STATE OF DELAWARE
               DEPARTMENT OF FINANCE                             COLLECTION INFORMATION STATEMENT
               DIVISION OF REVENUE              [If you need additional space, please attach a separate sheet with your
               820 N. FRENCH STREET                              name(s) and social secuirty number(s).]
               WILMINGTON, DE 19801
YOUR NAME & ADDRESS [INCLUDING COUNTY]:         PHONE NUMBERS: [CIRCLE BEST DAYTIME NUMBER]
                                                HOME:
                                                YOUR WORK:
                                                YOUR SPOUSE’S WORK:
                                                SOCIAL SECURITY NUMBER[S]:
                                                YOURS:                          YOUR SPOUSE’S: _           ______            __
                                                DATES OF BIRTH: YOURS: __               _    _    YOUR SPOUSE’S: __                _  __
YOUR EMPLOYER OR BUSINESS [NAME & ADDRESS]:     YOUR SPOUSE’S EMPLOYER OR BUSINESS [NAME & ADDRESS]:

AGE & RELATIONSHIP OF PEOPLE WHO LIVE WITH YOU [DEPENDENTS ONLY]:

BANK ACCOUNTS [INCLUDE SAVINGS & LOANS, CREDIT UNIONS, CERTIFICATES OF DEPOSIT, INDIVIDUAL RETIREMENT ACCOUNTS]:
                                                                 TYPE OF ACCOUNT
NAME OF INSTITUTION                     ADDRESS                  [CHECKING, SAVINGS] ACCOUNT NO.        BALANCE

CREDIT CARDS, CHECKING OVERDRAFT PROTECTION, LINE OF CREDIT:
NAME OF CREDIT CARD, BANK, ETC.        MIN. MONTHLY PAYMENT CREDIT LIMIT  AMOUNT OWED DATE OF FINAL PAYMENT

LIFE INSURANCE:        NAME OF COMPANY                      POLICY NUMBER      AMOUNT YOU CAN BORROW ON THE POLICY

REAL ESTATE:       ADDRESS [INCLUDING COUNTY] CURRENT VALUE      MORTGAGE BALANCE    PAID TO [NAME OF PERSON OR BANK]

MOTOR VEHICLES:    YEAR, MAKE & LICENSE NO.                CURRENT VALUE              LOAN BALANCE             DATE LOAN WILL BE PAID OFF

OTHER THINGS YOU OWN OR ARE CURRENTLY BUYING [STOCKS, BONDS, BOAT, ETC]:
                                      DESCRIPTION                                        CURRENT VALUE              LOAN BALANCE             DATE LOAN WILL BE PAID OFF

                                                   INCOME AND EXPENSES
                                                                                                                                                   $                                     FOR DOR USE ONLY
MONTHLY INCOME:
Your net pay [attach 3 recent paystubs]..........................................................................................
Your spouse’s net pay [attach 3 recent paystubs]...........................................................................
Rents paid to you............................................................................................................................
Pensions.........................................................................................................................................
Social Security................................................................................................................................
Profit from your business [attach statements]................................................................................
Commissions.................................................................................................................................
Other Income [source] _______________________________________ ...................................
MONTHLY EXPENSES: [Expenses must be reasonable for the size of your family, location, and unique circumstances]                                                                    ALLOWABLE PAYMENTS
                                                                                                                                                   $                                    [for DOR USE ONLY]
Rent...............................................................................................................................................
Mortgage.......................................................................................................................................
Alimony/Child Support...................................................................................................................
Groceries.......................................................................................................................................
Utilities:
Electricity............................................................................................................................
Heating Oil/Natural Gas.....................................................................................................
Water.................................................................................................................................
Telephone..........................................................................................................................
Transportation [Gas, Bus Fares, Etc.]...........................................................................................
Medical [Doctors & Medicine not paid by Insurance]....................................................................
Insurance:
   Auto....................................................................................................................................
Health.................................................................................................................................
Life......................................................................................................................................
Homeowners/Renters.........................................................................................................
Estimated Tax Payments...............................................................................................................
Auto Loans [Name of Financing Company, Bank, Etc.]:

Installment Payments [Name of Store, Bank, Credit Card, Amount of Payment & Date of
fiinal payment]

Other:
Total Allowable Monthly Expenses.................................................................................................................................................  $
Minimum Installment Payment....................................................................................................................................................... $
                                                   CONDITIONS
I agree to file returns and pay, when due, all other state taxes for which I may become liable during the term of this agreement.
I understand that until the amount owed is paid in full, any refunds due me will be applied against the balance I owe without affecting the terms of  this
agreement.
I understand that this agreement is based on my current financial circumstances and is subject to revision or cancellation if subsequent financial
information reflects a change in my ability to pay.
I understand that if I do not meet all of the conditions of the agreement, or it it is determined that collection of these taxes is endangered, permission
to make installment payments will be withdrawn.
ADDITIONAL INFORMATION [Expected changes to Income, Health, Etc.]:

                                                   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.  I agree to resolve my tax liability as prescribed by the Division of Revenue.

         Your Signature                                                              Spouse’s Signature [if joint return was filed]                                                         Date