) (Click to calculate page 5) Calculate (Click to clear form) Reset Form (Click to clear page) Reset Page (Click to go to Supplement Page) Supplement (Click to print form) Print Form (Click to print page) Print Page (Click to return to page 2) Page 2 (Click to select an option: 1) Unchecked (Click to select an option: 2) Unchecked (Click to select an option: 3) Unchecked (Click to select an option: 3) Unchecked (Click to select an option: No) Unchecked (Click to select an option: No) Unchecked (Click to select an option: No) Unchecked (Click to select an option: Yes) Unchecked (Click to select an option: Yes) Unchecked (Click to select an option: Yes) Unchecked (Click to select one option: 0) Unchecked (Click to select one option: 0) Unchecked (Click to select one option: 1) Unchecked (Click to select one option: 2) Unchecked (Click to select one option: 2) Unchecked (Click to select one option: No) Unchecked (Click to select one option: Yes) Unchecked (color 932) (Enter digits only; include area code) (Enter digits only; include area code) (Enter MMDDYY digits only) (Enter MMDDYY digits only) (Enter MMDDYYYY digits only) (Enter MMYYYY digits only) (Enter the amount of investments from supplemental page) (Term life insurance does not have a cash value ) If Yes : (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) 0 (text) Acrobat Reader 8 and 9 users: You may fill in and save this form with the data Once you save the form you cannot edit your data (text) Select only one account type below; enter information for that account (text) Select only one account type below; enter information for that account (text) Some fields on this page are Read Only You cannot enter data in these fields; they are calculated as you fill in the form (text) YELLOW fields are Read Only You cannot enter data in yellow fields; they are calculated as you fill in the form (text) You must calculate and enter line 12c amount (text) You must calculate and enter line 13c amount (text) You must calculate and enter line 15c amount (text) You must click the Yes checkbox to enter detailed information (text) You must click the Yes checkbox to enter detailed information (text) You must click the Yes checkbox to enter insurance information (Type digits only without dashes) (Type MMDDYY digits only) (Type MMDDYY digits only) (Type MMDDYY digits only) (Type MMDDYY digits only) (Type MMDDYY digits only) (Type MMDDYY digits only) (Type MMDDYYYY digits only) 1 such statement as long as a minimum of 3 months is represented 10 Do you receive income from sources other than your own business or your employer? Check all that apply: 11 CHECKING ACCOUNTS List all checking accounts (If you need additional space attach a separate sheet ) 11a Checking Name $ 11b Checking Name $ 11c Total Checking Account Balances 11c $ 13c Subtotal from supplemental page 13c $ 13d Total Net Investments 13d $ 14 CASH ON HAND Enter the total of any cash you have that is not currently in a bank 14 $ 15 AVAILABLE CREDIT List all lines of credit including credit cards (If you need additional space attach supplemental page ) 15a Name 15b Name 15c Subtotal from supplemental page 15c $ 15d Total Credit Available 15d $ 16 LIFE INSURANCE Do you have life insurance with a cash value? No Yes 1600 West Monroe 16a Name of Insurance Company: 16b Policy Number(s): 16d Current Cash Value 16d $ 16f Total Cash Value: Subtract line 16e from line 16d; enter the difference 16f $ 18b Are there any judgments against you? No Yes 18c Are you a party in a lawsuit? 18d Have you ever fi led bankruptcy? 18g Are you a beneficiary of a trust an estate? 18h Are you a participant in a profit sharing plan? 19a Year 1a Your Full Name 1b Your Social Security No 1c Your Date of Birth 1d Spouse s Full Name 1e Spouse s Social Security No 1f Spouse s Date of Birth 2 Marital Status (check one box): 3 Check one box: 20 REAL ESTATE List all real estate you own (If you need additional space attach a separate sheet ) 21a Furniture/Personal Effects 21b Artwork: 21c Jewelry: 22 Wages (Yourself) $ 25 Net Income from Business 26 Net Rental Income 33 Rent/Mortgage 34 Groceries (no of people ) 35 Installment Payments 36 Utilities: 36a Gas $ 36b Water $ 36c Electric $ 36d Phone $ 36e Total Utilities Expense 37 Transportation 38a Life $ 38c Car $ 38d Total Insurance Expense 39 Medical expenses 40 Estimated tax payments 41 Court ordered/Child support payment 42 Child/Dependent care 43 Other Expenses 44 TOTAL LIVING EXPENSES $ 45 NET DIFFERENCE: Subtract Total Living Expenses (line 44) from Total Net Income (line 32) $ 4a Street Address 4b City State ZIP Code 4c County of Residence 4d How long at this address? 5 Home Phone (with area code) 6 List the dependents you can claim on your tax return (attach sheet if more space is needed): 7 Are you or your spouse self employed or operate a business? Check Yes if either applies 7a Name of Business 7d Employer I D No 7b Street Address 7e Do you have employees? No Yes 7c City State Zip 8a Your Employer 9a Spouse s Employer 8b Street Address 9b Street Address 8c City State Zip 9c City State Zip 8d Work Phone (with area code) 9d Work Phone: (with area code) 8e How long with this employer? 9e How long with this employer? 8f Occupation 9f Occupation a) Subtotal Investment Account Net Values: List here and on page 2 line 13c a) $ Account Balance Account Credit Union or Financial Institution Account Credit Union or Financial Institution Routing No Account No Account Balance Account No Actual DOR Use ADOR 10896 (10/10) ADOR 10896 (10/10) Page 3 of 4 Section 9 begins on page 4 ADOR 10896 (10/10) Page 4 of 4 ADOR 10896 (10/10) Section 5 continues on page 2 ADOR 20 1020 Amount of debt $ amount you could amount you could Make/Model Analysis 24 Interest Dividends and all attachments and attachments and current balance for each piece of real estate owned and Life and retirement assets such as IRAs Keogh and 401(k) plans (If you need additional space attach supplemental page ) Anticipated amount to be received? $ When will the amount be received? are fi lled in are provided are provided 16e Outstanding Loan Balance 16e $ are provided 21g are provided Spouse s Signature Date Are there any garnishments against your wages? No Yes Arizona Department of Revenue Arizona Department of Revenue ARIZONA DEPARTMENT OF REVENUE ARIZONA DEPARTMENT OF REVENUE Arizona Department of Revenue Collection Information Statement (Personal) Assets and Description Current Loan/Lease Name of Purchase/Lease MonthlyLiabilities (Year Make Model Mileage) Value Balance Lender/Lessor Date Payment Attachments Attachments ATTACHMENTS REQUIRED Please include the following: ATTACHMENTS REQUIRED: Please include a statement from the life insurance companies that includes type and ATTACHMENTS REQUIRED: Please include proof of gross earnings and deductions for the past 3 months from ATTACHMENTS REQUIRED: Please include proof of pension/social security/other income for the past 3 months ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly payment amount ATTACHMENTS REQUIRED: You must complete a Collection Information Statement for Businesses available b) Subtotal Other Account Current Balances: List here and on page 2 line 12c b) $ Bank Routing No Bank Account No Current Balance Bank Routing No Bank Account No Current Balance Banking both have 30 Alimony brokerage accounts) for the past three months for all accounts Business c) Subtotal Credit Available: List here and on page 2 line 15c c) $ Cash Credit Cash etc cash/loan value amounts If currently borrowed against include loan amount and date of loan CAUTION ! Certification: Under penalties of perjury I declare that to the best of my knowledge and belief City State Zip City State Zip City State Zip Code City State Zip Code City State Zip Purchased Price Value Balance or Lien Holder Payment Payment Collection Information Statement (Personal) Collection Information Statement (Personal) Company Name Company Name Company Name Shares/Units Value (a) on loan? Amount (b) (a b) Complete all City State Zip continued continued Type of Full Name of Bank Savings & Loan Bank Bank Current County Credit Limit Amount Owed Available Credit Credit Limit Amount Owed Available Credit current data Attachments ATTACHMENTS REQUIRED: Please include your current bank statements (checking savings money market and deduct withholding or allotments you elect to take out of your pay such as insurance payments credit union deductions car payments Description Do you anticipate any increase in household income in the next two years? Do you owe any federal taxes? No Yes Do you owe any other government agency? No Yes Does this person Does this person each employer (e g pay stubs earnings statements) If year to date information is available send only 1 such Employment entry spaces 12c Subtotal from supplemental page 12c $ etc To calculate your gross monthly wages and/or salaries: Expense 23 Wages (Spouse) Expense Items expenses 38b Health $ Failure to complete all entry spaces may result in rejection or significant delay in the Federal and filled in and attach First Name Relationship Age live with you? First Name Relationship Age live with you? following: property taxes homeowner s or renter s insurance maintenance dues and fees from each payor including any statements showing deductions If year to date information is available send only Full Name of Credit Institution Credit Limit Amount Owed Available Credit fully paid 20b Furniture/Personal Effects includes the total current market value of your household such as furniture and appliances Groceries: Total of food expenses for one month Gross How much is owed? $ Amount of payment: $ How much will it increase? $ If only one 27 Pension/Social Security (Yourself) If yes amount of suit $ Possible completion date If yes date filed Date discharged If Yes how much? $ Amount of payment: $ If yes name of plan Value in plan $ If yes name of the trust estate If yes what asset? Value of asset at time of transfer $ If yes who is the creditor? Date creditor obtained judgement: If Yes who? If yes why will the income increase? (Attach sheet if you need additional space) in and attachments In the past 10 years have you transferred any assets out of your name for less than their actual value? Income Income and income and 32 TOTAL INCOME $ income list the 31 Other Income Indicate the Indicate the 19b Year Indicate type of account: Indicate type of account: Information Information Information Information 12b Insurance City State Zip insurance parking registration) Investment INVESTMENTS List all investment assets below Include stocks bonds mutual funds stock options certificates of deposits lines 11 thru 11c are List additional accounts not listed on page 2 Make/Model Medical Expenses: List medical expenses not covered by insurance ments are provided MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY $ MM/DD/YYYY MM/YYYY Monthly Monthly Date of Name of Institution necessary monthly business expenses If your net business income is a loss enter 0 Do not enter a negative number Net Income from Business: Enter your monthly net business income This is the amount you earn after you pay ordinary and Net Rental Income: Enter your monthly net rental income This is the amount you earn after you pay ordinary and necessary monthly Net Value Net Value No Shares/Units Current Value (a) No Shares/Units Current Value (a) NO YES Number of Current Used as collateral Loan Net Value on loan? Loan Amount (b) on loan? Loan Amount (b) or lease will be orders earning statements showing such deductions) for the past 3 months Other Other Other Account Type: Other Account Type: OTHER INFORMATION Respond to the following questions related to your financial condition (Attach a sheet if Other Personal Assets includes all artwork jewelry collections (coin/gun etc ) antiques or other assets Other Taxes Other: (List below) out of pocket expenses for the past 3 months Page 2 of 4 Section 7 continues on page 3 Payment: Enter per month per year Personal PERSONAL ASSETS List all personal assets below (If you need additional space attach a separate sheet ) Phoenix AZ 85007 Failure to complete all entry spaces may result in rejection or significant delay in the Previous ADOR 20 1070 Previous ADOR 20 1070 Previous ADOR 20 1070 property taxes etc Rent/Mortgage: For your principal residence: Total of rent or mortgage payment Add the average monthly expenses for the rental expenses If your net rental income is a loss enter 0 Do not enter a negative number require additional information to support N/A entries resolution of your account Routing No Section 1 Section 1 are fi lled in Section 2 Section 2 are fi lled in Section 3 Section 3 are fi lled in Section 4 Section 5 Section 5 12 OTHER ACCOUNTS List all accounts including brokerage accounts savings and money market accounts not listed on line 11 Section 5 are filled Section 6 Section 7 Section 7 18 Section 7 are fi lled in Section 8 19 PURCHASED AND LEASED AUTOMOBILES TRUCKS AND OTHER LICENSED ASSETS Include boats RV s motorcycles Section 8 are fi lled in Section 9 are fi lled in Section 9 Total Monthly Income Total Monthly Expenses Sections 4 and 5 Sections 6 and 7 If yes who is the creditor? Date creditor obtained judgement: sections are fi lled in sell the asset for sell the asset for Mileage Show the full name of the investment company bank savings and loan credit or other fi nancial institution Source spouse has a 28 Pension/Social Security (Spouse) statement as long as a minimum of 3 months is represented Street Address Street Address Street Address Street Address Street Address Street Address Date Purchase Current Loan Name of Lender Monthly of Final Subject matter of suit SUPPLEMENTAL PAGE: Investment Bank Credit Other Accounts tax liability but 29 Child Support the date the loan this statement of assets liabilities and other information is true correct and complete today tolls for one month total household 38 Insurance: trailers etc (If you need additional space attach a separate sheet ) Transportation: Total of lease or purchase payments registration fees normal maintenance fuel public transportation parking and Type of Full Name of Bank Savings & Loan Bank Bank Current Used as collateral Used as collateral Value Balance Name of Lender Payment Final Payment Wages salaries pensions and social security: Enter your gross monthly wages and/or salaries Enter your net income and when all spaces in when all spaces in when all spaces in when all spaces in when all spaces in 16c Owner of Policy: when all spaces in 21e when all spaces in all When was it transferred? To whom or where was it transferred? with the most 12d Total Other Account Balances 12d $ www azdor gov you need more space) Your Signature Date