IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING

                                         (ET+) 03-22
                        REV-484 
                                                                            STATEMENT OF  
                                                                          FINANCIAL CONDITION  
                                                                          FOR BUSINESSES
      If additional space is needed, attach separate sheet
      SECTION I                BUSINESS INFORMATION 
Start  Business Name                                                                                                       Business Phone Number
Ü
       Business Address

       City                                                                     County                                     State            ZIP Code

       Type of Ownership (select appropriate oval): Sole Proprietor            Corporation
            Partnership                                                        Other
       Preparer’s Name                                     Preparer’s Title                     FEIN                       Type of Business

       Owner, Partners, Officers, Major Shareholders, etc. Information
      NAME AND TITLE          EFFECTIVE DATE                      HOME ADDRESS                 PHONE NUMBER               SSN              TOTAL SHARE  
                                                                                                                                           OF INTEREST

      SECTION II               GENERAL FINANCIAL INFORMATION 
      If sole proprietor, include assets and liabilities of owner.
       Latest Filed PA Income Tax Return  Form                                  Tax Year Ended                           Net Income Before Taxes
                                                                                                                         $
       Bank Accounts. (List all types of accounts including payroll and general, saving, certificates of deposit, etc.) 
      NAME OF INSTITUTION                                         ADDRESS              TYPE OF ACCOUNT                    ACCOUNT          BALANCE
                                                                                                                          NUMBER

                                                                                                                                   $

                                                                                                                                   $

                                                                                                                                   $

                                                                                                                                   $
                                                                                               TOTAL (Enter in Section III, Line 2)  $

            Reset Entire Form                                             PAGE 1                     NEXT PAGE                        PRINT

                     REV-484 (ET+) 03-22 
SECTION II            GENERAL FINANCIAL INFORMATION (cont.)
 Bank credit available. (Lines of credit, etc.) 
   NAME OF INSTITUTION                          ADDRESS               CREDIT LIMIT   AMOUNT OWED    CREDIT                         MONTHLY PAYMENTS
                                                                                                    AVAILABLE

                                                                   $                  $           $                               $

                                                                   $                  $           $                               $

                                                                   $                  $           $                               $
                             TOTALS (Enter in Section III, Line 9 or 10 as appropriate.)  $       $                               $
 Safe Deposit Boxes Rented or Accessed (list all locations, box numbers and contents)
   BOX NUMBER                                   SAFE DEPOSIT BOX LOCATION                             CONTENTS

 Real Estate Property
   REAL PROPERTY DESCRIPTION                    TYPE OF OWNERSHIP                    ADDRESS (INCLUDE COUNTY AND STATE)

 a.

 b.

 c.

 d.
 Life Insurance (Owned with business as beneficiary.)
   NAME INSURED        COMPANY                          POLICY NUMBER                TYPE        FACE VALUE                      AVAILABLE LOAN VALUE
                                                                                             $                                    $
                                                                                             $                                    $
                                                                                             $                                    $
                                                                                             $                                    $
                                                                                     TOTALS (Enter in Section III, Line 4.)       $
Additional information regarding financial condition (Court proceedings, bankruptcies filed or anticipated, transfers of assets for less than full value, 
changes in market condition, etc./ include information regarding company participation in trust, estates, retirement plans, etc.)

   Reset Entire Form   PREVIOUS PAGE                              PAGE 2                    NEXT PAGE                              PRINT

           REV-484 (ET+) 03-22 
SECTION II         GENERAL FINANCIAL INFORMATION (cont.)
 Accounts/notes receivable. Include loans to stockholder, officers, partners, etc. 
           NAME                 ADDRESS                                              AMOUNT DUE DATE DUE STATUS

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $

                                                                                    $
                                TOTALS (Enter in Section III, Line 3.)  $

Reset Entire Form PREVIOUS PAGE       PAGE 3                                         NEXT PAGE           PRINT

                       REV-484 (ET+) 03-22 
SECTION III             ASSETS AND LIABILITIES ANALYSIS
   (A)                                     (B)                (C)             (D)               (E) 
ASSET OR LIABILITY                         DESCRIPTION   CURRENT MARKET       LIABILITIES  AMOUNT OF MONTHLY 
                                                              VALUE           BALANCE DUE       PAYMENT
1. Cash on hand
                                                        $
2. Bank Accounts
                                                        $
3. Accounts/Notes  
   receivable                                           $                $                  $
4. Life Insurance  
   Loan Value                                           $                $                  $
                        a.                              $                $                  $
5. Real Property        b.                              $                $                  $
                        c.                              $                $                  $
                        d.                              $                $                  $
                        a.                              $                $                  $
6. Vehicles (model, 
   year, license)       b.                              $                $                  $
                        c.                              $                $                  $
                        a.                              $                $                  $
7. Machinery and 
   Equipment (Specify)  b.                              $                $                  $
                        c.                              $                $                  $
8. Merchandise          a.                              $  $             $  $               $  $
   Inventory (Specify)
                        b.                              $  $             $  $               $  $
9. Other Assets         a.                              $                $                  $
   (Specify)
                        b.                              $                $                  $
                        a.                              $                $                  $
                        b.                              $                $                  $
                        c.
10. Other Liabilities                                   $                $                  $
   (Including notes  
   and judgements)      d.                              $                $                  $
                        e.                              $                $                  $
                        f.                              $                $                  $
                        g.                              $                $                  $
11. Federal Taxes Owed
                                                        $                $                  $
12. State Taxes Owed
                                                        $                $                  $
13. TOTALS
                                                        $                $                  $

   Reset Entire Form       PREVIOUS PAGE               PAGE 4           NEXT PAGE               PRINT

