COLLECTION INFORMATION STATEMENT FOR BUSINESSES

                                           • Complete all entry spaces with the most current data available.
                                           • Important!  Write “N/A” (not applicable) in spaces that do not apply.  We may 
ARIZONA DEPARTMENT OF REVENUE
    1600 West Monroe                       require additional information to support “N/A” entries.
    Phoenix, AZ  85007                     • Failure to complete all entry spaces may result in rejection or significant delay in the 
         (602)542-5551                     resolution of your account.
          www.azdor.gov
Section 1     1a Business Name                                                                    2c AZ Withholding No.
Business 
Information   1b Business Street Address                                                          2d Type of Entity   (Check appropriate box below):
                                                                                                    Partnership    Corporation    Other
              1c City                                 State                ZIP Code               2e Type of Business

              1d County                               1e Business Phone (with area code)          3a Contact Name
 Check this
box when all 
spaces in     2a Employer ID No. (EIN)                2b AZ Transaction Privilege Tax No.         3b Contact’s Business Phone (with area code)
Section 1 are                                                                                                                          Ext.
filled in
Section 2     4        PARTNERS, OFFICERS, MAJOR SHAREHOLDERS, ETC.
              4a       Full Name __________________________ Title                                        Social Security No.     
Business 
Personnel              Home Street Address                                                               Home Phone (           ) 
and                    City                            State                 Zip                         Ownership Percentage & Shares or Interest  
Contacts      4b  Full Name __________________________ Title                                             Social Security No.     
                       Home Street Address                                                               Home Phone (           ) 
                       City                            State                 Zip                         Ownership Percentage & Shares or Interest  
              4c  Full Name __________________________ Title                                             Social Security No.     
                       Home Street Address                                                               Home Phone (           ) 
                       City                            State                 Zip                         Ownership Percentage & Shares or Interest  
 Check this  4d  Full Name __________________________ Title                                             Social Security No.     
box when all 
spaces in              Home Street Address                                                               Home Phone (           ) 
Section 2 are 
filled in              City                            State                 Zip                         Ownership Percentage & Shares or Interest  
Section 3     5        OTHER FINANCIAL INFORMATION.  Respond to the following business financial questions.                                                                                 NO YES
Other         5a  Does this business have other business relationships (e.g. subsidiary or parent corporation, partnership etc.)? ..............                                              
Financial              If yes, list related EIN _____________________________.      Additional EIN ______________________________
Information   5b  Does anyone (e.g. officer, stockholder, partner or employees) have an outstanding loan borrowed from the business? ..                                                       
                       If yes, amount of loan $________________.  Date of loan ________________. MM/DD/YY       Current balance $_______________
              5c  Are there any judgments or liens against your business? ...................................................................................................                 
                       If yes, who is the creditor? _______________________________________________________________________
                       Date creditor obtained judgment/lien ________________.      MM/DD/YYAmount of debt $________________.
              5d  Is your business a party in a lawsuit? ..................................................................................................................................   
                       If yes, amount of suit $________________.  Possible completion date ________________.MM/DD/YY
                       Subject matter of suit ___________________________________________________________________________
              5e  Has your business ever filed bankruptcy? ...........................................................................................................................        
                       If yes, date filed  ________________. MM/DD/YY Date discharged ________________. MM/DD/YYPetition No. _____________________
              5f       In the past 10 years, have you transferred any assets from your business name for less than their actual value? ...........                                            
                       If yes, what asset? _________________________________.  Value of asset at time of transfer $_______________. 
                       When was it transferred? ________________. MM/DD/YY To whom or where was it transferred? _________________________
              5g  Do you anticipate any increase in business income (e.g. contracts bid but not yet awarded)? ..........................................                                      
                       If yes, why will the income increase?  (Attach sheet if you need additional space) __________________________________
                       How much will it increase? $________________.  When will the business income increase? ___________________
 Check this  5h  Is your business a beneficiary of a trust, an estate or a life insurance policy? ....................................................................                       
box when all           If yes, name of the trust, estate or policy? ___________________________________________________________
spaces in 
Section 3 are          Anticipated amount to be received? $________________.      When will the amount be received? _______________
filled in
ADOR 10847 (4/10)                                                                                                               Section 4 begins on page 2  
Previous ADOR 20-1020

Arizona Department of Revenue                                                                       Collection Information Statement for Businesses

