REV-488A FO (03-12)
                                            INSTRUCTIONS FOR
                                            COMPLETINGSTATEMENT
Bureau of Collections and Taxpayer Services OF FINANCIAL CONDITION
PO BOX 281041                               FOR INDIVIDUALS
Harrisburg, PA 17128-1041

The Statement of Financial Condition for Individuals provides the Pennsylvania Department of Revenue with credit and
statistical information that will be utilized in evaluating an individual’s financial status. Every item of the financial statement
must be completed and should reflect accurate information and amounts. If an item is not applicable to you, respond "N/A".
An incomplete Statement of Financial Condition for Individuals will not be considered.
The Statement of Financial Condition for Individuals is presented in six segments. Instructions are provided only for items
requiring clarification. Most of the requested items are self-explanatory and need no further interpretation.
General Information (Items 1-4)
Please verify the Social Security numbers reported in Items 4A and 4B.
Section I-Employment Information (Items 5-14)
This section should report all full-time and/or part-time employers that currently make payment(s) to you in the form of
wages, salaries and/or commissions for services performed. You may provide attachments if necessary. 
Section II-Personal Information (Items 15-18)
Provide personal and household information regarding you, your spouse and/or your dependents. 
Section III-General Financial Information (Items 19-26)
All information furnished in this section should be verified for accuracy. The department may conduct an inquiry to
substantiate this information.
Item 22:Include any line of credit available to you from a company credit union.  
Item 24:Report all business real estate holdings as well as your personal residence.
Item 25:Report insurance information as verified through your insurance agent. 
Item 26:Report any extraordinary situations, such as recent transfers of assets, court proceedings and anticipated changes
in employment.  
Section IV-Asset and Liability Analysis (Items 27-38)
This section resembles a balance sheet and should reflect accurate amounts for assets owned and debts owed.
Items 27:Report actual cash on hand, not cash in banks or other financial institutions.
Item 31:Report the current market value of your vehicle(s) as determined in an automobile blue book or by other property
valuation sources.
Item 33:Report other assets such as furniture, recreational vehicles, recreational or hobby tools, machinery and equipment
and miscellaneous household assets.
Item 35:Report all other liabilities and debts owed for medical bills, dental bills and educational expenses, including any
formal promissory note, loan arrangement or financial obligation currently assigned to you.
Items 3637:and Report all delinquent federal and state taxes.
Item 38:Report totals for all entries made in each column.
Section V-Monthly Income and Expense Analysis (Items 39-57)
Report all sources of income, both gross and net, earned and/or received on a monthly basis and all sources of necessary
living expenses paid and/or incurred on a monthly basis. Additional lines have been provided for reporting income and/or
expense items not already itemized in Section V. Each entry should be verified for accuracy. The department may request
supportive documents to substantiate this information.
Items 3940:and Report gross and net income figures obtained from all of your wage statements. If you are paid on a
weekly basis, multiply your weekly gross and net salary by 4.3 to arrive at your monthly gross and net income.
Item 46:Report total income, both gross and net, from all income sources identified under Items 39-45.
Items 47-55:Report accurate amounts for expenses verified by examining your checkbook for the last six months.
Item 49: Report allowable installment payments, the minimum payments on secured or legally perfected debts (car
payments, judgments, etc.). Do not include payments on encumbered assets (boats, recreational vehicle, etc.), which are
not necessary living expenses.
Item 56:Report total expenses from all liability sources identified under Items 47-55.
Certification  (Items 58-60)
Signature by you, your spouse or your attorney/accountant (POA attached), certifies that statements and entries contained
in the Statement of Financial Condition for individuals and/or accompanying schedules are correct to the best knowledge
and belief of the undersigned.  
Items 58-60:Provide your signature along with the date your signature was posted. If a joint income tax return was filed,
your spouse’s signature must also be provided.