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Form RO-1062 N.C Department of Revenue
(Rev. 5-19) CollectionInformationStatementforIndividuals
Note: Complete all blocks, except shaded areas. Write "N/A" (not applicable) in those blocks that do not apply.
1. Taxpayers' names and address (including County) 2a. Home phone number 3a. Taxpayer's social security number
3b. Spouse's social security number
2b. Cell phone number
4a. Taxpayer's date of birth
# of years at this address 2c. Business phone number 4b. Spouse's date of birth
Own Rent
Section 1. Personal Information
5. Do you have a power of attorney for tax matters? If yes, please attach a copy. Marital Status:
yes no married unmarried (single, divorced, widowed)
6. Age and relationship of dependents (exclude yourself and spouse) living in your household.

Section 2. Employment Information
7. Taxpayer's employer or business 7a. How long employed 7c. Occupation 7e. (Check appropriate box)
(name and address) Wage earner
7b. Number of exemptions 7d. Paydays Sole proprietor
claimed on Form NC-4
Partner/Member
8. Spouse's employer or business 8a. How long employed 8c. Occupation 8e. (Check appropriate box)
(name and address) Wage earner
8b. Number of exemptions 8d. Paydays Sole proprietor
claimed on Form NC-4
Partner/Member
Business phone #
9. Latest filed income tax 10. Number of exemptions 11. Adjusted Gross Income
return (tax year) claimed

Section 3 Liquid Assets
12. Cash on Hand. Include cash that is not in the bank. Total Cash on Hand $
13. Bank accounts (Include Savings & Loans, Credit Unions, Certificates of Deposits, Paypal accounts, Apple Pay accounts etc.)
Name of Institution Address Type of Account Account No. 3 month average
ending balance
13a.
13b.
13c.
13d.
13e.Total $
14. Virtual Currency/Cryptocurrency : (Bitcoin, Litecoin, etc)
Location(s) of Virtual
Currency (Mobile Wallet,
Name of Virtual Currency Wallet, Exchange Online and/or External Virtual Currency amount
Type of Virtual Currency or Digital Currency Exchange Hardware storage and value in US dollars. 3 month average
14a.
14b.
14c.
14d.
14e.Total $
15. Investment Accounts: Include stocks, bonds, mutual funds, stock options, certificates of deposit, & retirement assets such as IRAs, Keogh, & 401(k) plans.
Include all corporations, partnerships, limited liability companies or other business entities in which the individual is an officer,
director, owner, member, or otherwise has a financial interest.
Loan Balance
(if applicable)
Type of Investment Full Name & Address(City, State, Zip Code) Current As of Equity
or Financial Interest of Company Market Value mm/dd/yyyy Value Minus Loan
15a.
15b.
15c.

15d. Total Equity (Add lines 15a through 15c and amounts from any attachments) $
Form RO-1062 page 1

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16.    Life Insurance  (Name of Company)                                   Policy Number             Type   Face Amount                        Available Cash Value
16a.
16b.
16c. Total                                                                                                                                     $
Section 4                                                  Real Property
17.  Real property owned, rented, and leased.  Include all real property and land contracts. (For personal and business use if sole proprietor)
17a.  Primary Residence
Purchase/Lease Date       County                     Current Fair Market Current Loan              Amount of Monthly Date of Final                    Equity
     (mm/dd/yy)           Tax Value                  Value (FMV)         Balance                          Payment       Payment                 FMV minus loan
                                                                                                                                                $
Property Location (Street, Address, State, ZIP code)                     Lender/Lessor/Landlord Name, Address, (Street, Address, State, ZIP code)

Property County                                                          Landlord/Lessor Phone Number
First Mortgage Holder                                                    Second Mortgage/Home Equity Line

17b.  Property Description
Purchase/Lease Date       County                     Current Fair Market Current Loan              Amount of Monthly Date of Final                    Equity
     (mm/dd/yy)           Tax Value                  Value (FMV)         Balance                          Payment       Payment                 FMV minus loan
                                                                                                                                                $
Property Location (Street, Address, State, ZIP code)                     Lender/Lessor/Landlord Name, Address, (Street, Address, State, ZIP code)

Property County                                                          Landlord/Lessor Phone Number
17c. Total  Fair Market Value                        17d. Total Current Loan Balance                      17e. Net Equity

                                                     Attach additional sheets as needed
Section 5.                                           Licensed Assets/Vehicles 
18.    Vehicles Purchased  Include boats, RVs, motorcycles, trailers, mobile homes, aircraft, etc.  (For personal and business use if sole proprietor)
     18a. Description     Purchase/Lease Date        Current Fair Market Current Loan              Amount of Monthly Date of Final                    Equity
     (Make, Model,        (mm/dd/yy)                 Value (FMV)         Balance                          Payment       Payment                 FMV minus loan
     Year, Mileage)                                                                                                                             $
                                                                         Lender/Lessor Name, Address, (Street, Address, State, ZIP code)
       Make               Model               Year   Mileage

     18b. Description     Purchase/Lease Date        Current Fair Market Current Loan              Amount of Monthly Date of Final                    Equity
     (Make, Model,        (mm/dd/yy)                 Value (FMV)         Balance                          Payment       Payment                 FMV minus loan
     Year, Mileage)                                                                                                                             $
                                                                         Lender/Lessor Name, Address, (Street, Address, State, ZIP code)
       Make               Model               Year   Mileage

18c. Total Current Fair Market Value                 18d. Total Current Loan Balance                      18e. Net Equity

18f. Vehicles Leased  Include boats, RVs, motorcycles, trailers, mobile homes, aircraft, etc. (For personal and business use if sole proprietor)
     18g. Description     Purchase/Lease Date        Current Fair Market Amount of                 Amount of Monthly Date of Final                    Equity
     (Make, Model,        (mm/dd/yy)                 Value (FMV)         Monthly Payment                  Payment       Payment                 FMV minus loan
     Year, Mileage)                                                                                                                             $
                                                                         Lender/Lessor Name, Address, (Street, Address, State, ZIP code)
       Make               Model               Year   Mileage

Form RO-1062 page 2

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Section 6. Other Personal Assets
19. Other Assets (Include all assets listed on homeowners insurance policy)
Current Liabilities Equity Amount of Date of
Description Market Balance In Monthly Name and Address of Date Final
Value Due Asset Payment Lien/Note Holder/Obligee Pledged Payment
19a.

19b.

19c .

19d. Total Current Fair 19e. Total Current Loan Balance 19f. Net Equity
Market Value

Section 7. Judgments & Secured Liens (other secured debts)
20. Other Liabilities (Include judgments and any secured debt)
Liabilities Amount of Date of
Description Balance Monthly Name and Address of Date Final
Due Payment Lien/Note Holder/Obligee Pledged Payment
20a. IRS

20b.

20c.

20d.
Total Liabilities
Balance Due
Section 8. Notes, Charge Accounts and Medical Expenses
21. Available Credit (list bank charge cards, credit unions, lines of credit, medical expenses)
Type of Account Name and Address of Monthly Credit Amount Credit
or Card Financial Institution Payment Limit Owed Available
21a.
21b.
21c.
21d.

21e. Total Credit Available $
Section 9. Other Financial Information
22. Other information relating to your financial condition. If you check the yes box, please give dates and explain under remarks.
a. Court proceedings Yes No b. Bankruptcies Yes No
Remarks: Remarks:

c. Repossessions Yes No d. Recent transfer of assets Yes No
for less than full value
Remarks: Remarks:

e. Anticipated increase in income Yes No f. Participant or beneficiary to trust, Yes No
estate, profit sharing, etc.
Remarks: Remarks:

g. Do you receive government assistance h. Are all required state tax returns filed?
based on disability and/or financial need? Yes No Yes No
Remarks: Remarks:

Form RO-1062 page 3

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23. Number in Household 24. # Cars 25. # Car Loans 26. County
Section 10. Monthly Income and Expense Analysis
INCOME
Source Net
27. Wages/ Salaries ( Taxpayer) * Attach copy of most recent pay stub
28. Wages/Salaries (Spouse) * Attach copy of most recent pay stub
29. Rent paid to taxpayer
30. Other members of household
31. Pension(s)
32. Social Security
33. Profit from Business
34. Commissions
35. Other Income
36. Total Income $

NECESSARY LIVING EXPENSES
Source Amount Source Amount
37. Mortgage/Rent 43. Auto loans
38. Utilities 44. Health/Life Insurance
A. Telephone/Cell 45. Medical
B. Electricity 46. IRS Tax Payments
C. Heating 47. Miscellaneous Payments
D. Water/Garbage A. Child Support
39. Homeowner/renter insurance B. Alimony
40. Groceries C. Daycare
41. Gas/Maintenance, etc. D. Estimated tax
42. Auto Insurance 48. Total Expenses $
Calculated Disposable Income (total income less total expenses)

Expenses not generally allowed: We generally do not allow tuition for private schools, public or private college expenses, charitable
contributions, voluntary retirement contributions, payments on unsecured debts such as credit card bills, cable television and other similar
expenses. However, we may allow these expenses if it is proven that they are necessary for the health and welfare of the individual or family
or for the production of income.
Under penalties of perjury, I declare that to the best of my knowledge and belief this
Certification statement of assets, liabilities, and other information is true, correct and complete.
Your signature Spouse's signature (if joint return was filed) Date

Attachments Required for Wage Earners and Self-Employed Individuals:
Copies of the following items for the last 3 months from the date this form is submitted. (check all the attached items)
Income- Earnings statements, pay stubs, etc. from each employer, pension/social security/other income, self employment income
(commissions, invoices, sales, records, etc. and business financial statement if self-employed.)
Banks, Investments, and Life Insurance - Statements for all money market, brokerage, checking and savings accounts, certificates
of deposit, IRA, stocks/bonds, and life insurance policies with a cash value.
Assets - Statements from lenders on loans (i.e: mortgage statements, car loans), monthly payments, payoffs, and balances for all personal
and business assets. Include copies of UCC financing statements and accountant's depreciation schedules.
Expenses - Bills or statements for monthly recurring expenses of utilities, rent, insurance, property taxes, phone and cell phone,
insurance premiums, court orders requiring payments (child support, alimony, etc.), other out of pocket expenses.

Other - credit card statements, profit and loss statements, all loan payoffs, etc.

A copy of the last 2 year's Form 1040 with all attachments. Include all Schedules K-1 from Form 1120S or Form 1065, as applicable.
Form RO-1062 page 4

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Sections 11 and 12 must be completed only if the taxpayer is SELF-EMPLOYED
Section 11. Business Information
49. Is the business a sole proprietorship (filing Schedule C) Yes, Continue with Sections 11 and 12. No, Complete Business Financial Statement
All other business entities, including limited liability companies, partnerships or corporations, must complete business financial statement.
50. Business Name 51. Employer Identification Number 52. Type of Business

Federal or State Contractor
Yes No

53. Business Website 54. Total Number of Employees 55a. Average Gross Monthly Payroll

55b. Frequency of Tax Deposits

56. Does business engage in e-Commerce (Internet sales) Yes No
Payment Processor (e.g., PayPal, Authorize.net, Google Checkout, etc.) Name and Address (Street, City, State, Zip code) Payment Processor Account Number
57a.

57b.

Credit Cards Accepted by the Business
Credit Card Merchant Account Number Merchant Account Provider, Name & Address (Street, City, State, ZIP code)
58a.

58b.

58c.

59. Business Cash on Hand. Include cash that is not in a bank Total Cash on Hand $
Business Bank Accounts. Include checking accounts, online bank accounts, money market accounts, savings accounts, and stored value
cards (e.g. payroll cards, government benefit cards, etc.) Report Personal Accounts in Section 3.
Type of Full Name & Address (Street, City, State, ZIP code) of Bank, Account Number Account Balance
Account Savings & Loan, Credit Union or Financial Institution. As of
mm/dd/yyyy
60a.
$

60b.
$

60c. Total Cash in Banks (Add lines 60a, 60b, and amounts from any attachments) $
Accounts/Notes Receivable. Include e-payment accounts receivable and factoring companies, and any bartering or online auction accounts.
(List all contracts separately, including contracts awarded, but not started.) Include Federal and State Government Contracts.
Status (e.g., age, Date Due Invoice Number or Federal
Accounts/Notes Receivable & Address (Street, City, State, ZIP Code) factored, other) (mm/dd/yyyy) or State Government Contract Amount Due
Number
61a.
$

61b.
$

61c.
$

61d.
$

61e. Total Outstanding Balance (Add lines 61a through 61d and amounts from any attachments) $
Form RO-1062 page 5

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Business Assets. Include all tools, books, machinery, equipment, inventory or other assets used in trade or business. Include Uniform
Commercial Code (UCC) filings. Include Vehicles and Real Property owned/leased/rented by the business, if not shown in Section 10.
Current Fair Amount of Date of Final
Purchase/Lease/Rental Market Value Current Loan Monthly Payment Equity
Date (mm/dd/yyyy) (FMV) Balance Payment (mm/dd/yyyy) FMV Minus Loan
62. Property Description
$
Location (Street, City, State, ZIP code) and County \ Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code) and Phone

62a. Property Description
$
Location (Street, City, State, ZIP code) and County \ Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code) and Phone

62b. Total Fair Market Value 62c. Total Current Loan Balance 62d. Net Equity

Section 12 must be completed only if the taxpayer is SELF-EMPLOYED
Section 12. Sole Proprietorship Information (lines 63 through 83 should reconcile with business Profit and Loss Statement)
Accounting Method Used: Cash Accrual
Income and Expenses during the period (mm/dd/yyyy) to (mm/dd/yyyy)
Total Monthly Business Income
Source Gross Monthly Expense Items Actual Monthly
63. Gross Receipts 73. Materials Purchased
64. Gross Rental Income 74. Inventory Purchased
65. Interest 75. Gross Wages & Salaries
66. Dividends 76. Rent
67. Cash 77. Supplies
Other Income (Specify Below) 78. Utilities/Telephone
68 79. Vehicle Gasoline/Oil
69 80. Repairs & Maintenance
70 81. Insurance
71 82. Current Taxes
72. Total Income 83. Other Expenses, including installment payments
Add lines 63 through 71 $ 84. Total Expenses (Add lines 73 through 83) $
85. Net Business Income (line 72 minus 84) $
Enter the amount from line 85 on line 33, Section 10. If line 85 is a loss, enter "0" on line 33, Section 10.
Self-employed taxpayers must return to page 4 to sign the certification and include all applicable attachments.
Materials Purchased: Materials are items directly related to the Current Taxes: Real estate, state, and local income tax, excise,
production of a product or service. franchise, occupational, personal property, sales and the employer's
portion of the employment taxes.
Inventory Purchased: Goods bought for resale.
Net Business Income: Net profit from Form 1040, Schedule C may
Supplies: Supplies are items used to conduct business and are consumed be used if duplicated deductions are eliminated (e.g., expenses for
or used up within one year. This could be the cost of books, office business use of home already included in housing and utility expenses
supplies, professional equipment, etc. on page 4). Deductions for depreciation and depletion on Schedule C
are not cash expenses and must be added back to the net income
Utilities/Telephone: Utilities include gas, electricity, water, oil, figure. In addition, interest cannot be deducted if it is already included
other fuels, trash collection, telephone and cell phone. in any other installment payments allowed.
FINANCIAL ANALYSIS OF COLLECTION POTENTIAL
FOR INDIVIDUAL WAGE EARNERS AND SELF-EMPLOYED INDIVIDUALS (DOR USE ONLY)
Cash Available
(Lines 12, 13e, 14e, 15d, 16c, 21e, 59, 60c, 61e) Total Cash $
Distrainable Asset Summary
(Lines 17e, 18e, 19f, 62d) Total Equity $
Monthly Total Positive Income minus Expenses
(Line 36 minus Line 48) Monthly Available Cash $
Form RO-1062 page 6

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