REV-484A FO (06-13)

                   INSTRUCTIONS FOR COMPLETING
                   STATEMENT OF FINANCIAL CONDITION
BUREAU OF COLLECTIONS & 
TAXPAYER SERVICES        FOR BUSINESSES (REV-484)
HARRISBURG, PA 17128-1041

The Statement of Financial Condition for Businesses included in this packet provides the Pennsylvania Department of
Revenue with credit and statistical information that will be utilized in evaluating the financial position of your business.
Every item of the financial statement must be completed and should reflect accurate statements and amounts. If an
item is not applicable to your business, insert N/A. An incomplete Statement of Financial Condition for Businesses will
not be considered.
The Statement of Financial Condition for Businesses is presented in four segments. Instructions have been provided
only for items requiring further clarification. Most of the requested items are self-explanatory and need no further
interpretation.
Ownership Information (Items 1-7)
Please verify the federal employer identification number in Item 5 and the Social Security number(s) of the owner(s)
in Item 7.
Item 7must be completed for any type of ownership indicated in Item 3. A sole proprietorship must report the
individual owner’s name, partnership must report all partners and/or general partner’s names, and corporations must
report the names of all corporate officers. Attachments may be used as necessary.
Section I - General Financial Information (Items 8-15)
All information recorded in this section should be verified for accuracy. The department may conduct an inquiry to
substantiate this information.
If the business is a partnership, the Statement of Financial Condition for Businesses must be completed for partnership
assets and liabilities, and a separate Statement of Financial Condition for Individuals must be completed for each
general partner. 
Item 10should include all credit cards owned by the business. 
Item 13should include all life insurance policies owned by the business, such as Key-Man Life Insurance.
Item 14should report any extraordinary situations such as recent transfers of assets, court proceedings and anticipated
changes in business income.
Section II - Asset and Liability Analysis (Items 16-28)
This section resembles a balance sheet and should reflect accurate amounts.
Item 16should report actual cash on hand, not cash in banks or other financial institutions.
Item 21should report the current market value of business vehicles as determined in an automobile "blue book" or
by other property valuation sources.  
Item 25should report all debts owed by your business.
Items 2627and should report all delinquent federal and state business taxes.
Item 28should report totals for all entries made in each column.
Section III - Income and Expense Analysis (Items 29-49)
This section must report all sources of income and all business expenses directly attributable to the production of income.
Depreciation is not deemed an out-of-pocket expense and should not be included in the expense summary. Additional
lines have been provided for reporting income and/or expense items not already itemized in Section III. Each entry
should be verified for accuracy. The department may request supporting documents to substantiate this information. 
Item 29must reflect an operating period of 12 months.
Item 30must report the accounting method of the business (i.e., cash or accrual).
Item 36should report total income from all income sources listed under Items 31-35.
Item 48should report total expenses from all liability sources listed under Items 37-47.
Certification (Items 50-51)
Signature certifies that statements and entries contained in the Statement of Financial Condition and/or accompanying
schedules are correct to the best knowledge and belief of the undersigned.
Items 5051and must provide signature by a duly authorized representative, owner, partner or corporate officer along
with the applicable date the signatures were affixed.