Form TTB F 5600.17 TTB F 5600.17 Collection Information Statement for Individuals

OMB NO. 1513-0054 (01/31/2011)
DEPARTMENT OF THE TREASURY – ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
COLLECTION INFORMATION STATEMENT FOR INDIVIDUALS
(If you need additional space, please attach a separate sheet)
Section 1
Personal
Information

1. Full Name(s)

1a. Home
Telephone (

Best Time To Call:
am
pm

)

Street Address
City

State

Zip

2. Marital Status:

County of Residence

Married

How long at this address?

Unmarried (single, divorced, widowed)

Separated

3. Your Social Security No.(SSN)

-

-

3a. Your Date of Birth (mm/dd/yyyy)

4. Spouse’s Social Security No.

-

-

4a. Spouse’s Date of Birth (mm/dd/yyyy)

5.

Own Home

Rent

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

Check this
box when all
spaces in
Sect. 1 are
filled in.

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

Section 2
Your
Business
Information

7. Are you or your spouse self-employed or operate a business? (Check “YES” if either applies)

Check this
box when all
spaces in
Sect. 2 are
filled in and
attachments
provided.
Section 3
Employment
Information

First
Name

Relationship

No

Yes

Age

Does this person
live with you?

First
Name

Relationship

Age

No

Yes

No

Yes

No

Yes

No

Yes

If yes, provide the following information:

7a. Name of Business

7c. Employer Identification No. if available:

7b. Street Address

7d. Do you have employees?

City

State

Zip

-

No

Yes

7e. Do you have accounts/notes receivable?

No

Yes

If yes, please complete Section 8 page 5
ATTACHMENTS REQUIRED: Please include proof of self-employment income for the prior 3 months (e.g. invoices,
commissions, sales records, income statement).
8. Your Employer

9. Spouse’s Employer

Street Address

Street Address

City
Work telephone no. (

State
)

Zip

No

Yes

City

State

Work telephone no. (

)

Check this
box when all
spaces in
Sect. 3 are
filled in and
attachments
provided.

May we contact you at work?

Section 4
Other
Income
information

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

Check this
box when all
spaces in
Sect. 4 are
filled in and
attachments
provided.

Does this person
live with you?

Zip

-

May we contact you at work?

8a. How long with this employer?

9a. How long with this employer?

8b. Occupation

9b. Occupation

No

Yes

ATTACHMENTS REQUIRED: Please provide proof of gross earnings and deductions for the past 3 months from each
employer (e.g., pay stubs, earnings statements). If year-to-date information is available, send only 1 such statement as
long as a minimum of 3 months is represented.

Pension

Social Security

Other (specify, i.e. child support, alimony, rental)

ATTACHMENTS REQUIRED: Please provide proof of pension/social security/other income for the past 3 months from
each payer, including any statements showing deductions. If year-to-date information is available, send only 1 such
statement as long as a minimum of 3 months is represented.

TTB F 5600.17(03/2008)

Page 1 of 6

Section 5 begins on page 2

COLLECTION INFORMATION STATEMENT FOR INDIVIDUALS
NAME
Section 5
Banking,
Investment,
Cash, Credit,
and Life
Insurance
Information

SSN
11. CHECKING ACCOUNTS. List all checking accounts. (If you need additional space, attach a separate sheet.)
Type of
Account

Full Name of Bank, Savings & Loan
Credit Union or Financial Institution

11a.
Checking

Name

Bank
Routing No.

Bank Account No.

Current
Account
Balance
$

Street Address
City/State/Zip

Complete all
entry spaces
with the most
current data
available

11b.
Checking

Name

$

Street Address
11c.Total Checking Account Balances

City/State/Zip

$ 0.00

12. OTHER ACCOUNTS. List all accounts, including brokerage, savings, and money market, not listed on line 11.
Type of
Account

Full Name of Bank, Savings & Loan
Credit Union or Financial Institution

12a.

