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                                             COLLECTION INFORMATION STATEMENT (PERSONAL)

                                                 • 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
       YELLOW fields are Read-Only.  You cannot enter data in yellow fields; they are calculated as you fill in the form.
Section 1               1a Your Full Name                                               1b Your Social Security No.           1c Your Date of Birth
                                                                                                                                   MM/DD/YYYY
Personal                1d Spouse’s Full Name                                           1e Spouse’s Social Security No.       1f  Spouse’s Date of Birth
Information
                                                                                                                                   MM/DD/YYYY
                        2 Marital Status     (check one box): 3                   Check one box:
                             † Married     † Separated                      † Own Home     † Rent
                             † Unmarried (single, divorced, widowed)        † Other (specify, i.e. share rent, live with relative):
                        4a Street Address                                                       4b City                            State                                                     ZIP Code

                        4c County of Residence                         4d How long at this address?                   5 Home Phone (with area code)

                          6    List the dependents you can claim on your tax return (attach sheet if more space is needed):
                                                                            Does this person                                                                                                 Does this person
                               First Name           Relationship   Age  live with you?          First Name           Relationship                                        Age  live with you?
† Check this box                                                            † No    † Yes                                                                                                    † No † Yes
when all spaces in
Section 1 are fi lled in                                                     † No    † Yes                                                                                                    † No † Yes

Section 2                7    Are you or your spouse self-employed or operate a business?  Check “Yes” if either applies.
Your                           † No     † Yes  (If “Yes”, provide the following information)
                          
Business                 7a  Name of Business                                                     7d    Employer I.D. No.  
Information              7b Street Address                                                        7e  Do you have employees?     † No     † Yes
                           7c  City, State, Zip                                               
† Check this box                Attachments
when all spaces in                          ATTACHMENTS REQUIRED:  You must complete a Collection Information Statement for Businesses,
Section 2 are fi lled in                     ADOR 20-1020.

Section 3                  8a  Your Employer                                                 9a Spouse’s Employer  
Employment                 8b Street Address                                                 9b Street Address  
Information                8c  City, State, Zip                                              9c  City, State, Zip  
                           8d Work Phone (with area code)                                    9d Work Phone: (with area code)  
                           8e  How long with this employer?                                  9e  How long with this employer?  
                           8f Occupation                                                     9f Occupation  
  Check this box                Attachments ATTACHMENTS REQUIRED:  Please include proof of gross earnings and deductions for the past 3 months from 
†
when all spaces in                          each employer (e.g., pay stubs, earnings statements).  If year-to-date information is available, send only 1 such 
Section 3 are fi lled in                     statement as long as a minimum of 3 months is represented.

Section 4                  10  Do you receive income from sources other than your own business or your employer?  Check all that apply:
                            
Other                          † Pension      † Social Security       † Other (Specify, i.e. child support, alimony, rental)  
Income                          Attachments ATTACHMENTS REQUIRED:  Please include proof of pension/social security/other income for the past 3 months 
Information                                 from each payor including any statements showing deductions.  If year-to-date information is available, send only 
                                            1 such statement as long as a minimum of 3 months is represented.

Section 5                  11   CHECKING ACCOUNTS.  List all checking accounts.  (If you need additional space, attach a separate sheet.)
                              Type of       Full Name of Bank, Savings & Loan,                      Bank                      Bank                                                            Current
Banking,                      Account       Credit Union or Financial Institution                 Routing No.               Account No.                                                      Account Balance
Investment,                11a Checking   Name                                                                                                                                $ 
Cash, etc.
                                             Street Address 
† Check this box                             City, State, Zip 
when all spaces in      11b    Checking   Name                                                                                                                                $ 
Sections 4 and 5,
lines 11 thru 11c, are                       Street Address 
fi lled in and attach-                        City, State, Zip 
ments are provided
                        11c Total Checking Account Balances ............................................................................................................ 11c $ ______________
ADOR 10896 (10/10)                                                                                                            Section 5 continues on page 2  Æ
Previous ADOR 20-1070