Business Name  
                 6   PURCHASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS.  Include boats, RV’s, motorcycles, trailers, etc.  (If 
Section 4            you need additional space, attach a separate sheet.)
Business                        Description                  Current               Loan              Name of    Purchase               Monthly
Assets                      (Year, Make, Model, Mileage)             Value         Balance            Lender            Date            Payment
                 6a  Year 
 Current            Make/Model 
 Value:              Mileage                               $                     $                               MM/DD/YY  $ 
 Indicate the    6b  Year 
 amount you          Make/Model 
 could sell          Mileage                               $                     $                               MM/DD/YY  $ 
 the asset 
                 6c  Year 
 for today.
                     Make/Model 
                     Mileage                               $                     $                               MM/DD/YY  $ 

                 7   LEASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS.  Include boats, RV’s, motorcycles, trailers, etc.  (If you 
                     need additional space, attach a separate sheet.)
                                Description                  Lease                                                      Lease           Monthly
                             (Year, Make, Model)             Balance                     Name of Lessor                 Date            Payment
                 7a  Year 
                     Make/Model                            $                                                     MM/DD/YY  $ 
                 7b  Year 
                     Make/Model                            $                                                     MM/DD/YY  $ 
                 7c  Year 
                     Make/Model                            $                                                     MM/DD/YY  $ 
                 Attachments
                            ATTACHMENTS REQUIRED:  Please include your current statement from lender with monthly car payment amount 
                            and current balance of the loan for each vehicle purchased or leased.

                 8   REAL ESTATE.  List all real estate owned by the business.  (If you need additional space, attach a separate sheet.)
                                                                                                                                          Date
 Date of Final             Street Address       Date     Purchase              Current         Loan Name of Lender    Monthly           of Final
 Payment:                   City, State, Zip   Purchased     Price                 Value    Balance      or Lien Holder Payment           Payment
 Enter the date  8a   
 the loan or 
                      
 lease will be 
 fully paid.          
                     County                    MM/DD/YY $                   $             $                       $                       MM/DD/YY

                 8b   
                      
                     County                    MM/DD/YY $                   $             $                       $                       MM/DD/YY

                 8c   
                      
  Check this
  box when all       County                    MM/DD/YY $                   $             $                       $                       MM/DD/YY
 spaces on 
 this page of 
 Section 4 are   Attachments
 filled in and              ATTACHMENTS REQUIRED:  Please include your current statement from lender with monthly payment amount and 
 attachments                current balance for each piece of real estate owned.
 are provided
                                                                                                               Section 4 continues on page 3  
ADOR 10847 (4/10)                                                                                                                       Page 2 of 8
Previous ADOR 20-1020

Arizona Department of Revenue                                                                     Collection Information Statement for Businesses

Business Name  
                    9    BUSINESS ASSETS.  List all business assets and encumbrances below.  Include Uniform Commercial Code (UCC) filings.  (If 
Section 4                you need additional space, attach a separate sheet.)  Note:  If attaching a depreciation schedule, the attachment must include all 
continued
                         of the information requested below.
  Check this                                                    Current         Loan                               Monthly                                                                    Date of
 box if you 
 are attaching                       Description                 Value            Balance         Name of Lender   Payment                                                       Final Payment
 a depreciation 
 schedule for       9a   Machinery:
 machinery/ 
 equipment in                                                  $                $                                  $                                                             MM/DD/YY
 lieu of 
 completing                                                    $                $                                  $                                                             MM/DD/YY
 line 9.
                                                               $                $                                  $                                                             MM/DD/YY
 Current                Equipment:
 Value:
 Indicate the                                                  $                $                                  $                                                             MM/DD/YY
 amount you                                                    $                $                                  $                                                             MM/DD/YY
 could sell 
 the asset                                                     $                $                                  $                                                             MM/DD/YY
 for today.              Merchandise:
 Date of Final                                                $                $                                  $                                                             MM/DD/YY
 Payment:                                                      $                $                                  $                                                             MM/DD/YY
 Enter the date 
 the loan or              Other Assets:  (List below)
 lease will be      9b                                         $                $                                  $                                                             MM/DD/YY
 fully paid.
                    9c                                         $                $                                  $                                                             MM/DD/YY
  Check this
 box when all 
 spaces in          Attachments
 Section 4 are                 ATTACHMENTS REQUIRED:  Please include your current statement from lender with monthly payment amount and 
 filled in and                 current loan balance for assets listed which have an encumbrance.
 attachments 
 are provided

Section 5                                                                                                                                                                                        NO YES
                    10  Do you owe any federal taxes? .........................................................................................................................................    
Federal and 
Other                    If “Yes”, how much?  $_____________________           Amount of payment:  $_____________________
Taxes Owed
                    10a  Do you owe any other government agency? .....................................................................................................................             
                         If “Yes”, who?   
                         How much is owed?  $_____________________           Amount of payment:  $_____________________

Section 6           11   INVESTMENTS.  List all investment assets below.  Include stocks, bonds, mutual funds, stock options and certificates of 
Investment,              deposits.
Banking and                                                    Number of        Current        Used as collateral Loan                                                          Net Value
Cash                              Company Name                 Shares/Units     Value   (a)       on loan?         Amount   (b)                                                  (a - b)
Information
                    11a                                                       $                   No      Yes  $                                                         $ 
                    11b                                                       $                   No      Yes  $                                                         $ 
                    11c                                                       $                   No      Yes  $                                                         $ 
                    11d                                                       $                   No      Yes  $                                                         $ 
  Check this       11e                                                       $                   No      Yes  $                                                         $ 
 box when all 
 spaces in          11f Subtotal from supplemental pages ...............................................................................................................  11f  $ 
 Sections 5 and 
 6 are filled in
                    11g Total Net Investments:  Sum of the Net Values for lines 11a thru 11e plus line 11f ...................................  11g $ 
                                                                                                                   Section 6 continues on page 4  
ADOR    10847 (4/10)                                                                                                                                                                            Page 3 of 8
Previous ADOR 20-1020

Arizona Department of Revenue                                                                        Collection Information Statement for Businesses

Business Name  
                  12  BANK ACCOUNTS.  List all checking and savings accounts.
Section 6
continued             Type of    Full Name of Bank, Savings & Loan,                             Bank              Bank                                                                Current
                      Account    Credit Union or Financial Institution                          Routing No.       Account No.                                                       Account Balance
                  12a            Name                                                                                                                                            $ 
Complete all                     Street Address 
entry spaces
with the most                    City, State, Zip 
current data      12b            Name                                                                                                                                            $ 
available.
                                 Street Address 
                                 City, State, Zip 
                  12c            Name                                                                                                                                            $ 
                                 Street Address 
                                 City, State, Zip 
                  12d Total Bank Account Balances .................................................................................................................... 12d $ 
                     Attachments
                                 ATTACHMENTS REQUIRED:  Please include your current bank statements (checking and savings) for the past three 
                                 months for all accounts.
                  13  OTHER ACCOUNTS.  List all accounts including brokerage accounts, money market, additional checking and savings accounts 
                      not listed on line 12 and any other accounts not listed in this section.  If you need additional space, attach supplemental page.
                      Type of    Full Name of Bank, Savings & Loan,                             Bank              Bank                                                                Current
                      Account    Credit Union or Financial Institution                          Routing No.       Account No.                                                       Account Balance
                  13a  
                      Name of Institution                                                                                                                                        $ 
                      Street Address 
                      City, State, Zip 
                  13b  
                      Name of Institution                                                                                                                                        $ 
                      Street Address 
                      City, State, Zip 
                  13c Subtotal from supplemental pages ............................................................................................................... 13c $   
                  13d Total Bank Account Balances .................................................................................................................... 13d $ 
                     Attachments                         Please include your current bank statements (checking, savings, money market, and 
                                 ATTACHMENTS REQUIRED:  
                                 brokerage accounts) for the past three months for all accounts.
                  14  CASH ON HAND.  Include any money that you have that is not in the bank.
                  14a Total Cash on Hand .................................................................................................................................... 14a $  
                  15  AVAILABLE CREDIT.  List all lines of credit, including credit cards.  If you need additional space, attach supplemental page.
                       Full Name of Credit Institution                                          Credit Limit      Amount Owed                                                         Available Credit
                  15a Name                                                        $                            $                                                                $  
                      Street Address 
                      City, State, Zip 
  Check this     15b Name                                                        $                            $                                                                $  
 box when all         Street Address 
 spaces in 
 Section 6 are        City, State, Zip 
 filled in and 
 attachments 
 are provided     15c Subtotal from supplemental pages ............................................................................................................... 15c $ 
                  15d Total Credit Available .................................................................................................................................. 15d $ 
 ADOR 10847 (4/10)                                                     Section 7 begins on page 5.                                                                                    Page 4 of 8
Previous ADOR 20-1020

Arizona Department of Revenue                                                                             Collection Information Statement for Businesses

Business Name  
                      ACCOUNTS/NOTES RECEIVABLE.  List all contracts separately, including contracts awarded but not started.  (If you need 
Section 7             additional space, copy this page and attach to this package.)
Accounts/ 
Notes 
                      Description                                                                         Amount Due          Date Due  Age of Account
Receivable
                                                                                                                                            0 - 30 days
                   a) Name                                                                              $                     MM/DD/YY    30 - 60 days
                      Street Address                                                                                                      60 - 90 days
                      City, State, Zip                                                                                                    90+ days
                                                                                                                                            0 - 30 days
                   b) Name                                                                              $                     MM/DD/YY    30 - 60 days
                      Street Address                                                                                                      60 - 90 days
                      City, State, Zip                                                                                                    90+ days
                                                                                                                                            0 - 30 days
                   c) Name                                                                              $                     MM/DD/YY    30 - 60 days
                      Street Address                                                                                                      60 - 90 days
                      City, State, Zip                                                                                                    90+ days
                                                                                                                                            0 - 30 days
                   d) Name                                                                              $                     MM/DD/YY    30 - 60 days
                      Street Address                                                                                                      60 - 90 days
                      City, State, Zip                                                                                                    90+ days
                                                                                                                                            0 - 30 days
                   e) Name                                                                              $                     MM/DD/YY    30 - 60 days
                      Street Address                                                                                                      60 - 90 days
                      City, State, Zip                                                                                                    90+ days
                                                                                                                                            0 - 30 days
                   f) Name                                                                              $                     MM/DD/YY    30 - 60 days
                      Street Address                                                                                                      60 - 90 days
                      City, State, Zip                                                                                                    90+ days
                                                                                                                                            0 - 30 days
                   g) Name                                                                              $                     MM/DD/YY    30 - 60 days
                      Street Address                                                                                                      60 - 90 days
                      City, State, Zip                                                                                                    90+ days
                                                                                                                                            0 - 30 days
                   h) Name                                                                              $                     MM/DD/YY    30 - 60 days
                      Street Address                                                                                                      60 - 90 days
                      City, State, Zip                                                                                                    90+ days
                                                                                                                                            0 - 30 days
                   i) Name                                                                              $                     MM/DD/YY    30 - 60 days
                      Street Address                                                                                                      60 - 90 days
                      City, State, Zip                                                                                                    90+ days
If you need                                                                                                                                 0 - 30 days
additional space,
attach a separate  j) Name                                                                              $                     MM/DD/YY    30 - 60 days
sheet.
                      Street Address                                                                                                      60 - 90 days
                      City, State, Zip                                                                                                    90+ days

  Check this
 box when all 
 applicable spaces k) Add lines a through j ......................................................... k)  $ _______________
 in Section 7 are 
 filled in
                                                                                                                              Section 8 begins on page 6  
ADOR  10847 (4/10)                                                                                                                       Page 5 of 8
Previous ADOR 20-1020

Arizona Department of Revenue                                                              Collection Information Statement for Businesses

Business Name  
                 16  The following information applies to income and expenses for the following period.  A minimum of 6 months financial history is 
Section 8              required.
Monthly                From      MMDDYYYY/ /       to        MMDDYYYY/ /   .
Income and 
Expenses
                 17  Accounting Method Used:      Cash      Accrual

Complete all
entry spaces
with the most    The information included on lines 18 through 38 should reconcile to your Arizona business tax return.
current data
available not    Total Income                                              Total Expenses
to exceed 60     Source                                      Gross Monthly Expense Items                                              Actual Monthly

days in age.                                                                                      1                                  $
                 18 Gross Receipts                           $             26 Materials Purchased  

                 19 Gross Rental Income                                    27 Inventory Purchased2

                 20 Interest                                               28 Gross Wages & Salaries

                 21 Dividends                                              29 Rent
                 Other Income (lines 22-24):
                 22                                                        30 Supplies3

                 23                                                        31 Utilities/Telephone4

                 24                                                        32 Vehicle Gasoline/Oil

                                                                           33 Repairs & Maintenance
                 25 TOTAL INCOME(Add lines 18 through 24)  $
                                                                           34 Insurance

                                                                           35 Current Taxes5
                                                                           Other Expenses (include installment payments, specify in lines 36 - 37):
                                                                           36
                                                   
                                                                           37

                                                                           38 TOTAL EXPENSES(Add lines 26 through 37)  $

                     1 Materials Purchased:  Materials are items directly related to the production of a product or service.
                     2 Inventory Purchased:  Goods bought for resale.
                     3 Supplies:  Supplies are items used in your business that are consumed or used up within one year such as the cost of books, 
                      office supplies, professional instruments, etc.
                     4 Utilities:  Utilities include gas, electricity, water, fuel, oil, other fuels, trash collection and telephone.
                     5 Current Taxes:  Real estate, state and local income tax, excise, franchise, occupational, personal property, sales and the 
                      employer’s portion of employment taxes.

  Check this
 box when all 
 spaces in 
 Section 8 are 
 filled in

                                                                                                                                     Section 9 begins on page 7  
ADOR 10847 (4/10)                                                                                                                     Page 6 of 8
Previous ADOR 20-1020

Arizona Department of Revenue                                                 Collection Information Statement for Businesses

Business Name  
                                           Equity                                                                                                        Dateof
Section 9                                  MarketVBalance             Nameand           Address                                                          Final
Asset and                                                                     Lien/Note         Payment

Liability     39 Cashonhand                                                                     MM/DD/YYMM/DD/YY
Analysis
              40 Bankaccounts                                                                   MM/DD/YYMM/DD/YY
              41 Accounts/Notesreceived                                                         MM/DD/YYMM/DD/YY
Complete all
entry spaces  42 Lifeinsuranceloanvalue                                                         MM/DD/YYMM/DD/YY
              43 Real
with the most               a.                                                                  MM/DD/YYMM/DD/YY
current data     Property
available not               b.                                                                  MM/DD/YYMM/DD/YY
to exceed 60                c.                                                                  MM/DD/YYMM/DD/YY
days in age.
                            d.                                                                  MM/DD/YYMM/DD/YY
              44 Vehicles   a.                                                                  MM/DD/YYMM/DD/YY
                 (model,
                  year,     b.                                                                  MM/DD/YYMM/DD/YY
                 license)
                            c.                                                                  MM/DD/YYMM/DD/YY
              45 Merchan-   a.                                                                  MM/DD/YYMM/DD/YY
                 diseand
                  Equip-    b.                                                                  MM/DD/YYMM/DD/YY
                 ment
                  (specify) c.                                                                  MM/DD/YYMM/DD/YY
              46 Merchan-
                  dise      a.                                                                  MM/DD/YYMM/DD/YY
                 Inventory
                  (specify) b.                                                                  MM/DD/YYMM/DD/YY
               47  Other    a.                                                                  MM/DD/YYMM/DD/YY
                 Assets
                  (specify) b.                                                                  MM/DD/YYMM/DD/YY
              48 Other      a.                                                                  MM/DD/YYMM/DD/YY
                 Liabilities
                            b.                                                                  MM/DD/YYMM/DD/YY
                 (include 
                   notes    c.                                                                  MM/DD/YYMM/DD/YY
                  and 
                   judg-    d.                                                                  MM/DD/YYMM/DD/YY
                   ments)   e.                                                                  MM/DD/YYMM/DD/YY
                            f.                                                                  MM/DD/YYMM/DD/YY
                            g.                                                                  MM/DD/YYMM/DD/YY
 Check this                Statetaxesowed                                                      MM/DD/YYMM/DD/YY
box when all 
spaces in     49 Federaltaxesowed                                                               MM/DD/YYMM/DD/YY
Section 9 are 
filled in     50  TOTALS

Section 10
                 Additional information regarding financial condition:  (Court proceedings, bankruptcies filed or anticipated, transfers of assets for less than full value, 
Additional       changes in market conditions, etc..  Include information regarding company participation in trusts, estates, profit-sharing plans, etc.)
Information 
or 
Comments

                                                                                        Signature required on page 8  
   ADOR 10847 (4/10)
   Previous ADOR 20-1020

Arizona Department of Revenue                                     Collection Information Statement for Businesses

Business Name  

                              Failure to complete all entry spaces may result in rejection or significant delay in the 
                     CAUTION! resolution of your account.

                     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

                      Check this box when all spaces in all sections are filled in and
                              all attachments are provided.

ADOR 10847 (4/10)                                                                                               Page 8 of 8
Previous ADOR 20-1020