Name

Bank
Routing No.

Bank Account No.

Current
Account
Balance
$

Street Address
City/State/Zip
12b.

$

Name
Street Address
12c.Total Other Account Balances

City/State/Zip

$ 0.00

ATTACHMENTS REQUIRED: Please include your current bank statements (checking, savings, money market, and
brokerage accounts) for the past three months for all accounts.
13. INVESTMENTS. List All investment assets below. Include stocks, bonds, mutual funds, stock options, certificates of
deposit, and retirement assets such as IRAs, Keogh, and 401(k) plans. (If you need additional space, attach a separate
sheet.)
Name of Company

Current
Value:
Indicate the
amount you
could sell the
asset for
today.

Number of
Shares/Units

Current
Value

Loan
Amount

Used as collateral
on loan

13a.

$

$

NO

YES

13b.

$

$

NO

YES

13c.

$

$

NO

YES

$ 0.00
14. CASH ON HAND. Include any money that you have that is not in the bank.
14a. Total Cash on Hand
$
13d. Total Investments 13a + 13b +13c = 13d

15. AVAILABLE CREDIT. List all lines of credit, including credit cards.
Full Name of Credit Institution

Credit Limit

Amount Owed

15a. Name

Available Credit
$

Street Address
City/State/Zip
15b. Name

$

Street Address
City/State/Zip

Section 5 continued on page 3

15c. Total Credit Available

Page 2 of 6

$ 0.00

TTB F 5600.17 (03/2008)

COLLECTION INFORMATION STATEMENT FOR INDIVIDUALS
NAME
Section 5
continued

SSN
16. LIFE INSURANCE. Do you have life insurance with a cash value?

NO

YES

(Term Life insurance does not have a cash value.) If yes:
16a. Name of Insurance Company

Check this
box when all
spaces in
Sect. 5 are
filled in and
attachments
provided.

16b. Policy Number(s)

Section 6
Other
Information

17. OTHER INFORMATION. Respond to the following questions related to your financial condition: (Attach sheet if you
need more space.)

Check this
box when all
spaces in
Sect. 6 are
filled in.

16c. Owner of Policy
16d. Current Cash Value $

16e. Outstanding Loan Balance $

Subtract “Outstanding Loan Balance” line 16e from “Current Cash Value” line 16d = 16f $ 0.00
ATTACHMENTS REQUIRED: Please include a statement from the life insurance companies that includes type and
cash/loan value amounts. If currently borrowed against, include loan amount and date of loan.

17a. Are there any garnishments against your wages?
If yes, who is the creditor?

NO

17b. Are there judgments against you?
If yes, who is the creditor?

NO

17c. Are you a party in a lawsuit?
If yes, amount of suit $

YES
Judgment Date

Amount of debt $

YES
Judgment Date

Amount of debt $

NO
Possible completion date

17d. Did you ever file bankruptcy?
If yes, date filed

YES
Subject matter of suit

NO
YES
Date discharged

17e. In the past 10 years did you transfer any assets out of your name for less than their actual value?
If yes, what asset?
Value of asset at time of transfer
When was it transferred?

NO

YES

To who was it transferred?

17f. Do you anticipate any increase in household income in the next two years?
NO
YES
If yes, why will the income increase?
(Attach sheet if you need more space.)
How much will it increase? $
17g. Are you a beneficiary of a trust or an estate?
If yes, name of the trust or estate

Section 7
Assets and
Liabilities

NO

YES

Anticipated amount to be received $

When will the amount be received?

17h. Are you a participant in a profit sharing plan?
If yes, name of plan

NO
Value in plan $

YES

18. PURCHASED AUTOMOBILES, TRUCKS, AND OTHER LICENSED ASSETS.
Include boats, RVs, motorcycles, trailers, etc. (If you need additional space, attach a separate sheet.)
Description
(Year, Make, Model, Mileage)
18a

Current
Value

Current
Loan
Balance

Name of Lender

Purchase
Date

Amount of
Monthly
Payment

Year
Make/Model

Current
Value:
Indicate the
amount you
could sell the
asset for
today.

