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                                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 signifi cant 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.
fi lled in
Section 2     4        PARTNERS, OFFICERS, MAJOR SHAREHOLDERS, ETC.
Business      4a       Full Name __________________________ Title                                                                                                                                                                 Social Security No.       
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
fi lled in              City                                                 State                                                                                                               Zip                               Ownership Percentage & Shares or Interest  
Section 3     5        OTHER FINANCIAL INFORMATION.  Respond to the following business fi nancial 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. offi cer, stockholder, partner or employees) have an outstanding loan borrowed from the business? ..                                                                                                                                     … … 
                       If yes, amount of loan $________________.  Date of loan ________________.  Current balance $_______________                                                                           MM/DD/YY
              5c  Are there any judgments or liens against your business? ...................................................................................................                                                                                               … … 
                       If yes, who is the creditor? _______________________________________________________________________
                       Date creditor obtained judgment/lien ________________.       AmountMM/DD/YYof 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 fi led bankruptcy? ...........................................................................................................................                                                                                      … … 
                       If yes, date fi led  ________________.  DateMM/DD/YYdischarged ________________.  Petition No. _____________________                                                                   MM/DD/YY
              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? ________________.  To whomMM/DD/YYor 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 benefi ciary 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? _______________
fi lled in
ADOR 10847 (4/10)                                                                                                                                                                                                                                      Section 4 begins on page 2  Æ
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 4Section 4
                                 you need additional space, attach a separate sheet.)
BusinessBusiness               Description                                  ˜Current Loan                            Name of Purchase Monthly
AssetsAssets                               (Year, Make, Model, Mileage)          Value            Balance            Lender           Date          Payment
                              6a Year 
 ˜ ˜CurrentCurrent             Make/Model 
 VValue:alue:                    Mileage                                  $                     $                               MM DD YY $ 
 Indicate theIndicate the     6b Year 
 amount youamount you          Make/Model 
 could sellcould sell            Mileage                                  $                     $                               MM DD YY  $ 
 the assetthe asset
                              6c Year 
 forfor today..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
 ‘ ‘DateDate ofof FinalFinal     Street Address                Date  Purchase  Current         ˜                Loan Name of Lender    Monthly        of Final
 Payment:Payment:                          City, State, Zip   Purchased     Price                Value    Balance      or Lien Holder  Payment        Payment
 Enter the dateEnter the date 8a  
 the loan orthe loan or
                                  
 lease will belease will be
 fully paid.fully paid.           
                                 County                       MM DD YY $                $               $                            $                MM DD YY

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

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

        YELLOW fields are Read-Only.  You cannot enter data in yellow fields; they are calculated as you fill in the form.
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) fi lings.  (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 
 fi lled in and                   current loan balance for assets listed which have an encumbrance.
 attachments
 are provided

Section 5                                                                                                                                                                                                                                          NO YES
Federal and                                                                                                                                                                                                                                        … … 
                    10  Do you owe any federal taxes? ......................................................................................................................................... 
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 certifi cates of 
Investment,                deposits.  If you need additional space, attach supplemental page.
Banking and                                                                                                                                                                             Number of ˜Current    Used as collateral Loan         Net Value
Cash                              Company Name                    Shares/Units  Value  on loan?(a)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  ...............................................................................................................You must calculate and enter line 11f amount.                11f $ 
 Sections 5 and
 6 are fi lled 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  Æ
ADOR    10847 (4/10)                                                                                                                                                                    Supplement                                                Page 3 of 8
Previous ADOR 20-1020

Arizona Department of Revenue                                                                        Collection Information Statement for Businesses

Business Name  
                                                                                                                                                                                                                          Supplement
                  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    ...............................................................................................................You must calculate and enter line 13c amount.13c   $

