PA-2 (Rev. 1/06)           Government of the District of Columbia • Office of Tax and Revenue  •  Collection Division 
                                               Collection Information Statement for Businesses 
  
 Note: Complete all blocks.  Write “N/A” (not applicable) in blocks that do not apply. 
  
 Name and address of  business (list other locations or other businesses that you own on                                             Business phone number      (      ) 
 a separate sheet & attach)                                                                                                           
                                                                                                                                     Check appropriate box 
  
                                                                                                                                     † Sole Proprietor     †  Corporation    †                          Partnership    † LLC   † Other  
                                                                                                                                                                 
 Name and title of person being interviewed                                                                                          Employer Identification #  Type of business 
                                                                                                                                                                 
 Information about owner, partners, officers, major shareholder, etc. 
                                                                                                                                                                                                         
          Name and Title                Effective Date  Home Address                                                                  Phone Number               SSN                                      Total Shares     
                                                                                                                                                                                                         
                                                                                                                                     (      )                                                            
                                                                                                                                                                                                         
                                                                                                                                     (      )                                                            
                                                                                                                                                                                                         
                                                                                                                                     (      )                                                            
                                                                                                                                                                                                         
                                                                                                                                     (      )                                                            
                                                                                                                                                                                                         
                                                                                                                                     (      )                                                            
  
 General Financial Information 
                                                                                                                                                                
 Latest filed federal individual and/or   Form         Tax Year ended                                                                                          Net Income before taxes 
 business income  tax return  (please      
 attach a copy)Î 
  
 Bank accounts (List all types of accounts including payroll, general, savings, certificates of deposit, etc.) 
                                                                                                                                                                                                          
  Name of Institution                      Address                                                                                     Type of Account           Account Number                                         Balance 
                                                                                                                                                                                                          
                                                                                                                                                                                            Total     Î   
  
 Bank credit available (Lines of credit, etc.) 
                                                                                                                                                                                                          
  Name of Institution                                   Address                                                                     Credit Limit  Amount Owed     Credit Available                        Monthly Payments 
                                                                                                                                                                                                          
                                                                                                                       Totals     Î                                                                       
 
 Location, box number and contents of all safe deposit boxes rented or accessed: 
  

 General Financial Information (continued) 
  
 Real Property 
                                                                                            
               Brief Description and Type of Ownership                                                                   Physical Address 
                                                                                            
 Life Insurance policies owned with business as beneficiary 
                                                                                                                                            
      Name Insured                                    Company          Policy Number                          Type        Face Amount        Available Loan Value 
                                                                                                                                            
                                                                      Total    Î 
Additional information regarding financial condition (Court proceedings, bankruptcies filed or anticipated, transfers of assets for less than full value, changes in market value, 
etc.; include information regarding company participation in trusts, estates, profit sharing plans, etc.) 
 
 Accounts / Notes receivable (Include current contract jobs, loans to stockholders, officers, partner, etc.) 
                                                                                                                                           
      Name                                                    Address                                         Amount Due   Date Due                                                      Status
                                                                                                                                           
                                                                                    Total  Î 
      

 Asset and Liability Analysis 
                                                                                                        
  Description                 Current Liabilities  Equity  Amount of Name and Address of       Date    Date of 
                              Market   Balance     in      monthly   Lien/Note Holder/Obligee  Pledged Final     
                              Value    Due         Asset   payment                                     Payment 
                                                                                                        
 Cash on hand                                                                                           
                                                                                                        
 Bank accounts                                                                                          
                                                                                                        
 Accounts/Notes Receivable                                                                              
                                                                                                        
 Life Insurance loan value                                                                              
                                                                                                        
               a.                                                                                       
 Real                                                                                                   
 Property      b.                                                                                       
                                                                                                        
               c.                                                                                       
                                                                                                        
               d.                                                                                       
                                                                                                        
               a..                                                                                      
 Vehicles                                                                                               
 (Model,       b.                                                                                       
                                                                                                        
 year, and     c.                                                                                       
 license)                                                                                               
               d.                                                                                       
                                                                                                        
 Machinery     a.                                                                                       
   and                                                                                                  
               b.                                                                                       
 equipment                                                                                              
  (Specify)    c.                                                                                       
                                                                                                        
               d.                                                                                       
  
 Merchandise   a.                                                                                       
 inventory                                                                                              
 (Specify)     b.                                                                                       
                                                                                                        
 Other assets  a.                                                                                       
 (Specify)                                                                                              
               b.                                                                                       
                                                                                                        
               a.                                                                                       
                                                                                                        
               b.                                                                                       
 Other                                                                                                  
 liabilities   c.                                                                                       
 (including                                                                                             
 notes, and    d.                                                                                       
 judgments)                                                                                             
               e.                                                                                       
                                                                                                        
               f.                                                                                       
                                                                                                        
               g.                                                                                       
                                                                                                        
               h.                                                                                       
  
 Federal taxes owed                                                                                     
  
 Total                                                                                                  
  
 Income and Expense Analysis 
  
 The following information applies to income and expenses during the period                                       To  _________________                      
   

 Income and Expense Analysis 
               Income                                                                               Expenses
                                                                                                                                                                                                 
 Gross receipts from sales, services, etc. $  Materials purchased                                                                                                                               $ 
                                                                                                                                                                                                 
 Gross rental income                          Net wages and salaries                                                                                                                             
                                               Number of employees                            
                                                                                                                                                                                                 
 Interest                                     Rent                                                                                                                                               
                                                                                                                                                                                                 
 Dividends                                    Installment payments                                                                                                                               
                                                                                                                                                                                                 
 Other income (specify)                       Supplies                                                                                                                                           
                                                                                                                                                                                                 
                                              Utilities / Telephone                                                                                                                              
                                                                                                                                                                                                 
                                              Gasoline / Oil                                                                                                                                     
                                                                                                                                                                                                 
                                              Repairs and maintenance                                                                                                                            
                                                                                                                                                                                                 
                                              Insurance                                                                                                                                          
                                                                                                                                                                                                 
                                              Current taxes                                                                                                                                      
                                                                                                                                                                                                 
                                              Other (Specify)                                                                                                                                    
                                                                                                                                                                                                 
 Total income                              $  Total Expenses                                                                                                                                    $ 
                                                                                                                                                                                                 
                                              Net difference                                                                                                                                    $ 
  
 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                                                                                                                                                                                      Date 
  
 Financial Verification / Analysis    (to be completed by The Collection Division) 
                                                                                                                                                                                                 
                          Item               Date Information or                                    Date Property                                                                               Estimated Forced 
                                             Encumbrance Verified                                   Inspected                                                                                   Sale Equity 
                                                                                                                                                                                                 
 Sources of Income/Credit (D&B Report)                                                                                                                                                           
                                                                                                                                                                                                 
 Expenses                                                                                                                                                                                        
                                                                                                                                                                                                 
 Real Property                                                                                                                                                                                   
                                                                                                                                                                                                 
 Vehicles                                                                                                                                                                                        
                                                                                                                                                                                                 
 Machinery and Equipment                                                                                                                                                                         
                                                                                                                                                                                                 
 Merchandise                                                                                                                                                                                     
                                                                                                                                                                                                 
 Accounts/Notes Receivable                                                                                                                                                                       
                                                                                                                                                                                                 
 Corporate Information, If Applicable                                                                                                                                                            
                                                                                                                                                                                                 
 U.C.C.: Senior/Junior Lienholder                                                                                                                                                                
                                                                                                                                                                                                 
 Other Assets/Liabilities                                                                                                                                                                        
  
 Explain any differences “Net Difference” (or  P&L ) and the installment agreement payment amount: