RI 433 B                                COLLECTION INFORMATION STATEMENT FOR BUSINESSES
Rhode Island Division
of Taxation                          Complete all entry spaces with the most current data available
                                     Write "N/A" (not applicable) in spaces that do not apply.
(Revised 11/02)
Section 1
            Business Name                                                           Contact Name________________________
Business                                                                            Title ________________________________
Information Business St. Address                                                    Business Telephone  (    )_______________
                                                                                    Extension
            City________________________________ State_________Zip____________ Best Time To Call______________________

            Business Telephone Number (    ) _________________                      Contact Name                _______________
            Employer Identification Number ___________________                      Contact Home Telephone ______________
                                                                                    Best Time To Call_____________________
            Type of Entity (Check Appropriate Box)
            (  ) Partnership        (  ) Corporation        (  ) Other______________

            Type Business __________________________________________

Section 2   PERSON RESPONSIBLE FOR DEPOSITING PAYROLL TAXES

Business    Full Name                                                               Social Security Number  _____/___/______ 
Personnel   Home St. Address                                                        Home Telephone No. (    ) ______________
and         City___________________________ State_______Zip__________               Title ________________________________
Contacts

            PERSON RESPONSIBLE FOR REMITTANCE OF SALES TAXES

            Full Name                                                               Social Security Number  _____/___/______ 
            Home St. Address                                                        Home Telephone No. (    ) ______________
            City___________________________ State_______Zip__________               Title ________________________________

            PARTNERS, OFFICERS,  ETC.

            Full Name                                                               Social Security Number  _____/___/______ 
            Home St. Address                                                        Home Telephone No. (    ) ______________
            City___________________________ State_______Zip__________               Title ________________________________

            PARTNERS, OFFICERS,  ETC.

            Full Name                                                               Social Security Number  _____/___/______ 
            Home St. Address                                                        Home Telephone No. (    ) ______________
            City___________________________ State_______Zip__________               Title ________________________________

            PARTNERS, OFFICERS,  ETC.

            Full Name                                                               Social Security Number  _____/___/______ 
            Home St. Address                                                        Home Telephone No. (    ) ______________
            City___________________________ State_______Zip__________               Title ________________________________

            PARTNERS, OFFICERS,  ETC.

            Full Name                                                               Social Security Number  _____/___/______ 
            Home St. Address                                                        Home Telephone No. (    ) ______________
            City___________________________ State_______Zip__________               Title ________________________________

                                                                    Page 2

Section 3  OTHER FINANCIAL INFORMATION

Other      Does this business have other business relationships (e.g. subsidiary or parent, corp., partnership, etc.)?    (  ) No  (  ) Yes    
Financial       If yes, list related EIN ________________________         Additional EIN ________________________
Information
           Does anyone (e.g.officer, stockholder, partner or employees) have an outstanding loan from the business?  (  ) No (  ) Yes
               If yes, amount of loan $ ______________ Date of Loan ______________ Current Balance $ _______________

           Are there any judgments or liens against your business? …………………………………………………………  (  ) No (  ) Yes
               If yes, who is creditor _________________________ Date of judgment/lien ___________ Amount of debt $___________

           Is your business a party in a lawsuit?…………….………………………………………………….……………….  (  ) No (  ) Yes
               If yes, amount of suit $ ______________ Possible completion date __________  Subject matter of suit _____________

           Has your business ever filed bankruptcy?…………………………………………………………………………….. (  ) No (  ) Yes
               If yes, date filed ___________________      Date discharged _____________________ Petition No. _________________

Section 4
           PURCHASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS:                Include boats, RV's motorcycles, 
Business   (If you need additional space, attach a separate sheet.)                trailers, etc.
Assets
           Description                Current          Current            Name of                Purchase Amount of 
                                      Value            Loan               Lender                 Date Monthly
                                                       Balance                                        Payment
           Year __________________
           Make/Model_________________
           Mileage_____________________ $________________                                         _______ $ _______

           Description                Current          Current            Name of                Purchase Amount of 
                                      Value            Loan               Lender                 Date Monthly
                                                       Balance                                        Payment
           Year __________________
           Make/Model_________________
           Mileage_____________________ $              $                                          _______ $ _______

           Description                Current          Current            Name of                Purchase Amount of 
                                      Value            Loan               Lender                 Date Monthly
                                                       Balance                                        Payment
           Year __________________
           Make/Model_________________
           Mileage_____________________ $              $                                          _______ $ _______

           LEASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS.                   Include boats, RV's motorcycles, 
           (If you need additional space, attach a separate sheet.)                trailers, etc.

           Description                Current          Current            Name of                Purchase Amount of 
                                      Value            Loan               Lender                 Date Monthly
                                                       Balance                                        Payment
           Year __________________
           Make/Model_________________
           Mileage_____________________ $              $                                          _______ $

           Description                Current          Current            Name of                Purchase Amount of 
                                      Value            Loan               Lender                 Date Monthly
                                                       Balance                                        Payment
           Year __________________
           Make/Model_________________
           Mileage_____________________ $              $                                          _______ $

                                                          Page 3

Section 4 REAL ESTATE.           List all real estate you owned by business. (If you need additional space, attach a 
                                                                     separate sheet.)
Continued
           Street Address, City, Date    Purchase Current Loan       Name of Lender     Amount of   Date of 
           State, Zip and County Purchased  Price Value   Balance    or Lien Holder     Monthly      Final
                                                                                        Payment      Payment

                                  _______ $_______ $_______ $_______                    $_______

                                  _______ $_______ $_______ $_______                    $_______

                                  _______ $_______ $_______ $_______                    $_______

Section 4 BUSINESS ASSETS.       List all business assets and encumbrances below.

Continued  Description                  Current   Loan    Name of Lender                Amount      Date of
                                        Value     Balance                               of Monthly Final
                                                                                                    Payment

           Tools used in Trade/Business $_______ $_______ ___________________________ $_______ ________

           Other: 
           Machinery                    $_______ $_______ ___________________________ $_______ ________
           Equipment                    $_______ $_______ ___________________________ $_______ ________
                                        $_______ $_______ ___________________________ $_______ ________
                                        $_______ $_______ ___________________________ $_______ ________
                                        $_______ $_______
                                        $_______ $_______
                                        $_______ $_______

Section 5  INVESTMENTS .         List all  investment assets below.  Include stocks, bonds, mutual funds, stock options and 
                                                            certificates of deposits.

           Name of Company                  Number of     Current                Loan               Used as collateral
Invest-                                    Shares/Units   Value                  Amount             on loan
ment,
Banking
and Cash                                    ____________  $                      $                  (  ) No                 (  ) Yes
Information
                                            ____________  $                      $                  (  ) No                 (  ) Yes

                                            ____________  $                      $                  (  ) No                 (  ) Yes

                                                                                  Total Investments  $ _______________

                                                                         Page 4

Section 5 BANK ACCOUNTS.     List all checking and savings accounts. (If you need additional space, attach a separate sheet.)

Continued Type of             Full Name of Bank or Financial Institution        Bank                          Current
          Account                                                               Account No.                   Account Balance

          Checking  Name ______________________________________                    _______________________     $________________
                         St. Address _________________________________
                         City/State/Zip ________________________________

          Checking  Name ______________________________________                    _______________________     $________________
                         St. Address _________________________________
                         City/State/Zip ________________________________

          Savings        Name ______________________________________               _______________________     $________________
                         St. Address _________________________________
                         City/State/Zip ________________________________

                         Name ______________________________________               _______________________     $________________
                         St. Address _________________________________
                         City/State/Zip ________________________________

                         Name ______________________________________               _______________________     $________________
                         St. Address _________________________________
                         City/State/Zip ________________________________

                                                                                Total Bank Account Balances    $________________

Section 5
          CASH ON HAND.      Include any money that you have that is not in the bank.
Continued
                                                                                          Total Cash on Hand   $ _______________

          AVAILABLE CREDIT.    List all lines of credit, including credit cards.
          Full Name of 
          Credit Institution                                             Credit Limit Amount Owed             Available Credit

          Name_______________________________________                    $ _______________ $ _______________ $ _______________
          Street Address _______________________________
          City/State/Zip   _______________________________

          Name_______________________________________                    $ _______________ $ _______________ $ _______________
          Street Address _______________________________
          City/State/Zip   _______________________________
                                                                                       Total Credit Available  $ _______________

                                                         Page 5

Section 6  Total Income                                  Total Expenses
           Source                       Gross Monthly    Description                     Actual Monthly
Monthly
Income and Gross Receipts               $______________  Materials Purchased             $______________

Expense    Gross Rental Income            ______________ Inventory Purchased               ______________

           Interest                       ______________ Gross Wages & Salaries            ______________

           Dividends                      ______________ Rent                              ______________

           Other Income (Specify)         ______________ Supplies                          ______________

                _______________________   ______________ Utilities/Telephone               ______________

                _______________________   ______________ Vehicle Gasoline & Oil            ______________

                _______________________   ______________ Repairs/Maintenance               ______________

                _______________________   ______________ Insurance                         ______________

                                          ______________ Taxes                             ______________

                                                         Other Expenses (Include install-
                                                         ment payments, specify)
                                                              ______________________       ______________

                                                              ______________________       ______________

                                                              ______________________       ______________

                                                              ______________________       ______________

           Total Income                 $ ______________ Total  Expenses                 $ ______________

           Total Income less Expenses:                   $________________

           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.

           Print Name                                    Title

           _____________________________________         ____________________________________
           Your Signature                                Date