                  13d Total Bank Account Balances .................................................................................................................... 13d $                                               
                     Attachments ATTACHMENTS REQUIRED:  Please include your current bank statements (checking, savings, money market, and 
                                 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 
 fi lled in and
 attachments
 are provided     15c Subtotal from supplemental pages    ...............................................................................................................You must calculate and enter line 15c amount.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, attach supplemental page.)
Accounts/
Notes
Receivable            Description                                                                 Amount Due         Date Due        Age of Account
                                                                                                                                  †    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
                                                                                                                   You must calculate and enter 
 † Check this      k) Subtotal from supplemental pages ...................................... k) $ _______________ line k amount.
 box when all
 applicable spaces
 in Section 7 are                                                                                                                    Supplement
 fi lled in         l) Total Accounts/Notes Receivable:  Add lines a through k.                l) $ _______________

                                                                                                                       Section 8 begins on page 6  Æ
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 fi nancial 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.
                  18 Gross Receipts                           $             26 Materials Purchased  1                                $

                 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, 
                       offi ce 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
 fi lled in

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

Arizona Department of Revenue                                                              Collection Information Statement for Businesses
                                                                                           DATE FIELDS: 
                                                                                           Type only the MMDDYY digits. Acrobat will enter 
Business Name                                                                              the slashes for you.
                                                Current Liabilities      Equity in Monthly                                                                       Date of
Section 9                                       Market Value Balance Due Asset     Payment Name and Address of                                            Date   Final
Asset and                         Description   $ $ $ $  Lien/Note Holder/Obligee Pledged Payment
Liability      39  Cash on hand                                                                                MM DD YYMM DD YY
Analysis
               40 Bank accounts                                                                                MM DD YYMM DD YY
               41 Accounts/Notes received                                                                      MM DD YYMM DD YY
Complete all
entry spaces   42  Life insurance loan value                                                                   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
                    dise and
                 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                   State taxes owed                                                                MM DD YYMM DD YY
box when all
spaces in      49  Federal taxes owed                                                                          MM DD YYMM DD YY
Section 9 are
fi lled in      50 TOTALS

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

                                                                                            Signature required on page 8  Æ
  ADOR    10847 (4/10)                                                                                                                                    Page 7 of 8
  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 signifi cant delay in the 
                     !
                     CAUTION   resolution of your account.

                     Certifi cation:  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.

                      PrintTYPENameYOUR NAME                 TYPETitleYOUR TITLE

                     #                                       
                      Your Signature                         Date

                                             Print Form    Reset Form

                     † Check this box when all spaces in all sections are fi lled in and
                             all attachments are provided.

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

Arizona Department of Revenue                                                                                Collection Information Statement for Businesses

Business Name  
SUPPLEMENTAL PAGE:  Investment, Bank, Credit, Other Accounts                                                 List additional accounts not listed on pages 3 or 4.
Show the full name of the investment company, bank, savings and loan, credit, or other fi nancial institution.

 Company Name                                                Street Address                                  City, State, Zip Code
A
 Select only one account type below; enter information for that account.            Used as collateral                                                         Net Value
 Indicate type of account:          No. Shares/Units             Current Value (a)  on loan?                  Loan Amount (b)                                  (a - b)
 † Investment Account                                        $                     † No † Yes                $
 Other Account Type:                Bank Routing No.           Bank Account No.     Current Balance
                                                                                   $
                                    Credit Limit                 Amount Owed        Available Credit
 † Credit Account                 $                          $                     $
 Company Name                                                Street Address                                  City, State, Zip Code
B
 Select only one account type below; enter information for that account.            Used as collateral                                                         Net Value
 Indicate type of account:          No. Shares/Units             Current Value (a)  on loan?                  Loan Amount (b)                                  (a - b)
 † Investment Account                                        $                     † No † Yes                $
 Other Account Type:                Bank Routing No.           Bank Account No.     Current Balance
                                                                                   $
                                    Credit Limit                 Amount Owed        Available Credit
 † Credit Account                 $                          $                     $
 Company Name                                                Street Address                                  City, State, Zip Code
C
 Select only one account type below; enter information for that account.            Used as collateral                                                         Net Value
 Indicate type of account:          No. Shares/Units             Current Value (a)  on loan?                  Loan Amount (b)                                  (a - b)
 † Investment Account                                        $                     † No † Yes                $
 Other Account Type:                Bank Routing No.           Bank Account No.     Current Balance
                                                                                   $
                                    Credit Limit                 Amount Owed        Available Credit
 † Credit Account                 $                          $                     $
 Company Name                                                Street Address                                  City, State, Zip Code
D
 Select only one account type below; enter information for that account.            Used as collateral                                                         Net Value
 Indicate type of account:          No. Shares/Units             Current Value (a)  on loan?                  Loan Amount (b)                                  (a - b)
 † Investment Account                                        $                     † No † Yes                $
 Other Account Type:                Bank Routing No.           Bank Account No.     Current Balance
                                                                                   $
                                    Credit Limit                 Amount Owed        Available Credit
 † Credit Account                 $                          $                     $
                                                                                                             Page 3
 a) Subtotal Investment Account Net Values:  List here and on page 3, line 11f   ..............................................................a) $           

 b) Subtotal Bank Account Current Balances:    List here and on page 4, line 13c ...........................................................b) $              
                                                                                                             Page 4
 c) Subtotal Credit Available:  List here and on page 4, line 15c .......................................................................................c) $  

 ADOR 10847 (4/10)                                  Print Page               Reset Page
 Previous ADOR 20-1020

Arizona Department of Revenue                                                        Collection Information Statement for Businesses

Business Name  
SUPPLEMENTAL PAGE:  Accounts/Notes Receivable                                        List additional accounts not listed on page 5.
   ACCOUNTS/NOTES RECEIVABLE.  List all contracts separately, including contracts awarded but not started.

   Description                                                      Amount Due       Date Due             Age of Account
                                                                                               †    0 - 30 days
A) Name                                                          $                                †30 - 60 days
   Street Address                                                                              †  60 - 90 days
   City, State, Zip                                                                            †  90+ days
                                                                                               †    0 - 30 days
B) Name                                                          $                                †30 - 60 days
   Street Address                                                                              †  60 - 90 days
   City, State, Zip                                                                            †  90+ days
                                                                                               †    0 - 30 days
C) Name                                                          $                                †30 - 60 days
   Street Address                                                                              †  60 - 90 days
   City, State, Zip                                                                            †  90+ days
                                                                                               †    0 - 30 days
D) Name                                                          $                                †30 - 60 days
   Street Address                                                                              †  60 - 90 days
   City, State, Zip                                                                            †  90+ days
                                                                                               †    0 - 30 days
E) Name                                                          $                                †30 - 60 days
   Street Address                                                                              †  60 - 90 days
   City, State, Zip                                                                            †  90+ days
                                                                                               †    0 - 30 days
F) Name                                                          $                                †30 - 60 days
   Street Address                                                                              †  60 - 90 days
   City, State, Zip                                                                            †  90+ days
                                                                                               †    0 - 30 days
G) Name                                                          $                                †30 - 60 days
   Street Address                                                                              †  60 - 90 days
   City, State, Zip                                                                            †  90+ days
                                                                                               †    0 - 30 days
H) Name                                                          $                                †30 - 60 days
   Street Address                                                                              †  60 - 90 days
   City, State, Zip                                                                            †  90+ days
                                                                                               †    0 - 30 days
I) Name                                                          $                                †30 - 60 days
   Street Address                                                                              †  60 - 90 days
   City, State, Zip                                                                            †  90+ days
                                                                                               †    0 - 30 days
J) Name                                                          $                                †30 - 60 days
   Street Address                                                                              †  60 - 90 days
   City, State, Zip                                                                            †  90+ days

K) Subtotal Receivables:  List here and on page 5, line k ..... K) $ _______________                       Page 5

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