DEPARTMENT OF REVENUE
                        Statement of Financial Condition for Businesses
      REV-484 FO (06-13)                                  If additional space is needed, attach separate sheet.
Start 1. Name and address of business                   2. Business phone number
Ü                                                       3. Type of ownership. Check appropriate box.
                                                          Sole proprietor              Other (specify)
                                                          Corporation
                                                          Partnership
      4. Preparer’s name and title                                                             5. Federal employer identification number 6. Type of business

      7. Information about owner, partners, officers, major shareholders, etc.
      Name and TitleEffective          Home Address       Phone           Social SecurityTotal Share
                        Date                              Number            Number or Interest
                        MM/DD/YYYY

      SECTION I – GENERAL FINANCIAL INFORMATIONIf sole proprietor, include assets and liabilities of owner.
      8. Latest filed Pennsylvania income tax return                               Form                        Tax year ended            Net income before taxes
                                                                                $
      9. Bank accounts  List all types of accounts including payroll and general, saving, certificates of deposit, etc.

      Name of Institutions        Address                 Type of AccountAccount NumberBalance

                                                                                $

                                                          TOTALEnter in Item 17.$
      10. Bank credit available  (Lines of credit, etc.)
      Name of Institution         Address               Credit LimitAmount OwedCredit AvailableMonthly Payments

                                                        $ $               $      $

                        TOTALSEnter in item 24 or 25 as appropriate.$     $      $
      11. Location, box number and contents of all safe deposit boxes rented or accessed

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SECTION I – GENERAL FINANCIAL INFORMATION (continued)
12. Real Property

  Brief Description and Type of Ownership                 Include county and state.                                                           Address  

a.

b.

c.

d.
13. Life insurance policies owned with business as beneficiary

  Name Insured      Company                      Policy NumberType Face ValueAvailable Loan
                                                                                 Value

                                                                   $         $

                                                          TOTALEnter in Item 19.$
14. Additional information regarding financial condition  (Court proceedings, bankruptcies filed or anticipated, transfers of assets for less than
full value, changes in market conditions, etc.; include information regarding company participation in trust, estates, retirement plans, etc.)

15. Accounts/notes receivable  Include loans to stockholders, officers, partners, etc.
        Name                                              Address                                                                             Amount Due Date Due Status
                                                                   MM/DD/YYYY
                                                         $

                                   TOTALEnter in Item 18.$

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SECTION II – ASSETS AND LIABILITIES ANALYSIS
                                                                                 (c)                              (d)                          (e)
        (a)                                                                      Current Market(b)                Liabilities                  Amount of
    Asset or Liability                                                           ValueDescription       Balance Due                            Monthly Payment
16. Cash on hand                                                   $
17. Bank Accounts
18. Accounts/Notes receivable                                                                  $       $
19. Life Insurance loan value
20. Real Property                                           a.
                              b.
                              c.
                              d.
21. Vehicles (Model, year     a.
and license)                  b.
                              c.
22. Machinery and equipment                                 a.
(Specify)                     b.
                              c.
23. Merchandise inventory                                   a.
(Specify)                     b.
24. Other assets                                            a.
(Specify)                     b.
25. Other liabilities  a.(Including
notes and judgments)          b.
                              c.
                              d.
                              e.
                              f.
                              g.
26. Federal taxes owed
27. State taxes owed
28.                  TOTAL                                         $                               $           $
SECTION III – INCOME AND EXPENSE ANALYSIS
29. The following information applies to income and expensesAccountingMM/DD/YYYY method used                                              30.
during the period                                                                or
                         Income                                                                                                                Expenses
31. Gross receipts from sales, services, etc.                                                        $                                37.      Materials purchased $
32. Gross rental income                                                                                                                   38.  Net wages and sales
33. Interest                                                       39.           Rent
34. Dividends                                                      40.           Installment payments
35. Other income  (Specify)                                        41.           Supplies
                                                                   42.           Utilities/Telephone
                                                                   43.           Gasoline/Oil
                                                                   44.           Repairs and maintenance
                                                                   45.           Insurance
                                                                   46.           Current taxes
                                                                   47.           Other  (Specify)

36.                                      TOTAL$                                             48.        TOTAL$
                                                                   49.           Net difference
                                                                     (Item 36 minus Item 48)                    $

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.
50. Signature                                                                                          51. DateMM/DD/YYYY
                  Signature of Officer – Please sign after printing

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