                        REV-484 (ET+) 03-22 
SECTION IV                INCOME AND EXPENSE ANALYSIS
The following information applies to income and expenses  Accounting Method Used
during the period                        to
PART A - INCOME
14. Gross receipts from sales, services, etc.                                              $
15. Gross rental income                                                                    $
16. Interest                                                                               $
17. Dividends                                                                              $
18. Other income (Specify)                                                                 $
                                                                                           $
                                                                                           $
                                                                                           $
                                                                                           $
                                                                                           $
                                                                                           $
                                                                                           $
                                                                                           $
                                                                                           $
19. TOTAL                                                                                  $
PART B - EXPENSES
20. Materials purchased                                                                    $
21. Net wages and sales                                                                    $
22. Rent                                                                                   $
23. Installment payments                                                                   $
24. Supplies                                                                               $
25. Utilities/Telephone                                                                    $
26. Gasoline/Oil                                                                           $
27. Repairs and maintenance                                                                $
28. Insurance                                                                              $
29. Current taxes                                                                          $
30. Other (Specify)                                                                        $
                                                                                           $
                                                                                           $
31. TOTAL                                                                                  $
32. Net Difference (Line 19 minus Line 31)                                                 $
SECTION V                 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                                               Signature                          Date
                                                                    SIGN AFTER PRINTING

Reset Entire Form           PREVIOUS PAGE                PAGE 5                 NEXT PAGE   PRINT

No text to extract.

                                                                 Instructions for REV-484 
REV-484 IN (ET+) 03-22                                           Statement of Financial Condition for Businesses  
                                                                 LIFE INSURANCE  
GENERAL INFORMATION
                                                                 Include all life insurance policies owned by the business, 
The Statement of Financial Condition for Businesses provides     such as Key-Man Life Insurance. 
the Pennsylvania Department of Revenue with credit and           ADDITIONAL INFORMATION  
statistical information that will be utilized in evaluating the  REGARDING FINANCIAL CONDITION 
financial position of your business. Every item of the financial Report any extraordinary situations such as recent transfers 
statement must be completed and should reflect accurate          of assets, court proceedings and anticipated changes in 
statements and amounts. If an item is not applicable to your     business income. 
business, insert N/A. An incomplete Statement of Financial 
Condition for Businesses will not be considered.                                     SECTION III                           
The Statement of Financial Condition for Businesses is           ASSETS AND LIABILITIES ANALYSIS 
presented in  five sections. Instructions have been 
                                                                                          LINES 1-13
provided only for items requiring further clarification. Most                                                              
of the requested items are self-explanatory and need no          This section resembles a balance sheet and should reflect 
further interpretation.                                          accurate amounts.  

LINE INSTRUCTIONS                                                                         LINE 1                           
                                                                 Report actual cash on hand, not cash in banks or other 
                       SECTION I                                 financial institutions.  
BUSINESS INFORMATION 
                                                                                          LINE 6
Please verify the federal employer identification number                                                                   
and the Social Security number(s) of the owner(s).               Report the current market value of business vehicles as 
                                                                 determined in an automobile “blue book” or by other property 
Information about owner, partners, officers, major 
                                                                 valuation sources.  
shareholders, etc. must be completed for any type of 
ownership indicated. A sole proprietorship must report the                                LINE 10
individual owner’s name, partnership must report all                                                                       
partners and/or general partner’s names, and corporations        Report all debts owed by your business.  
must report the names of all corporate officers. 
                                                                                    LINES 11 AND 12
Attachments may be used as necessary                                                                                       
                                                                 Report all delinquent federal and state business taxes.  
                       SECTION II                   
                                                                                          LINE 13
GENERAL FINANCIAL INFORMATION                                                                                              
All information recorded in this section should be verified for  Report totals for all entries made in each column.  
accuracy.  The department may conduct an inquiry to 
substantiate this information.                                                       SECTION IV                            
If the business is a partnership, the Statement of Financial     INCOME AND EXPENSE ANALYSIS 
Condition for Businesses must be completed for partnership 
                                                                                          LINES 14-32
assets and liabilities, and a separate Statement of Financial                                                              
Condition for Individuals must be completed for each             This section must report all sources of income and all 
general partner.                                                 business expenses directly attributable to the production of 
                                                                 income. Depreciation is not deemed an out-of-pocket 
BANK CREDIT AVAILABLE                                            expense and should not be included in the expense 
Include all credit cards owned by the business.                  summary. Additional lines have been provided for reporting 

www.revenue.pa.gov                                                                                        REV-484         1
RETURN TO FORM                                                                            NEXT PAGE       PRINT

income and/or expense items not already itemized in 
Section III. Each entry should be verified for accuracy. The                   SECTION V             
department may request supporting documents to                CERTIFICATION 
substantiate this information.                                Signature certifies that statements and entries contained in 
REPORTING PERIOD                                              the Statement of Financial Condition and/or accompanying 
Must reflect an operating period of 12 months.                schedules are correct to the best knowledge and belief of 
                                                              the undersigned. 
ACCOUNTING METHOD USED 
                                                              Must provide signature by a duly authorized representative, 
Report the accounting method of the business (i.e., cash 
                                                              owner, partner or corporate officer along with the applicable 
or accrual).   
                                                              date the signatures were affixed.
                 LINE 19
                                                 
Report total income from all income sources listed under 
Lines 14-18.  

                 LINE 31
                                                 
Report total expenses from all liability sources listed under 
Lines 20-30.  

2 REV-484                                                                                      www.revenue.pa.gov
RETURN TO FORM                                                                 PREVIOUS PAGE   PRINT