Fillable Form RO-1062 N.C Department of Revenue: Section 1. (North Carolina)

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Form RO-1062 N.C Department of Revenue: Section 1. (North Carolina)

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Form RO-1062 N.C Department of Revenue
(
Rev. 5-19
)
Collection Information Statement for Individuals
Note: Com
p
lete all blocks
,
exce
p
t shaded areas. Write "N/A"
(
not a
pp
licable
)
in those blocks that do not a
pp
l
y
.
1. Taxpayers' names and address (including County) 2a. Home phone number 3a. Taxpayer's social security number
3b. Spouse's social security number
2b. Cell phone number
4a. Taxpayer's date of birth
# of years at this address 2c. Business phone number 4b. Spouse's date of birth
Own Rent
Section 1. Personal Information
5. Do you have a power of attorney for tax matters? If yes, please attach a copy. Marital Status:
yes no married unmarried (single, divorced, widowed)
6. Age and relationship of dependents (exclude yourself and spouse) living in your household.
Section 2. Employment Informatio
n
7. Taxpayer's employer or business 7a. How long employe
d
7c. Occupation 7e. (Check appropriate box)
(name and address) Wage earne
r
7b. Number of exemptions
7d. Paydays Sole proprieto
claimed on Form NC-4
Partner/Member
8. Spouse's employer or business 8a. How long employe
d
8c. Occupation 8e. (Check appropriate box)
(name and address) Wage earne
r
8b. Number of exemptions
8d. Paydays Sole proprieto
claimed on Form NC-4
Partner/Member
Business phone #
9. Latest filed income tax 10.
Number of exemptions 11. Adjusted Gross Income
return (tax year) claimed
Section 3 Li
q
uid Assets
Total Cash on Hand $
13. Bank accounts (Include Savings & Loans, Credit Unions, Certificates of Deposits, Paypal accounts, Apple Pay accounts etc.)
Name of Institution Address Type of Accoun
t
Account No.
13a.
13b.
13c.
13d.
13e.Total
14. Virtual Currency/Cryptocurrency : (Bitcoin, Litecoin, etc)
14a.
14b.
14c.
14d.
14e.Total
As of
mm/dd/yyy
y
15a.
15b.
15c.
15d. Total Equity (Add lines 15a through 15c and amounts from any attachments)
Form RO-1062 page 1
3 month average
ending balance
12. Cash on Hand. Include cash that is not in the bank.
$
15. Investment Accounts: Include stocks, bonds, mutual funds, stock options, certificates of deposit, & retirement assets such as IRAs, Keogh, & 401(k) plans.
Include all corporations, partnerships, limited liability companies or other business entities in which the individual is an officer,
director, owner, member, or otherwise has a financial interest.
Loan Balance
(if applicable)
Type of Investment Full Name & Address(City, State, Zip Code) Current Equity
Name of Virtual Currency Wallet, Exchange
or Digital Currency Exchange
Location(s) of Virtual
Currency (Mobile Wallet,
Online and/or External
Hardware storageType of Virtual Currency
Virtual Currency amount
and value in US dollars. 3 month average
$
or Financial Interest of Company Market Value Value Minus Loan
$
4
PRINT
✖
CLEAR
16. Life Insurance (Name of Company)
Policy Number Type Face Amount Available Cash Value
16a.
16b.
16c. Total
Section 4 Real Pro
p
ert
y
17. Real property owned, rented, and leased. Include all real property and land contracts. (For personal and business use if sole proprietor)
17a. Primary Residence
Property Location (Street, Address, State, ZIP code) Lender/Lessor/Landlord Name, Address, (Street, Address, State, ZIP code)
Property County Landlord/Lessor Phone Number
First Mortgage Holder Second Mortgage/Home Equity Line
17b. Property Description
Property Location (Street, Address, State, ZIP code) Lender/Lessor/Landlord Name, Address, (Street, Address, State, ZIP code)
Property County Landlord/Lessor Phone Number
17c. Total Fair Market Value 17d. Total Current Loan Balance 17e. Net E
q
uit
y
Attach additional sheets as needed
Section 5. Licensed Assets/Vehicles
18.
Vehicles Purchased Include boats, RVs, motorcycles, trailers, mobile homes, aircraft, etc. (For personal and business use if sole proprietor)
Lender/Lessor Name, Address, (Street, Address, State, ZIP code)
Lender/Lessor Name, Address, (Street, Address, State, ZIP code)
18c. Total Current Fair Market Value 18d. Total Current Loan Balance 18e. Net E
q
uit
y
18f.
Vehicles Leased Include boats, RVs, motorcycles, trailers, mobile homes, aircraft, etc. (For personal and business use if sole proprietor)
Lender/Lessor Name, Address, (Street, Address, State, ZIP code)
Form RO-1062 page 2
Purchase/Lease Date County Current Fair Market Current Loan Amount of Monthly
FMV minus loan
Date of Final Equity
$
$
(mm/dd/yy) Tax Value Value (FMV) Balance Payment Payment
Date of Final Equity
FMV minus loan
$
Purchase/Lease Date County Current Fair Market Current Loan Amount of Monthly
(mm/dd/yy) Tax Value Value (FMV) Balance Payment Payment
18a. Description Purchase/Lease Date Current Fair Market Current Loan Date of Final Equity
(Make, Model, (mm/dd/yy) Value (FMV) Balance Payment Payment
Amount of Monthly
FMV minus loan
Make Model Year Mileage
Year, Mileage)
$
18b. 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
$
Make Model Year Mileage
Year, Mileage)
Equity
(Make, Model, (mm/dd/yy) Value (FMV) Monthly Payment Payment Payment
Date of Final
FMV minus loan
18g. Description Purchase/Lease Date Current Fair Market Amount of Amount of Monthly
Make Model Year Mileage
Year, Mileage)
$
Section 6. Other Personal Assets
19. Other Assets (Include all assets listed on homeowners insurance policy)
19a.
19b.
19c .
19d. Total Current Fair 19e. Total Current Loan Balance 19f. Net E
q
uit
y
Market Value
Section 7. Jud
g
ments & Secured Liens
(
other secured debts
)
20. Other Liabilities (Include
j
ud
g
ments and an
y
secured debt)
20a. IRS
20b.
20c.
20d.
Total Liabilities
Balance Due
Section 8.
N
otes
,
Char
g
e Accounts and Medical Ex
p
enses
21. Available Credit (list bank charge cards, credit unions, lines of credit, medical expenses)
Type of Account Name and Address of Monthly Credit Amount Credit
or Card Financial Institution Payment Limit Owed Available
21a.
21b.
21c.
21d.
21e. Total Credit Available
Section 9.
Other Financial Information
22. Other information relating to your financial condition. If you check the yes box, please give dates and explain under remarks.
a. Court proceedings Yes
No b. Bankruptcies
Yes
No
Remarks: Remarks:
c. Repossessions
Yes
No d. Recent transfer of assets
Yes
No
for less than full value
Remarks: Remarks:
e. Anticipated increase in income
Yes
No f. Participant or beneficiary to trust,
Yes
No
estate, profit sharing, etc.
Remarks: Remarks:
g. Do you receive government assistance h. Are all required state tax returns filed?
based on disability and/or financial need?
Yes
No
Yes
No
Remarks: Remarks:
Form RO-1062 page 3
Date o
f
Description Market Balance I
n
Monthl
y
Name and Address of Date Final
Current Liabilities Equity Amount o
f
Value Due Asset Paymen
t
Lien/Note Holder/Obligee Pledge
d
Paymen
t
Liabilities Amount of Date of
Description Balance Monthly Name and Address of Date Final
Due Payment Lien/Note Holder/Obligee Pledged Payment
$
Number in Household County
Section 10. Monthl
y
Income and Ex
p
ense Anal
y
sis
36. Total Income
37. Mortgage/Rent 43. Auto loans
38. Utilities 44. Health/Life Insurance
A. Telephone/Cell 45. Medical
B. Electricity 46. IRS Tax Payments
C. Heating 47. Miscellaneous Payments
D. Water/Garbage A. Child Support
39. Homeowner/renter insurance B. Alimony
40. Groceries C. Daycare
41. Gas/Maintenance, etc. D. Estimated tax
42. Auto Insurance
48. Total Expenses
Calculated Disposable Income (total income less total expenses)
Expenses not generally allowed: We generally do not allow tuition for private schools, public or private college expenses, charitable
contributions, voluntary retirement contributions, payments on unsecured debts such as credit card bills, cable television and other similar
expenses. However, we may allow these expenses if it is proven that they are necessary for the health and welfare of the individual or family
or for the production of income.
Under penalties of perjury, I declare that to the best of my knowledge and belief this
Certification
statement of assets, liabilities, and other information is true, correct and complete.
Your signature Spouse's signature (if joint return was filed) Date
Attachments Required for Wage Earners and Self-Employed Individuals:
Copies of the following items for the last 3 months from the date this form is submitted. (check all the attached items)
Income- Earnin
g
s statements
,
p
a
y
stubs
,
etc. from each em
p
lo
y
er
,
p
ension/social securit
y
/other income
,
self em
p
lo
y
ment incom
e
(
commissions
,
invoices
,
sales
,
records
,
etc. and business financial statement if self-em
p
lo
y
ed.
)
Banks, Investments, and Life Insurance - Statements for all money market, brokerage, checking and savings accounts, certificates
of deposit, IRA, stocks/bonds, and life insurance policies with a cash value.
Assets - Statements from lenders on loans (i.e: mortgage statements, car loans), monthly payments, payoffs, and balances for all personal
and business 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, phone and cell phone,
insurance premiums, court orders requiring payments (child support, alimony, etc.), other out of pocket expenses.
Other - credit card statements
,
p
rofit and loss statements
,
all loan
p
a
y
offs
,
etc.
A copy of the last 2 year's Form 1040 with all attachments. Include all Schedules K-1 from Form 1120S or Form 1065, as applicable.
Form RO-1062 page 4
23. 24. # Cars 25. # Car Loans 26.
INCOME
Source Net
27. Wages/ Salaries ( Taxpayer) * Attach copy of most recent pay stub
28. Wages/Salaries (Spouse) * Attach copy of most recent pay stub
29. Rent paid to taxpayer
30. Other members of household
31. Pension(s)
32. Social Security
33. Profit from Business
34. Commissions
35. Other Income
$
NECESSARY LIVING EXPENSES
Source Amount Source Amount
$
Section 11. Business Information
49. Is the business a sole proprietorship (filing Schedule C) Yes, Continue with Sections 11 and 12. No, Complete Business Financial Statement
All other business entities, including limited liability companies, partnerships or corporations, must complete business financial statement.
50. Business Name 51. Employer Identification Number 52. Type of Business
Federal or State Contractor
Yes No
53. Business Website 54. Total Number of Employees 55a. Average Gross Monthly Payroll
55b. Frequency of Tax Deposits
56. Does 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
57a.
57b.
Credit Cards Accepted by the Business
Credit Card Merchant Account Number
Merchant Account Provider, Name & Address
(Street, City, State, ZIP code)
58a.
58b.
58c.
59. Business Cash on Hand. Include cash that is not in a bank
Total Cash on Hand $
Business Bank Accounts. Include checking accounts, online bank accounts, money market accounts, savings accounts, and stored value
car
d
s
(
e.g. payro
ll
car
d
s, government
b
ene
fi
t car
d
s, etc.
)
Report Persona
l
Accounts
i
n Sect
i
on 3.
Type of Full Name & Address (Street, City, State, ZIP code) of Bank, Account Number Account Balance
Account Sav
i
ngs & Loan, Cre
di
t Un
i
on or F
i
nanc
i
a
l
Inst
i
tut
i
on. As o
f
mm/dd/yyyy
60a.
$
60b.
$
60c. Total Cash in Banks (Add lines 60a, 60b, and amounts from any attachments)
$
Accounts/Notes Receivable. Include e-payment accounts receivable and factoring companies, and any bartering or online auction accounts.
(
List all contracts se
p
aratel
y,
includin
g
contracts awarded
,
but not started.
)
Include Federal and State Government Contracts.
Status (e.g., age, Date Due Invoice Number or Federal
Accounts/Notes Receivable & Address (Street, City, State, ZIP Code) factored, other) (mm/dd/yyyy) or State Government Contract Amount Due
Number
61a.
$
61b.
$
61c.
$
61d.
$
61e. Total Outstanding Balance (Add lines 61a through 61d and amounts from any attachments)
$
Form RO-1062 page 5
Sections 11 and 12 must be completed only if the taxpayer is SELF-EMPLOYED
Business Assets. Include all tools, books, machinery, equipment, inventory or other assets used in trade or business. Include Uniform
Commercial Code (UCC) filings. Include Vehicles and Real Property owned/leased/rented by the business, if not shown in Section 10.
Current Fair Amount of Date of Final
Purchase/Lease/Rental Market Value Current Loan Monthly Payment Equity
Date (mm/dd/yyyy) (FMV) Balance Payment (mm/dd/yyyy) FMV Minus Loan
62. Property Description
$
Location (Street, City, State, ZIP code) and County \ Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code) and Phone
62a. Property Description
$
Location (Street, City, State, ZIP code) and County \ Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code) and Phone
62b. Total Fair Market Value 62c. Total Current Loan Balance 62d. Net E
q
uit
y
Section 12.
Sole Proprietorship Information
(lines 63 through 83 should reconcile with business Profit and Loss Statement)
Accounting Method Used: Cash Accrual
Income and Expenses during the period (mm/dd/yyyy) to (mm/dd/yyyy)
63. Gross Receipts 73. Materials Purchased
64. Gross Rental Income 74. Inventory Purchased
65. Interest 75. Gross Wages & Salaries
66. Dividends 76. Rent
67. Cash 77. Supplies
Other Income (Specify Below) 78. Utilities/Telephone
68 79. Vehicle Gasoline/Oil
69 80. Repairs & Maintenance
70 81. Insurance
71 82. Current Taxes
72. Total Income
83. Other Expenses,
including installment payments
Add lines 63 through 71
84. Total Expenses (Add lines 73 through 83)
85. Net Business Income (line 72 minus 84)
Materials Purchased: Materials are items directly related to the Current Taxes: Real estate, state, and local income tax, excise,
p
roduction of a product or service. franchise, occupational, personal property, sales and the employer's
p
ortion of the employment taxes.
Inventory Purchased: Goods bought for resale.
Net Business Income: Net profit from Form 1040, Schedule C may
Supplies: Supplies are items used to conduct business and are consumed
b
e used if duplicated deductions are eliminated (e.g., expenses for
or used up within one year. This could be the cost of books, office
b
usiness use of home already included in housing and utility expenses
supplies, professional equipment, etc. on page 4). Deductions for depreciation and depletion on Schedule C
are not cash expenses and must be added back to the net income
Utilities/Telephone: Utilities include gas, electricity, water, oil,
figure. In addition, interest cannot be deducted if it is already included
other fuels, trash collection, telephone and cell phone. in any other installment payments allowed.
FINANCIAL ANALYSIS OF COLLECTION POTENTIAL
FOR INDIVIDUAL WAGE EARNERS AND SELF-EMPLOYED INDIVIDUALS (DOR USE ONLY)
Cash Available
(Lines 12, 13e, 14e, 15d, 16c, 21e, 59, 60c, 61e) Total Cash $
Distrainable Asset Summary
(Lines 17e, 18e, 19f, 62d) Total Equity $
Monthly Total Positive Income minus Expenses
(Line 36 minus Line 48) Monthly Available Cash $
Form RO-1062 page 6
Section 12 must be completed only if the taxpayer is SELF-EMPLOYED
Total Monthly Business Income
Source Gross Monthly Expense Items Actual Monthly
$ $
$
Enter the amount from line 85 on line 33, Section 10. If line 85 is a loss, enter "0" on line 33, Section 10.
Self-employed taxpayers must return to page 4 to sign the certification and include all applicable attachments.
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Form RO-1062 N.C Department of Revenue: Section 1. (North Carolina)

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Completed 15 July 2020

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