RI 433 A                              COLLECTION INFORMATION STATEMENT FOR WAGE EARNERS
Rhode Island Division                                   AND SELF-EMPLOYED INDIVIDUALS   
of Taxation
                                           Complete all entry spaces with the most current data available
(Revised 11/02)                            Write "N/A" (not applicable) in spaces that do not apply.

Section 1
           Full Name(s)                                                                             Home Telephone (    )
Personal                                                                                            Best Time To Call:
Info       Street Address
                                                                                                    Marital Status:
           City________________________________ State_________Zip____________                       (  ) Married (  ) Separated 
                                                                                                    (  ) Single

           Your Social Security  Number           ____/___/_____                                    Date of Birth        ___/___/_____
           Spouse's Social Security Number        ____/___/_____                                    Spouse's DOB    ___/___/_____ 

           (  ) Own Home  (  ) Rent  (  ) Other (specify, i.e. share rent, live with relative) 

           List the dependents you can claim on your tax return: (Attach sheet if more space is needed)

           First Name   Relationship   Age           Does This Person  First Name   Relationship   Age              Does This Person
                                                       Live With You                                                  Live With You

                                                      (  ) No (  ) Yes                                                (  ) No (  ) Yes
                                                      (  ) No (  ) Yes                                                (  ) No (  ) Yes
                                                      (  ) No (  ) Yes                                                (  ) No (  ) Yes

           Adjusted Gross Income from Current Year Filing of Federal Personal Income Tax Return:                  $

Section 2  Are you or your spouse self-employed or a partner operating a business?

           Sole Proprietor  (  ) Partnership  (  )

Your       Name of Business                                                                    Employer  I.D. No.
Business
Info       Street Address                                                                      Business Telephone (    ) ______________

           City __________________________State _____ Zip ___________                          Do you have employees?   (  ) No  (  )  Yes

           Do you have accounts receivable?                       (  ) No   (  ) Yes

Section 3  Employer                                                    Spouse's Employer

           Street Address                                              Street Address

Employ-    City ___________________State _____ Zip _________           City ___________________State _____ Zip _________
ment Info
           Work Telephone No.    (    )______(    )______________      Work Telephone No. (    )______________

           May we contact you at work?  (  ) No  (  )  Yes             May we contact you at work?  (  ) No  (  )  Yes

           Occupation  __________________________________              Occupation____________________________________

Section 4  Do you receive income from sources other than your own business or employer?  (Check all that apply)

Other      (  ) Pension     (  ) Social Security     (  ) Other (specify, i.e. child support, alimony, rental)_________________    
Income 
Info

                                                           Page 2

Section 5  CHECKING ACCOUNTS. List all checking accounts. ( If additional space is needed, attach a separate sheet.)

Banking    Type of            Full Name of Bank, Savings & Loan,                       Bank Account No.           Current Balance
Investment Account            Credit Union or Financial Institution
Cash
Credit     Checking           Name_______________________________________             _________________  $ _______________
Life Ins-                     Street Address _______________________________
urance                        City/State/Zip   _______________________________

           Checking           Name_______________________________________             _________________  $ _______________
                              Street Address _______________________________
                              City/State/Zip   _______________________________
                                                                    Total Checking Account Balances              $ _______________

           OTHER ACCOUNTS.    List all accounts,including brokerage, savings, and money market, not listed previously.

           Type of            Full Name of Bank, Savings & Loan,                       Bank Account No.           Current Balance
           Account            Credit Union or Financial Institution

                              Name_______________________________________             _________________  $ _______________
                              Street Address _______________________________
                              City/State/Zip   _______________________________

                              Name_______________________________________             _________________  $ _______________
                              Street Address _______________________________
                              City/State/Zip   _______________________________

                                                                    Total Other Account Balances                 $ _______________

           INVESTMENTS.

           Name of Company         Number of               Current                    Loan                      Used as collateral 
                                 Shares/Units              Value                      Amount                    on loan
Current
Value:                            ____________             $                          $                         (  ) No (  ) Yes
Indicate
the amount                        ____________             $                          $                         (  ) No (  ) Yes
you could
sell the                          ____________             $                          $                         (  ) No (  ) Yes
asset for 
today.
                                                                                              Total Investments  $ _______________

           CASH ON HAND.      Include any money that you have that is not in the bank.

                                                                                           Total Cash on Hand    $ _______________

           AVAILABLE CREDIT.    List all lines of credit, including credit cards.
           Full Name of 
           Credit Institution                              Credit Limit               Amount Owed               Available Credit

           Name_______________________________________     $ _______________ $ _______________ $ _______________
           Street Address _______________________________
           City/State/Zip   _______________________________

           Name_______________________________________     $ _______________ $ _______________ $ _______________
           Street Address _______________________________
           City/State/Zip   _______________________________
                                                                                        Total Credit Available   $ _______________

                                                                     Page 3

Section 5   LIFE INSURANCE.     Do you have life insurance with a cash value?          (  ) No (  ) Yes
Continued                      (Term Life Insurance does not have a cash value.)

                               If yes:

            Name of Insurance Company
            Policy Number(s)
            Owner of Policy
            Current Cash Value $                                     Outstanding Loan Balance  $

                 Net Difference of Current Cash Value and Outstanding Loan Balance             $

Section 6   OTHER INFORMATION.

