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                                                                                                                                                                                    PRINT CLEAR

    Form RO-1063                           N.C Department of Revenue
Web-fill (Rev. 12-09)                      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
1e.  Type of Business                                                        3b.  Monthly Gross Payroll
1f.  Type of Website                                                         3c.  Frequency of Tax Deposits

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

BusinessSectionFinancial3 Statement- Page 1                    Liquid Assets

Business Financial Statement- (Rev. 12/09)                                                                                                                   Page 2
    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
     numeric characters
    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)                                       $

Business Financial Statement- Page 2

Business Financial Statement- (Rev. 12/09)                                                                                                                          Page 3
    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.)
    17.  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)                                                 $
    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)                                                  $
    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

Business Financial Statement- (Rev. 12/09)                                                                                                                           Page 4
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                 Should be able to enter alpha and numeric characters on the line provided for the property description field.
                                                    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

Business Financial Statement- (Rev. 12/09)                                                                                                                    Page 5
22.  Vehicles Leased and Purchased. Include boats, RVs, motorcycles, trailers, mobile homes, 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 Financial Statement- (Rev. 12/09)                                                                                                                                     Page 6
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 income tax return filed.
Additional information or proof may be subsequently requested.
   FINANCIAL ANALYSIS OF COLLECTION POTENTIAL
   FOR BUSINESSES                                                                                                                              (DOR USE ONLY)
Cash Available
(Lines 15, 16d, 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