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Instructions for REV-488
Statement of Financial Condition for Individuals
REV-488 A (ET) 01-20
The Statement of Financial Condition for Individuals provides Item 26: Report any extraordinary situations, such as
the Pennsylvania Department of Revenue with credit and sta- recent transfers of assets, court proceedings and anticipat-
tistical information that will be utilized in evaluating an individ- ed changes in employment.
ual’s financial status. Every item of the financial statement
SECTION IV
must be completed and should reflect accurate information
and amounts. If an item is not applicable to you, respond ASSET & LIABILITY ANALYSIS
"N/A". An incomplete Statement of Financial Condition for
ITEMS 27-38
Individuals will not be considered.
This section resembles a balance sheet and should reflect
The Statement of Financial Condition for Individuals is pre- accurate amounts for assets owned and debts owed.
sented in six segments. Instructions are provided only for
Item 27: Report actual cash on hand, not cash in banks or
items requiring clarification. Most of the requested items are other financial institutions.
self-explanatory and need no further interpretation.
Item 31:Report the current market value of your vehicle(s)
GENERAL INFORMATIONas determined in an automobile blue book or by other prop-
erty valuation sources.
ITEMS 1-4 Item 33: Report other assets such as furniture, recreational
Please verify the Social Security numbers reported in Items vehicles, recreational or hobby tools, machinery and equip-
4A and 4B. ment and miscellaneous household assets.
SECTION I Item 35: Report all other liabilities and debts owed for med-
ical bills, dental bills and educational expenses, including
EMPLOYMENT INFORMATION any formal promissory note, loan arrangement or financial
obligation currently assigned to you.
ITEMS 5-14
This section should report all full-time and/or part-time Items 36 37:and Report all delinquent federal and state
employers that currently make payment(s) to you in the taxes.
form of wages, salaries and/or commissions for services Item 38: Report totals for all entries made in each column.
performed. You may provide attachments if necessary.
SECTION V
SECTION II
MONTHLY INCOME & EXPENSE ANALYSIS
PERSONAL INFORMATION ITEMS 39-57
ITEMS 15-18 Report all sources of income, both gross and net, earned
Provide personal and household information regarding you, and/or received on a monthly basis and all sources of nec-
your spouse and/or your dependents. essary living expenses paid and/or incurred on a monthly
basis. Additional lines have been provided for reporting
SECTION III income and/or expense items not already itemized in
Section V. Each entry should be verified for accuracy. The
GENERAL FINANCIAL INFORMATION department may request supportive documents to substan-
tiate this information.
ITEMS 19-26
All information furnished in this section should be verified Items 39 40:and Report gross and net income figures
obtained from all of your wage statements. If you are paid
for accuracy. The department may conduct an inquiry to
on a weekly basis, multiply your weekly gross and net
substantiate this information.
salary by 4.3 to arrive at your monthly gross and net
Item 22: Include any line of credit available to you from a income.
company credit union. Item 46: Report total income, both gross and net, from all
Item 24: Report all business real estate holdings as well as income sources identified under Items 39-45.
your personal residence. Item 47-55: Report accurate amounts for expenses verified
by examining your checkbook for the last six months.
Item 25: Report insurance information as verified through
your insurance agent. Item 49: Report allowable installment payments, the
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