Mileage
18b

Year
Make/Model
Mileage

18c

Year
Make/Model
Mileage

TTB F 5600.17(03/2008)

Page 3 of 6

Section 7 continued on page 4

COLLECTION INFORMATION STATEMENT FOR INDIVIDUALS
NAME
Section 7
continued

SSN
19. LEASED AUTOMOBILES, TRUCKS, AND OTHER LICENSED ASSETS.
Include boats, RVs, motorcycles, trucks, etc. (If you need additional space, attach a separate sheet.)
Description
(Year, Make, Model)
19a

Name and
Address
of Lesser

Lease
Balance

Lease
Date

Amount of
Monthly
Payment

Year
Make/Model

19b
Current
Value
Indicate the
amount you
could sell the
asset for
today.

Date of
Final
Payment:
Enter the
date the loan
or lease will
be fully paid.

$

Year
Make/Model

$

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly car payment amount and
current balance of the loan for each vehicle purchased or leased.
20. REAL ESTATE. List all real estate you own. (If you need additional space attach a separate sheet.)
Street Address, City,
State, Zip, and County

Date
Purchased

Purchase
Price

Name of
Lender or
Lien Holder

Amount
of
Monthly
Payment

Current
Value

Loan
Balance

$

$

$

$

$

$

Date
of Final
Payment

20a.

20b.

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly payment amount and
current balance for each piece of real estate owned.
21. PERSONAL ASSETS. List all Personal Assets below. If you need additional space, attach 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.
Amount of
Monthly
Payment

Current
Value

Loan
Balance

$

$

$

21b. Artwork

$

$

$

21c. Jewelry

$

$

$

21d.

$

$

$

21e.

$

$

$

Description
21a. Furniture/Personal Effects

Name of Lender

Date of Final
Payment

Other: List below

22. BUSINESS ASSETS. List all business assets and encumbrances below; include Uniform Commercial Code (UCC)
filings. (If you need additional space, attach a separate sheet.) Tools use in Trade or Business includes the basic tools or
books used to conduct your business, excluding automobiles. Other Business Assets includes any other machinery,
equipment, inventory, or other assets.

Check this
box when all
spaces in
Sect. 7 are
filled in and
attachments
provided.

Amount of
Monthly
Payment

Current
Value

Loan
Balance

$

$

$

22b. Machinery

$

$

$

22c. Equipment

$

$

$

22d.

$

$

$

22e.

$

Description
22a. Tools used in Trade/Business

Name of Lender

Date of Final
Payment

Other: List below

Section 8 begins on page 5

$

Page 4 of 6

$

TTB F 5600.17 (03/2008)

COLLECTION INFORMATION STATEMENT FOR INDIVIDUALS
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Section 8
Accounts/
Notes
Receivable

23.

SSN

ACCOUNTS/NOTES RECEIVABLES. List all contracts separately, including contracts awarded, but not started.

(If you need additional space, attach a separate sheet.)
Description

Amount Due

Date Due

Age of Account
0 -- 30 days

Use only if
needed.

Check this
box if Section
8 not
needed.

23a.Name

$

30 -- 60 days

Street Address

60 -- 90 days

City/State/Zip

90 + days
0 -- 30 days

23b.Name

$

30 -- 60 days

Street Address

60 -- 90 days

City/State/Zip

90 + days
0 -- 30 days

23c.Name

$

30 -- 60 days

Street Address

60 -- 90 days

City/State/Zip

90 + days
0 -- 30 days

23d.Name

$

30 -- 60 days

Street Address

60 -- 90 days

City/State/Zip

90 + days
0 -- 30 days

23e.Name

$

30 -- 60 days

Street Address

60 -- 90 days

City/State/Zip

90 + days
0 -- 30 days

23f.Name

$

30 -- 60 days

Street Address

60 -- 90 days

City/State/Zip

90 + days
0 -- 30 days

23g.Name

$

30 -- 60 days

Street Address

60 -- 90 days

City/State/Zip

90 + days
0 -- 30 days

Check this
box when all
spaces in
Sect. 8 are
filled in.

23h.Name

$

30 -- 60 days

Street Address

60 -- 90 days

City/State/Zip

90 + days

0.00

Add Lines 23a through 23h = 23l

TTB F 5600.17(03/2008)

Page 5 of 6

Section 9 begins on page 6

COLLECTION INFORMATION STATEMENT FOR INDIVIDUALS
NAME
Section 9
Monthly
Income and
Expenses
Analysis
If only one
spouse has a
tax liability,
but both
have income,
list the total
household
income and
expenses.

SSN
TOTAL INCOME

TOTAL EXPENSES

Source

Gross Monthly

Expense Items (4)

Actual Monthly

24. Wages (Yourself) (1)

$

35. Food Clothing and Misc. (5)

$

25. Wages (Spouse) (1)

36. Housing and Utilities (6)

26. Interest and Dividends

37. Transportation (7)

27. Net Income from Business (2)

38. Health Care

28. Net Rental Income (3)

39. Taxes (Income and FICA)

29. Pension/Social Security (Yourself)

40. Court ordered payments

30. Pension/Social Security (Spouse)

41. Child/dependent care

31. Child Support

42. Life insurance

32. Alimony

43. Other secured debt

33. Other

44. Other expenses

34. Total Income

45. Total Living Expenses

$ 0.00

$0.00

(1) Wages, salaries, pensions, and social security: Enter your gross monthly wages and/or salaries. Do not deduct
withholding or allotments you elect to take out of your pay, such as insurance payments, credit union deductions, car
payments etc. To calculate your gross monthly wages and/or salaries:
If paid weekly – multiply weekly gross wages by 4.3. Example: $425.89 X 4.3 = $1,831.33
If paid bi-weekly (every 2 weeks) – multiply bi-weekly gross wages by 2.17. Example: $972.45 X 2.17 = $2,110.22
If paid semi-monthly (twice each month) – multiply semi-monthly wages by 2. Example: $856.23 X 2 = $1,712.46
(2) Net Income from Business: Enter your monthly net business income. This is the amount you earn after you pay
ordinary and necessary monthly business expenses. This figure should relate to the yearly net profit from your Form
1040 Schedule C. If it is more or less than the previous year, you should attach an explanation. If your net business
income is a loss, enter “0”. Do not enter a negative number.
(3) Net Rental Income: Enter your monthly net rental income. This is the amount you earn after you pay ordinary and
necessary monthly rental expenses. If your net income is a loss enter “0”. Do not enter a negative number.
(4) Expenses not generally allowed: We generally do not allow you to claim tuition for private schools, public or private
college expenses, charitable contributions, and 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 you can
prove that they are necessary for the health and welfare of you or your family or for the production of income.
(5) Food, Clothing and Misc: Total of clothing, food, housekeeping supplies and personal care products for one month.

Check this
box when all
spaces in
Sect. 7 are
filled in.
Check this
box when all
spaces in all
sections are
filled in and
all
attachments
provided.

(6) Housing and Utilities: For your principal residence: Total of rent or mortgage payment. Add the average monthly
expenses for the following: property taxes, home owner’s or renter’s insurance, maintenance, dues, fees, and utilities.
Utilities include gas, electricity, water, fuel, oil, other fuels, trash collection, and telephone.
(7) Transportation: Total of lease or purchase payments, vehicle insurance, registration fees, normal maintenance, fuel,
public transportation, parking, and tolls for one month.
CAUTION
Failure to complete all entry spaces may result in rejection or significant delay in the resolution of your accounts.
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.
Print Name

Title

Your Signature

Date

Page 6 of 6

TTB F 5600.17 (03/2008)