Other       Are there any garnishments against your wages?           (  ) No  (  ) Yes 
Information      If yes, who is the creditor?"                              Date of Judgement          Amt Owed $

            Are there any other judgements against you?              (  ) No  (  ) Yes 
                 If yes, who is the creditor?"                              Date of Judgement          Amt Owed $

            Are you a party in a lawsuit?                            (  ) No  (  ) Yes 
                 If yes, amount of suit $_______________ Possible completion date________ Subject matter of suit________________

            Did you ever file bankruptcy?                            (  ) No  (  ) Yes 
                If yes, date filed_____________________ Date discharged_______________________

            Are you a beneficiary of a trust or an estate?           (  ) No  (  ) Yes 
                If yes, name of trust or estate____________________________ Anticipated amount to be received $_______________

            Are you a participant in a profit sharing plan?          (  ) No  (  ) Yes 
                If yes, name of plan____________________________________ Value in plan $________________________

Section 7   PURCHASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS:                   Include boats, RV's motorcycles, 
            (If you need additional space, attach a separate sheet.)                   trailers, etc.
Assets and
Liabilities Description                        Current      Current         Name of            Purchase Amount of 
                                               Value        Loan            Lender             Date    Monthly
                                                            Balance                                    Payment
            Year __________________
            Make/Model_________________
            Mileage_____________________ $________________                                      _______ $ _______

            Description                        Current      Current         Name of            Purchase Amount of 
                                               Value        Loan            Lender             Date    Monthly
                                                            Balance                                    Payment
            Year __________________
            Make/Model_________________
            Mileage_____________________ $                  $                                   _______ $ _______

            Description                        Current      Current         Name of            Purchase Amount of 
                                               Value        Loan            Lender             Date    Monthly
                                                            Balance                                    Payment
            Year __________________
            Make/Model_________________
            Mileage_____________________ $                  $                                   _______ $ _______

                                                                   Page 4
Section 7 LEASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS.                    Include boats, RV's motorcycles, 
Continued (If you need additional space, attach a separate sheet.)                 trailers, etc.

          Description                  Current   Current                   Name of        Purchase Amount of 
                                       Value     Loan                      Lender         Date                        Monthly
                                                 Balance                                                              Payment
          Year      __________________
          Make/Model_________________
          Mileage_____________________ $         $                                         _______ $

          Description                  Current   Current                   Name of        Purchase Amount of 
                                       Value     Loan                      Lender         Date                        Monthly
                                                 Balance                                                              Payment
          Year      __________________
          Make/Model_________________
          Mileage_____________________ $         $                                         _______ $

          REAL ESTATE.          List all real estate you own. (If you need additional space, attach a separate sheeet.)

          Street Address, City, Date    Purchase Current           Loan    Name of Lender Amount of   Date of 
          State, Zip and County Purchased  Price Value             Balance or Lien Holder Monthly                      Final
                                                                                          Payment                      Payment

                                 _______ $_______ $_______ $_______                       $_______

                                 _______ $_______ $_______ $_______                       $_______

          PERSONAL ASSETS.        List all personal assets below. (If you need additional space, attach a separate sheet.)
          Furniture/Personal Effects includes the total current market value of your household such as furniture and
          appliances.  Other personal assets includes all artwork, jewelry, collections (coin, gun, etc.), antiques or
          other assets.

          Description                  Current   Loan              Name of Lender         Amount                      Date of
                                       Value     Balance                                  of Monthly Final
                                                                                          Payment                     Payment

          Furniture/Personal Effects

          Other:
          Artwork                      $_______ $_______ ___________________________ $_______ ________
          Jewelry                      $_______ $_______ ___________________________ $_______ ________
                                       $_______ $_______ ___________________________ $_______ ________
                                       $_______ $_______ ___________________________ $_______ ________

          BUSINESS ASSETS.      List all business assets and encumbrances below.

          Description                  Current   Loan              Name of Lender         Amount                      Date of
                                       Value     Balance                                  of Monthly Final

          Tools used in Trade/Business $_______ $_______ ___________________________ $_______ ________

          Other: 
          Machinery                    $_______ $_______ ___________________________ $_______ ________
          Equipment                    $_______ $_______ ___________________________ $_______ ________
                                       $_______ $_______ ___________________________ $_______ ________
                                       $_______ $_______ ___________________________ $_______ ________

                                                            Page 5
Section 7  Other Liabilities (including judgements, notes, other charge accounts, Federal taxes)
Continued
                                                    Balance Name of Lender                      Monthly Date of
           Description                              Owed                                        Payment Final Pmt
                   Federal Tax Liability            $_______ ___________________________ $_______ ________
                   ___________________________ $_______ ___________________________ $_______ ________
                   ___________________________ $_______ ___________________________ $_______ ________
                   ___________________________ $_______ ___________________________ $_______ ________
                   ___________________________ $_______ ___________________________ $_______ ________
                   ___________________________ $_______ ___________________________ $_______ ________

                         Total Other Liabilities    $

Section 8  REFERENCES:        Name, address and telephone number of next of kin or other reference.
Prior
History    Name                                                         Telephone Number  (    )_____________
           Street Address
           City, State, Zip

           Prior names or aliases used by you.

           Prior address, if present address is less than two years old.

Section 9  Total Income                                     Total Living Expenses
           Source                        Gross Monthly      Expense Items                       Actual Monthly
Monthly
Income and Wages(Yourself)               $ ______________   Food, Clothing, Misc.               $ ______________
Expense    Wages(Spouse)                   ______________   Housing and Utiliities                ______________
Analysis   Interest/Dividends              ______________   Transportation                        ______________
           Net Income from Business        ______________   Health Care                           ______________
           Net Rental Income               ______________   Taxes                                 ______________
           Pension/Soc Sec (Yourself)      ______________   Court Ordered Payments                ______________
           Pension/Soc Sec (Spouse)        ______________   Child/Dependent care                  ______________
           Child Support                   ______________   Life Insurance                        ______________
           Alimony                         ______________   Other Secured Debt                    ______________
           Other                           ______________   Other Expenses                        ______________

           Total Income                  $ ______________   Total Living Expenses               $ ______________

           Total Income less Total 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                            Date