Arizona Department of Revenue                                                                                                                                Collection Information Statement (Personal)
Name                                                                                                                                           SSN  
Section 5             12  OTHER ACCOUNTS.  List all accounts including brokerage accounts, savings and money market accounts not listed on line 11.
continued                 Type of       Full Name of Bank, Savings & Loan,                                                                     Bank               Bank                                                        Current
                          Account       Credit Union or Financial Institution                                                               Routing No.           Account No.                                               Account Balance
Banking,              12a   
Investment,               Name of Institution                                                                                                                                                                            $ 
Cash, Credit,
and Life               Street Address  
Insurance                 City, State, Zip  
Information           12b   
                          Name of Institution                                                                                                                                                                            $ 
                       Street Address  
Complete all              City, State, Zip  
entry spaces          12c Subtotalfrom supplemental page .................................................................................................................You must calculate and enter line 12c amount. 12c $ 
with the most         12d Total Other Account Balances ................................................................................................................... 12d $ 
current data                Attachments ATTACHMENTS REQUIRED:  Please include your current bank statements (checking, savings, money market, and 
available.                              brokerage accounts) for the past three months for all accounts.                                                                                                                     Supplement
                      13  INVESTMENTS.  List all investment assets below.  Include stocks, bonds, mutual funds, stock options, certifi cates of deposits, 
 ˜Current Value:          and retirement assets such as IRAs, Keogh, and 401(k) plans.  (If you need additional space, attach supplemental page.)
                                                                                                   Number of  ˜Current                         Used as collateral Loan                                                        Net Value
Indicate the                            Company Name                                      Shares/Units  Value                           (a) on loan? Amount            (b)                                                     (a - b)
amount you could      13a                                                                                    $                                  † No     † Yes  $                                                         $ 
sell the asset for    13b                                                                                    $                                  † No     † Yes  $                                                         $ 
today.                13c Subtotalfrom supplemental page .................................................................................................................You must calculate and enter line 13c amount. 13c $ 
                      13d Total Net Investments  ................................................................................................................................. 13d $ 
                      14  CASH ON HAND.  Enter the total of any cash you have that is not currently in a bank ..............................  14 $ 
                      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  
                      15b Name                                                                                                         $                      $                                                          $ 
                       Street Address  
                          City, State, Zip  
                      15c Subtotalfrom supplemental page .................................................................................................................You must calculate and enter line 15c amount. 15c $ 
                      15d Total Credit Available .................................................................................................................................. 15d $ 
                      16  LIFE INSURANCE.  Do you have life insurance with a cash value? .....................................................................                                                                … No  † Yes
                          (Term life insurance does not have a cash value.)  If “Yes”:                                                You must click the Yes checkbox to enter insurance information.
                      16a  Name of Insurance Company:  
 † Check this box     16b Policy Number(s):                                           
 when all spaces in   16c  Owner of Policy:                                           
 Section 5 are fi lled 16d Current Cash Value .................................................................................................... 16d $ 
 in and attachments
 are provided         16e  Outstanding Loan Balance ......................................................................................... 16e $ 
                      16f  Total Cash Value:  Subtract line 16e from line 16d; enter the difference ....................................................  16f $ 
                            Attachments ATTACHMENTS REQUIRED:  Please include a statement from the life insurance companies that includes type and 
                                        cash/loan value amounts.  If currently borrowed against, include loan amount and date of loan.
Section 6                                                                                                                             You must click the Yes checkbox to enter detailed information.
                      17  Do you owe any federal taxes? .............................................................................................................................. 
Federal and                                                                                                                                                                                                                   … No  † Yes
Other Taxes               If “Yes”, how much?  $_____________________           Amount of payment:  $_____________________
Owed                  17a  Do you owe any other government agency? ..........................................................................................................                                                 … No  † Yes
                          If “Yes”, who?   
                          How much is owed?  $_____________________           Amount of payment:  $_____________________
Section 7             18  OTHER INFORMATION.  Respond to the following questions related to your fi nancial condition.  (Attach a sheet if
                          you need more space).                                                                                       You must click the Yes checkbox to enter detailed information.
Other
Information           18a  Are there any garnishments against your wages? .................................................................................................                                                   … No  † Yes
                          If yes, who is the creditor? ____________________________  Date creditor obtained judgement:  ______________                            MM/DD/YY
                          Amount of debt $_________________
 † Check this box
 when all spaces in   18b Are there any judgments against you? ...................................................................................................................                                            … No  † Yes
 Sections 6 and 7         If yes, who is the creditor? ____________________________  Date creditor obtained judgement:  ______________                            MM/DD/YY
 are fi lled in            Amount of debt $_________________
ADOR  10896 (10/10)                                                                                 Page 2 of 4                                                   Section 7 continues on page 3  Æ
Previous ADOR 20-1070

Arizona Department of Revenue                                                                                                                                Collection Information Statement (Personal)
Name                                                                                                                                            SSN  
Section 7                                                                       You must click the Yes checkbox to enter detailed information.                                                             NO YES
continued                18c  Are you a party in a lawsuit? ............................................................................................................................................   … … 
                              If yes, amount of suit $________________  Possible completion date ________________                               MM/DD/YY
Other
Information                   Subject matter of suit ____________________________________________________________________________
                         18d Have you ever fi led bankruptcy? ......................................................................................................................................        … … 
                              If yes, date fi led  ________________ MM/DD/YYDate discharged ________________            MM/DD/YY
                         18e  In the past 10 years, have you transferred any assets out of your name for less than their actual value? ......................                                              … … 
                              If yes, what asset? __________________________________  Value of asset at time of transfer $_______________ 
                              When was it transferred?  ________________  ToMM/DD/YYwhom or where was it transferred? _________________________
                         18f  Do you anticipate any increase in household income in the next two years? ..................................................................                                 … … 
                              If yes, why will the income increase?  (Attach sheet if you need additional space) __________________________________
                              How much will it increase? $________________ … per month,   … per year
                         18g Are you a benefi ciary of a trust, an estate? ......................................................................................................................           … … 
                              If yes, name of the trust, estate  __________________________________________________________________
                              Anticipated amount to be received? $________________      When will the amount be received? _______________                            MM/YYYY
 † Check this box
 when all spaces in      18h Are you a participant in a profi t sharing plan? ..................................................................................................................            … … 
 Section 7 are fi lled in      If yes, name of plan _______________________________________________  Value in plan $________________
Section 8                19   PURCHASED AND LEASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS.  Include boats, RV’s, motorcycles, 
                              trailers, etc.  (If you need additional space, attach a separate sheet.)
Assets and                Description                                                                           ˜Current Loan/Lease                        Name of Purchase/Lease Monthly
Liabilities                        (Year, Make, Model, Mileage)                                                 Value         Balance                 Lender/Lessor         Date                         Payment
                         19a Year  
                          Make/Model  
 ˜Current Value:              Mileage                                                                        $             $                                           MM/DD/YY  $ 
 Indicate the            19b Year  
 amount you could         Make/Model  
 sell the asset for           Mileage                                                                        $             $                                           MM/DD/YY  $ 
 today.
                         20   REAL ESTATE.  List all real estate you own.  (If you need additional space, attach a separate sheet.)
                                                                                                                                                                                                           ‘Date
                            Street Address                                       Date  Purchase  Current                  ˜                        Loan    Name of Lender   Monthly                        of Final
                                      City, State, Zip                      Purchased                           Price       Value                  Balance   or Lien Holder Payment                        Payment
                         20a  
 ‘Date of Final
                               
 Payment:  Enter
                               
 the date the loan                                                          MM/DD/YY                                                                                                                     MM/DD/YY
                              County                                                                         $          $                        $                      $                                  
 or lease will be
 fully paid.
                         20b   
                               
                              County                                        MM/DD/YY                         $          $                        $                      $                                  MM/DD/YY
                               Attachments ATTACHMENTS REQUIRED:  Please include your current statement from lender with monthly payment amount 
                                           and current balance for each piece of real estate owned.

                         21   PERSONAL ASSETS. List all personal assets below.  (Ifyou                                       need additional space, attach a separate sheet.)  
                              Furniture/Personal Effects includes the total current market value of your household such as furniture and appliances.
                              Other Personal Assets includes all artwork, jewelry, collections (coin/gun, etc.), antiques or other assets.
                                                                                                                ˜Current Loan                                          Monthly Date of‘
                                              Description                                                       Value         Balance                 Name of Lender   Payment    Final Payment
                         21a Furniture/Personal Effects                    $  $                                                                                      $                                   MM/DD/YY

                              Other: (List below)
                         21b Artwork:                                                                       $               $                                        $                                   MM/DD/YY
                         21c Jewelry:                                                                       $               $                                        $                                   MM/DD/YY
 † Check this box        21d                                                                                $               $                                        $                                   MM/DD/YY
 when all spaces in      21e                                                                                $               $                                        $                                   MM/DD/YY
 Section 8 are fi lled in 21f                                                                                $               $                                        $                                   MM/DD/YY
 and attachments
 are provided            21g                                                                                $               $                                        $                                   MM/DD/YY
ADOR  10896 (10/10)                                                                                             Page 3 of 4                                          Section 9 begins on page 4                    Æ
Previous ADOR 20-1070

Arizona Department of Revenue Some fields on this page are Read-Only.  You cannot enter data in these fields; they are calculated as you fill in the form.Collection Information Statement (Personal)
Name                                                                                                           SSN  
Section 9                          Total Monthly Income                                                   Total Monthly Expenses
                                   Source                                           Gross           Net  Expense Items                               Actual DOR Use
Monthly
Income and                         22 Wages (Yourself)                    $               $              33 Rent/Mortgage                          $
Expense                            23 Wages (Spouse)                                                     34 Groceries (no. of people         )
Analysis                          24 Interest - Dividends                                                35 Installment Payments
                                  25 Net Income from Business                                            36 Utilities:
                                  26 Net Rental Income                                                      36a Gas           $
If only one                       27 Pension/Social Security (Yourself)                                     36b Water         $
spouse has a                      28 Pension/Social Security (Spouse)                                       36c Electric      $
tax liability, but                29 Child Support                                                          36d Phone         $
both have                         30 Alimony                                                                36e  Total Utilities Expense
income, list the                  31 Other Income                                                        37 Transportation
total household                                                                                          38 Insurance:
income and                       32 TOTAL INCOME                          $               $                 38a Life          $
expenses.                                                                                                   38b Health        $
                                                                                                            38c Car           $
                                                                                                            38d Total Insurance Expense
                                                                                                         39 Medical expenses
                                                                                                         40 Estimated tax payments
                                                                                                         41 Court-ordered/Child support payment
                                                                                                         42 Child/Dependent care
                                                                                                         43 Other Expenses
                                                                                                         44    TOTAL LIVING EXPENSES  $
                         45 NET DIFFERENCE:                Subtract Total Living Expenses (line 44) from Total Net Income (line 32). . . . . . . . $ 0
                         Wages, salaries, pensions, and social security:  Enter your gross monthly wages and/or salaries.  Enter your net income and            
                          deduct withholding or allotments you elect to take out of your pay, such as insurance payments, credit union deductions, car payments, 
                          etc.  To calculate your gross monthly wages and/or salaries:
                            • If paid weekly:  Multiply weekly gross wages by 4.3.  Example:  $425.89 x 4.3 = $1,831.33
                            • If paid bi-weekly (every 2 weeks):  Multiply bi-weekly gross wages by 2.17.  Example:  $972.45 x 2.17 = $2,110.22
                            • If paid semi-monthly (twice each month):  Multiply semi-monthly gross wages by 2.  Example:  $856.23 x 2 = $1,712.46
                           Net Income from Business:  Enter your monthly net business income.  This is the amount you earn after you pay ordinary and 
                                   necessary monthly business expenses.  If your net business income is a loss, enter “0”.  Do not enter a negative number.
                                   Net Rental Income:  Enter your monthly net rental income.  This is the amount you earn after you pay ordinary and necessary monthly 
                                   rental expenses.  If your net rental income is a loss, enter “0”.  Do not enter a negative number.
                                   Rent/Mortgage:  For your principal residence:  Total of rent or mortgage payment.  Add the average monthly expenses for the 
                                   following:  property taxes, homeowner’s or renter’s insurance, maintenance, dues, and fees.
                                   Groceries:  Total of food expenses for one month.
                                   Transportation:  Total of lease or purchase payments, registration fees, normal maintenance, fuel, public transportation, parking and 
                                   tolls for one month.
                                   Medical Expenses:  List medical expenses not covered by insurance.
                                                  ATTACHMENTS REQUIRED.  Please include the following:
                                                           • Proof of all current expenses that you paid for the past 3 months, including utilities, rent, insurance, 
                                               Attachments property taxes, etc.
                                                           • Proof of all non-business transportation expenses (e.g., car payments, lease payments, fuel, oil, 
 † Check this box                                          insurance, parking, registration).
 when all spaces in                                        • Proof of all payments for health care, including health insurance premiums, co-payments, and other 
 Section 9 are fi lled in                                   out-of-pocket expenses, for the past 3 months.
 and attachments
 are provided.                                             • Copies of any court order requiring payment and proof of such payments (e.g., cancelled checks, money 
                                                           orders, earning statements showing such deductions) for the past 3 months.
                                               Failure to complete all entry spaces may result in rejection or signifi cant delay in the 
                                               resolution of your account.
                                              !
                                   CAUTION
                                                  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.
 † Check this box                              #                                                                 
 when all spaces in all                            Your Signature                                                  Date
 sections are fi lled in
 and all attachments                                                                                             
 are provided                                      Spouse’s Signature                                              Date
ADOR 10896 (10/10)                                                                        Page 4 of 4
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Arizona Department of Revenue                                                                                 Collection Information Statement (Personal)
Name                                                                                    SSN  

SUPPLEMENTAL PAGE:  Investment, Bank, Credit, Other Accounts                                                 List additional accounts not listed on page 2.
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               $                             $                    $

 a) Subtotal Investment Account Net Values:     List here and on page 2, line 13c .............................................................a) $                  

 b) Subtotal Other Account Current Balances:     List here and on page 2, line 12c ...........................................................b) $                   
 c) Subtotal Credit Available:  List here and on page 2, line 15c .......................................................................................Page 2 c) $  

ADOR 10896 (10/10)
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