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                                                                                                                                                                     PRINT          CLEAR

     Form  RO-1063                   N.C Department of Revenue
  (Rev. 5-19)                        Collection Information Statement for Business
Note: Complete all entry spaces with the current data available or "N/A" (not applicable).  Failure to complete all entry spaces may result in rejection of your
request or significant delay in account resolution.  Include attachments if additional space is needed to respond completely to any questions.
Section 1.  Business Information
1a.  Business name                                                           2a.  Employer Identification No. (EIN)
                                                                             2b.  Type of Entity (Check appropriate box below)
                                                                                                                         Partnership Corporation                     Other
1b.  Business Street Address
    Mailing Address                                                                                                      Limited Liability Company (LLC) classified as a corporation
    City
    State                                            ZIP                                                                 Other LLC - Include number of members

1c.  County                                                                  2c.  Date Incorporated/Established
                                                                                                                                                                          mm/dd/yyyy
1d.  Business Telephone                                                      3a.  Number of Employees
                                                                             3b.  Monthly Gross Payroll
1e.  Type of Business                                                        3c.  Frequency of Tax Deposits

1f.  Type of Website

4. Does the business engage in e-Commerce (internet sales)                   Yes                                         No
Payment Processor (e.g., PayPal, Authorize.net, Google Checkout, etc.), Name and Address (Street, City, State, ZIP code)                Payment Processor Account Number
5a.

5b.

Credit cards accepted by the business
Type of Credit Card (e.g., Visa, MasterCard, etc.)   Merchant Account Number   Merchant Account Provider Name and Address (Street, City, State, ZIP code)

6a.                                                                                                                                                             Phone

6b.                                                                                                                                                             Phone

6c.                                                                                                                                                             Phone
Section 2.  Business Personnel and Contacts
Partners, Officers, LLC, Members, Major Shareholders, Etc.
7a.  Full Name                                                               Social Security Number
    Title                                                                    Home Telephone
    Home Address                                                             Work/Cell Phone
    City                              State            ZIP                   Ownership Percentage &  Shares or Interest
    Responsible for Depositing Taxes                 Yes   No
7b.  Full Name                                                               Social Security Number
    Title                                                                    Home Telephone
    Home Address                                                             Work/Cell Phone
    City                              State            ZIP                   Ownership Percentage &  Shares or Interest
    Responsible for Depositing Taxes                 Yes   No
7c.  Full Name                                                               Social Security Number
    Title                                                                    Home Telephone
    Home Address                                                             Work/Cell Phone
    City                              State            ZIP                   Ownership Percentage &  Shares or Interest
    Responsible for Depositing Taxes                 Yes   No
7d.  Full Name                                                               Social Security Number
    Title                                                                    Home Telephone
    Home Address                                                             Work/Cell Phone
    City                              State            ZIP                   Ownership Percentage &  Shares or Interest
    Responsible for Depositing Taxes                 Yes   No

Business Financial Statement- Page 1

    Section 3.  Other Financial Information (Attach copies of all applicable documentation.)
    8.  Does the business use a Payroll Service Provider or Reporting Agent (If yes, answer the following)                         Yes               No
    Name and Address (Street, City, State, ZIP code)                                                                Effective dates (mm/dd/yyyy)

    9.  Is the business a party to a lawsuit ( If yes, answer the following)                                                       Yes               No
                                                     Location of Filing                            Represented by                      Docket/Case No.

     Plaintiff            Defendant
    Amount of Suit                                   Possible Completion Date (mm/dd/yyyy) Subject of Suit

    10.  Has the business ever filed bankruptcy ( If yes, answer the following)                                                    Yes               No
    Date Filed (mm/dd/yyyy)            Date Dismissed or Discharged (mm/dd/yyyy)           Petition No.                            Location

    11.  Do any related parties (e.g., officers, partners, employees) have outstanding amounts owed
      to the business ( If yes, answer the following)                                                                              Yes               No
    Name and Address (Street, City, State, ZIP code)         Date of Loan           Current balance                                Payment Date       Payment Amt.
                                                                                    as of 

                                                                                    $                                                                $
    12.  Have any assets been transferred, in the last 10 years, from this business for less than full 
     value ( If yes, answer the following)                                                                                         Yes               No
    List Asset                                         Value at Time                  Petition No.                         Location
                                                         of transfer
                                                     $                                 
    13.  Does this business have other affiliations (e.g., subsidiary or parent companies) 
     ( If yes, answer the following)                                                                                               Yes               No
    Related Business Name and Address (Street, City, State, ZIP code)                                               Related Business EIN:

    14.  Any increase/decrease in income anticipated ( If yes, answer the following)                                               Yes               No
    Explain (use attachment if needed)                                                     How much will it increase/decrease       When will it increase/decrease
                                                                                           $
    Section 4.  Business Asset and Liability Information
    15.  Cash on Hand.  Include cash that is not in the bank.                                          Total Cash on Hand                  $
     Business Bank Accounts.  Include online bank accounts, money market accounts, savings accounts, checking accounts, and stored value cards
     (e.g., payroll cards, government benefit cards, etc.) List safety deposit boxes including location and contents
                                                                                                                                     Account Balance 
    Type of                     Full Name and Address (Street, City, State, ZIP code)                    Account Number              as of 
    Account                 of Bank, Savings & Loan, Credit Union or Financial Institution                                                  mm/dd/yyyy
16a.
                                                                                                                                   $
16b.
                                                                                                                                   $
16c.
                                                                                                                                   $

16d.  Total Cash in Banks (Add lines 16 a through 16c and amounts from any attachments)                                            $
    17. Virtual Currency/Cryptocurrency : (Bitcoin, Litecoin, etc)

                                                                                           Location(s) of Virtual Currency 
                                       Name of Virtual Currency Wallet, Exchange  (Mobile Wallet, Online and/or  Virtual Currency amount 
     Type of Virtual Currency                          or Digital Currency Exchange        External Hardware storage       and value in US dollars.  3 month average 
17a.
17b.
     17c. Total                                                                                                                                     $

    Accounts/Notes Receivable.  Include e-payment accounts receivable and factoring companies, and any bartering or online auction accounts.
    (List all contracts separately,  including contracts awarded, but not started.)
    18.  Is the business a Federal or State Government Contractor                               Yes        No  (Include Federal or State Government contracts below)
    Accounts/Notes Receivable & Address Status (e.g., age,                          Date Due        Invoice Number or Federal or                  Amount Due
        (Street, City, State, ZIP code) factored, other)                           (mm/dd/yyyy)   State Government Contract Number
18a.

                                                                                                                                                 $
Contact Name:
    Phone:
18b.

                                                                                                                                                 $
Contact Name:
    Phone:
18c.

                                                                                                                                                 $
Contact Name:
    Phone:
18d.

                                                                                                                                                 $
Contact Name:
    Phone:
18e.

                                                                                                                                                 $
Contact Name:
    Phone:

    18f.  Outstanding Balance (Add lines 18a through 18 e and amounts from any attachments)                                                      $
    19. Investments.  List all investment assets below.  Include stocks, bonds, mutual funds, stock options, and certificates of deposit.
    Name of Company & Address           Used as collateral                           Current Value            Loan Balance                         Equity
    (Street, City, State, ZIP code)     on loan                                                                                              Value Minus Loan
19a.

                                        Yes                                    No
    Phone:                                                                         $                       $                               $
19b.

                                        Yes                                    No
    Phone:                                                                         $                       $                               $

    19c.  Total Investments (Add lines 19a, 19b, and amounts from any attachments)                                                         $                             -
    20. Available Credit.   Include all lines of credit and credit cards.                             Amount Owed                            Available Credit
    Full Name & Address  (Street, City, State, ZIP code) of Credit Institution     Credit Limit      As of                                  As of
                                                                                                               mm/dd/yyyy                            mm/dd/yyyy
20a.

                                                                               $                    $                                     $
    Account No.
20b.

                                                                               $                    $                                    $
    Account No.

    20c.  Total Available Credit (Add lines 20a, 20b, and amounts from any attachments)                                                   $
Business Financial Statement- Page 3

21.  Real property owned, rented, and leased    .  Include all real property and land contracts. 
21a.  Primary Residence
                                                    Current Fair                                     Amount of    Date of Final       Equity
  Purchase/Lease Date                County        Market Value      Current Loan                      Monthly  Payment                       FMV
     (mm/dd/yyyy)                     Tax Value     (FMV)           Balance                            Payment   (mm/dd/yyyy)      Minus Loan

                      $                         $                $                               $                              $
Location (Street, City, State, ZIP code)                               Lender/Lesser/Landlord Name, Address (Street, City, State, ZIP code) 

Property County                                                    Landlord/Lessor Phone Number
First Mortgage Holder                                              Second Mortgage Home Equity Line

21b.  Property Description
                                                    Current Fair                                     Amount of    Date of Final       Equity
  Purchase/Lease Date                County        Market Value      Current Loan                      Monthly  Payment                       FMV
     (mm/dd/yyyy)                     Tax Value     (FMV)           Balance                            Payment   (mm/dd/yyyy)      Minus Loan

                      $                         $                $                               $                              $
Location (Street, City, State, ZIP code)                               Lender/Lesser/Landlord Name, Address (Street, City, State, ZIP code) 

Property County                                                    Landlord/Lessor Phone Number

21c.  Property Description
                                                    Current Fair                                     Amount of    Date of Final       Equity
  Purchase/Lease Date                County        Market Value      Current Loan                      Monthly  Payment                       FMV
     (mm/dd/yyyy)                     Tax Value     (FMV)           Balance                            Payment   (mm/dd/yyyy)      Minus Loan

                      $                         $                $                               $                              $
Location (Street, City, State, ZIP code)                               Lender/Lesser/Landlord Name, Address (Street, City, State, ZIP code) 

Property County                                                    Landlord/Lessor Phone Number

21d.  Property Description
                                                    Current Fair                                     Amount of    Date of Final       Equity
  Purchase/Lease Date                County        Market Value      Current Loan                      Monthly  Payment                       FMV
     (mm/dd/yyyy)                     Tax Value     (FMV)           Balance                            Payment   (mm/dd/yyyy)      Minus Loan

                      $                         $                $                               $                              $
Location (Street, City, State, ZIP code)                               Lender/Lesser/Landlord Name, Address (Street, City, State, ZIP code) 

Property County                                                    Landlord/Lessor Phone Number

21e. Total  Fair Market Value                   21f. Total Current Loan Balance                                21g. Net Equity
$                                                 $                                                            $
                                                Attach additional sheets as needed
Business Financial Statement- Page 4

22.  Vehicles Leased and Purchased.  Include boats, RVs, motorcycles, trailers, mobile homes, aircraft, etc. 
22a. Description       Purchase/Lease Date            Current Fair Market    Current Loan              Amount of Monthly Date of Final          Equity
(Make, Model,          (mm/dd/yy)                         Value (FMV)        Balance                         Payment     Payment               FMV minus loan
Year, Mileage)                                                                                                                                 $
                                                                           Lender/Lessor Name, Address, (Street, Address, State, ZIP code)
  Make                 Model                  Year          Mileage

22b. Description       Purchase/Lease Date            Current Fair Market    Current Loan              Amount of Monthly Date of Final          Equity
(Make, Model,          (mm/dd/yy)                         Value (FMV)        Balance                         Payment     Payment               FMV minus loan
Year, Mileage)                                                                                                                                 $
                                                                           Lender/Lessor Name, Address, (Street, Address, State, ZIP code)
  Make                 Model                  Year          Mileage

22c. Description       Purchase/Lease Date            Current Fair Market    Current Loan              Amount of Monthly Date of Final          Equity
(Make, Model,          (mm/dd/yy)                         Value (FMV)        Balance                         Payment     Payment               FMV minus loan
Year, Mileage)                                                                                                                                 $
                                                                           Lender/Lessor Name, Address, (Street, Address, State, ZIP code)
  Make                 Model                  Year          Mileage

22d. Description       Purchase/Lease Date            Current Fair Market    Current Loan              Amount of Monthly Date of Final          Equity
(Make, Model,          (mm/dd/yy)                         Value (FMV)        Balance                         Payment     Payment               FMV minus loan
Year, Mileage)                                                                                                                                 $
                                                                           Lender/Lessor Name, Address, (Street, Address, State, ZIP code)
  Make                 Model                  Year          Mileage

22e. Total  Fair Market Value                             22f. Total Current Loan Balance                          22g. Net Equity
$                                                           $                                                      $
Business Equipment.    Include all machinery, equipment, merchandise inventory, and/or other assets. 
Include Uniform Commercial Code (UCC) filings.
                                                              Current Fair                               Amount of     Date of Final                 Equity
                                      Purchase/Lease Date    Market Value      Current Loan                Monthly       Payment                  FMV
                                         (mm/dd/yyyy)         (FMV)           Balance                      Payment    (mm/dd/yyyy)                Minus Loan
23a.  Asset Description
                                                          $                $                         $                                         $
Location (Street, City, State, ZIP code) and County                        Lender/Lesser/Landlord Name, Address (Street, City, State, ZIP code) and Phone

23b.  Asset Description
                                                          $                $                         $                                         $
Location (Street, City, State, ZIP code) and County                        Lender/Lesser/Landlord Name, Address (Street, City, State, ZIP code) and Phone

23c.  Asset Description
                                                          $                $                         $                                         $
Location (Street, City, State, ZIP code) and County                        Lender/Lesser/Landlord Name, Address (Street, City, State, ZIP code) and Phone

23d.  Asset Description
                                                          $                $                         $                                         $
Location (Street, City, State, ZIP code) and County                        Lender/Lesser/Landlord Name, Address (Street, City, State, ZIP code) and Phone

23e. Total  Fair Market Value                             23f. Total Current Loan Balance                          23g. Net Equity
$                                                           $                                                      $
Business Financial Statement- Page 5

Business Liabilities.   Include notes and judgments below.  
                                                                                                                          Date of Final
          Business Liabilities                  Secured/          Date Pledged                       Balance Owed            Payment                                  Payment
                                              Unsecured           (mm/dd/yyyy)                                            (mm/dd/yyyy)                                 Amount
24a.  Description                             Secured
                                              Unsecured                                       $                                                $
Name
Street Address
City/State/ZIP code                                                                                                    Phone:
24b.  Description                             Secured
                                              Unsecured                                       $                                                $
Name
Street Address
City/State/ZIP code                                                                                                    Phone:
24c.  Description                             Secured
                                              Unsecured                                       $                                                $
Name
Street Address
City/State/ZIP code                                                                                                    Phone:
24d. Total Balance Owed             $                                                               24e. Total  Payments      $
   Section 5.  Monthly Income/Expense Statement for Business
Accounting Method Used:                       Cash                               Accrual
Income and Expenses during the period          (mm/dd/yyyy)                                                to (mm/dd/yyyy)
                        Total Monthly Business Income                                                                Total Monthly Business Expenses
                       Source                               Gross Monthly                                          Expense Items                                      Actual Monthly
25  Gross Receipts from Sales/Services                                                        36  Materials Purchased
26  Gross Rental Income                                                                       37  Inventory Purchased
27  Interest Income                                                                           38  Gross Wages & Salaries
28  Dividends                                                                                 39  Rent
29  Cash                                                                                      40  Supplies
Other Income (Specify below)                                                                  41  Utilities/Telephone
30                                                                                            42 Vehicle Gasoline/Oil
31                                                                                            43  Repairs & Maintenance
32                                                                                            44  Insurance
33                                                                                            45  Current Taxes
34                                                                                            46  Other Expenses (Specify)
35  Total Income                                                                              47  DOR Use Only
(Add Lines 25 through 34)                     $                                                     Allowable Installment Payments
                                                                                              48  Total Expenses
                                                                                                    (Add Lines 36 through 47)                   $
Materials Purchased: Materials are items directly related to the production of a              Utilities/Telephone: Utilities include gas, electricity, water, oil, other fuels,
 a product or service.                                                                         trash collection, telephone and cell phone.
Inventory Purchased: Goods bought for resale.                                                 Current Taxes: Real estate, state, and local income tax, excise, franchise,
Supplies: Supplies are items used to conduct business and are consumed or used up             occupational, personal property, sales and the employer's portion of the
within one year.  This could be the cost of  books, office supplies, professional equipment . the employment taxes.
   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.
   Signature                                                                                  Title                                       Date

   Print Name of Officer, Partner or LLC Member

   Attachments Required:  Copies of the following items for the last 3 months from the date this form is submitted (check all attached items):
          Banks and investments- Statements for all money market, brokerage, checking/savings accounts, certificates of deposit, stocks/bonds.
          Assets- Statements from lenders on loans, monthly payments, payoffs, and balances, for all assets.  Include copies of UCC financing
          statements and accountant's depreciation schedules.
          Expenses- Bills or statements for monthly recurring expenses of utilities, rent, insurance, property taxes, telephone and cell phone,
          insurance premiums, court orders requiring payments, other expenses.
          Other- credit card statements, profit and loss statements, all loan payoffs, etc.
          Copy of the last 2 income tax return filed. (Corporate Income, Partnership, etc,) 
Additional information or proof may be subsequently requested.
   FINANCIAL ANALYSIS OF COLLECTION POTENTIAL
   FOR BUSINESSES                                                                                                                              (DOR USE ONLY)
Cash Available
(Lines 15, 16d, 17c, 18f, 19c, and 20c)                                                                                Total Cash              $
Distrainable Asset Summary
(Lines 21g, 22g,  and 23g)                                                                                             Total Cash              $
Monthly Income Minus Expenses
(Line 35 Minus Line 48)                                                                                                Total Cash              $
Business Financial Statement- Page 6