Government of the District of Columbia • Office of Tax and Revenue • Collection Division 
                             
 Form PA-1(Rev. 1/06) 
                                            Collection Information Statement for Individuals 
  
 Note: Complete all blocks, Write “N/A” (not applicable) in blocks that do not apply. 
                                                                                                                                       
 Taxpayer(s) Name & Address                                  Home Phone Number                                                        Fax Number 
                                                             (     )                                                                  (     ) 
                                                                                                                                       
                                                             Taxpayer’s Social Security Number                                        Spouse’s Social Security Number 
                                                                                                                                       
 Employment Information 
                                                                                                                                      
 Taxpayer’s employer or business (name and address)         Business phone number                                                    Title: 
                                                            (     )                                                                   
                                                                                                                                      
                                                            Payday(s)                                                                (Check appropriate box) 
                                                                                                                                       Wage Earner    Partner 
                                                                                                                                      Sole Proprietor   
                                                                                                                                      
 Spouse’s employer or business (name and address)           Business phone number                                                    Occupation 
                                                            (     )  
                                                                                                                                      
                                                            Payday(s)                                                                (Check appropriate box) 
                                                                                                                                        Wage Earner     Partner 
                                                                                                                                      
                                                                                                                                       Sole Proprietor   
  
 Personal Information 
                                                               
 Name, address and telephone number of next of kin or other   Other names or aliases 
 reference                                                     
  
 Date           Taxpayer                    Spouse            Latest filed income tax return                                        Number of exemptions Adjusted Gross Income 
 of birth                                                                                                                                                 
  
 General Financial Information 
  
 Bank accounts (include savings & loans, credit unions, IRA and retirement plans, certificates of deposits, etc.) 
                                                                                                                                                    
  Name of Institution                       Address         Type of Account                                                         Account Number        Balance
                                                                                                                                                    
                                                                                                                                                   $ 
                                                                                                                                                    
                                                                                                                                                   $ 
                                                                                                                           Total    

 General Financial Information 
  
 Credit cards and lines of credit from banks, credit unions, and savings and loans 
                                                                                                                                                                                      
  Type of                                    Name and Address of                                              Monthly         Credit   Amount                                         Credit 
  Account or Card                            Financial Institution            Payment                                         Limit    Owed                                           Available  
                                                                                 
                                                                  Totals                                                                                                              
  
 Safe deposit boxes rented or accessed (List all locations, box numbers, and contents) 
  
                                             Form                            Tax Year ended                                            Net Income before taxes 
 Latest filed federal individual income tax 
 return (please attach a copy)   
                                                                           
  Real Property (Brief description and type of ownership)                                                                             Physical Address
   
             Life Insurance (Name of Company)                                Policy Number                               Type         Face Amount                             Available Loan Value 
                                                                                                                                                                             
                                                                                                       Total                                                                 
  
 Securities (stocks, bonds, mutual funds, money market funds, government securities, etc.): 
                                                                                                                                                                             
                               Kind                                          Quantity of                                 Current      Where                                           Owner of  
                                                                             Denomination                                Value        Located                                         Record 
                                                                                                                                                                             
 Other information relating to your financial condition.  If you check the “Yes” box, please give dates and explain on page 4, Additional 
 Information or Comments: 
 Court proceedings                        Yes            No             Bankruptcies         Yes       No 
                                                                                                                
                                                                                                               Recent transfers of assets for less than full value             
 Repossessions                               Yes     No 
                                                                                                                      Yes       No 
                                                                                                                
                                                                                                               Participation or beneficiary to trust, estate, profit sharing         
 Anticipated increase in income     Yes                           No 
                                                                                                                    
                                                                                                                      Yes       No 

Asset and Liability Analysis 
                                                                                                                                
 Description               Curr. Mkt  Liabilities Equity                        Amount of    Name and Address of       Date    Date of 
                            Value     Balance Due in  Asset                     Mo. Payment  Lien/Note Holder/Obligee  Pledged Final Payment 
                                                                                                                                
Cash                                                                                                                            
                                                                                                                                
Bank Accounts                                                                                                                   
                                                                                                                                
Securities                                                                                                                      
                                                                                                                                
Cash or Loan value of                                                                                                           
insurance 
                                                                                                                                
Vehicles (model, year,                                                                                                          
license, tag number 
                                                                                                                                
                  a.                                                                                                            
                                                                                                                                
                  b.                                                                                                            
                                                                                                                                
                  c.                                                                                                            
                                                                                                                                
Real Property                                                                                                                   
                                                                                                                                
                  a.                                                                                                            
                                                                                                                                
                  b.                                                                                                            
                                                                                                                                
                  c.                                                                                                            
                                                                                                                                
Other Assets                                                                                                                    
                                                                                                                                
                  a.                                                                                                            
                                                                                                                                
                  b.                                                                                                            
                                                                                                                                
                  c.                                                                                                            
                                                                                                                                
Bank revolving credit                                                                                                           
                                                                                                                                
Other Liabilities a.                                                                                                            
 including 
judgements,                                                                                                                     
notes & other     b.                                                                                                            
charge accts                                                                                                                    
                  c.                                                                                                            
                                                                                                                                
Federal taxes owed $                                                                                                            
                                                                                                                                
Totals                                            $                             $                                               
 
Financial Verification / Analysis (To be completed by the Collection Division ) 
                                                                                                                        
                           Item                   Date Information/EncumbranceVerified       Date Property Inspected   Est. Force Sale Equity 
                                                                                                                        
Personal Residence                                                                                                      
                                                                                                                        
Other Real Property                                                                                                     
                                                                                                                        
Vehicles                                                                                                                
                                                                                                                        
Other Personal Property                                                                                                 
                                                                                                                        
State Employment (Husband and Wife)                                                                                     
                                                                                                                        
Income Tax Return                                                                                                       
                                                                                                                        
Wage Statements                                                                                                         
                                                                                                                        
Sources of Income Credit (D&B Report)                                                                                   
                                                                                                                        
Expenses                                                                                                                
                                                                                                                        
Other Assets / Liabilities                                                                                              

Monthly Income and Expense Analysis 
                                                    
          Income                                                                            Necessary
                                                                                             Living Expenses 
          Source                       Gross    Net
                                                                                                              
Wages / Salaries                    $         $    Rent / Mortgage                                           $  
(Taxpayer) 
                                                                                                              $    
Wages / Salaries                                   Groceries (# of people                   ) 
(Spouse) 
                                                                                                              
Interest - Dividends                               Installment payments                                       $ 
                                                                                                              
Net Business Income                 $              Utilities                                                  $       
                                                   Gas        $__________________ 
                                                   Water    $__________________ 
                                                                                                              
Rental Income                                      Electric  $                                                $ 
                                                   Phone     $                                        
                                                                                                              
Pension (Taxpayer)                                 Transportation                                             $ 
                                                                                                              
Pension (Spouse)                                   Insurance                                                  
                                                   Life      $                                          
                                                   Health  $                                          
                                                                                                              
Child Support                                       Home  $                                                    $ 
                                                    Car      $                                          
                                                                                                              
Alimony                                            Medical                                                     
                                                                                                              
Other                                              Estimated tax payments                                     
                                                                                                              
                                                   Court ordered payments                                     
                                                                                                              
                                                   Other expenses (specify)                                   
                                                                                                              
Total Income                        $         $    Total Expenses                                            $ 
                                                                                                              
                                                   Net difference (income less necessary                      
                                                   living expenses)                                          $ 
 
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. 
                                                                                             
Your Signature                               Spouse’s signature (if joint return was filed) Date 
                                                                                             
Additional information or comments: