Instructions for REV-484 
                                                              Statement of Financial Condition for Businesses
REV-484 A (ET) 01-20

The Statement of Financial Condition for Businesses                             SECTION II
included in this packet provides the Pennsylvania                                                                     
Department of Revenue with credit and statistical             ASSET & LIABILITY ANALYSIS 
information that will be utilized in evaluating the financial ITEMS 16-28 
position of your business.  Every item of the financial 
                                                              This section resembles a balance sheet and should reflect 
statement must be completed and should reflect accurate       accurate amounts. 
statements and amounts. If an item is not applicable to your 
business, insert N/A. An incomplete Statement of Financial    Item 16 should report actual cash on hand, not cash in 
Condition for Businesses will not be considered.              banks or other financial institutions. 
The Statement of Financial Condition for Businesses is        Item 21 should report the current market value of business 
presented in four segments. Instructions have been provided   vehicles as determined in an automobile "blue book" or by 
only for items requiring further clarification. Most of the   other property valuation sources.   
requested items are self-explanatory and need no further      Item 25 should report all debts owed by your business. 
interpretation. 
                                                              Items 2627 and  should report all delinquent federal and 
                                                              state business taxes. 
        OWNERSHIP INFORMATION
                                                              Item 28 should report totals for all entries made in each col-
ITEMS 1-7                                                     umn. 
Please verify the federal employer identification number in 
                                                                                SECTION III
Item 5 and the Social Security number(s) of the owner(s) in                                                           
Item 7. 
                                                              INCOME & EXPENSE ANALYSIS 
Item 7 must be completed for any type of ownership indi-      ITEMS 29-49 
cated in Item 3. A sole proprietorship must report the indi-  This section must report all sources of income and all busi-
vidual owner’s name, partnership must report all partners     ness expenses directly attributable to the production of 
and/or general partner’s names, and corporations must         income. Depreciation is not deemed an out-of-pocket 
report the names of all corporate officers. Attachments may   expense and should not be included in the expense sum-
be used as necessary                                          mary. Additional lines have been provided for reporting 
                                                              income and/or expense items not already itemized in 
                SECTION I                                     Section III. Each entry should be verified for accuracy. The 
                                                              department may request supporting documents to substan-
GENERAL FINANCIAL INFORMATION                                 tiate this information.  
ITEMS 8-15                                                    Item 29 must reflect an operating period of 12 months. 
All information recorded in this section should be verified 
                                                              Item 30 must report the accounting method of the business 
for accuracy. The department may conduct an inquiry to 
                                                              (i.e., cash or accrual). 
substantiate this information. 
                                                              Item 36 should report total income from all income sources 
If the business is a partnership, the Statement of Financial  listed under Items 31-35. 
Condition for Businesses must be completed for partner-
ship assets and liabilities, and a separate Statement of      Item 48 should report total expenses from all liability 
Financial Condition for Individuals must be completed for     sources listed under Items 37-47. 
each general partner.  
Item 10 should include all credit cards owned by the busi-                     CERTIFICATION 
ness.                                                         Signature certifies that statements and entries contained in 
                                                              the Statement of Financial Condition and/or accompanying 
Item 13 should include all life insurance policies owned by   schedules are correct to the best knowledge and belief of 
the business, such as Key-Man Life Insurance.                 the undersigned. 
Item 14 should report any extraordinary situations such as    Items 5051 and  must provide signature by a duly author-
recent transfers of assets, court proceedings and anticipat-  ized representative, owner, partner or corporate officer 
ed changes in business income.along with the applicable date the signatures were affixed.

www.revenue.pa.gov                                                                                   REV-484 A       1