REV-488 FO (08-09)

                                         Statementof Financial Condition forIndividuals
                                                                          (If additional space is needed, attach separate sheet)
1. Taxpayer’s name(s) and address(es) (including county)              2. Home phone number                              3. Marital status

                                                                      4. Social Securitya. Taxpayer                     b. Spouse
                                                                      Number(s)
SECTION I – EMPLOYMENT INFORMATION
5. Taxpayer’s employer of business (name and address) or                                                                             6. Business phone number            7. Occupation

                                                                      8. Paydays         (Check appropriate9. box)  Sole
                                                                                         Wage earner                ProprietorPartner
10. Spouse’s employer or business (name and address) or                                                                              11. Business phone number           12. Occupation

                                                                      13. Paydays        (Check appropriate14. box)Sole
                                                                                         Wage earner                ProprietorPartner
SECTION II – PERSONAL INFORMATION
15. Name, address and telephone number of nextAge and relationship of dependents (exclude17. Number16. of exemptions
  of kin or other reference                                                                  husband and wife) living in your household                     claimed on Form W-4

18. Date of birth                              a. Taxpayer                                                              b. Spouse
SECTION III – GENERAL FINANCIAL INFORMATION
19. Latest PA income tax return(taxfiled year)                        20. Adjusted gross income on return
21. Bank accounts (include Savings and Loans, Credit Unions, IRA and KEOGH accounts, Certificates of Deposit, etc.)
    Name of Institutions                                                           Address                                           Type of Account Account Number            Balance
                                                                                                          $

Total (Enter in Item 28)                                                                                  $
22. Bank charge cards, lines of credit, etc.
Type of Account or Card                                                  Name and Address of                                         Monthly         Credit    Amount                  Credit
                                         Financial Institution                                     Payment              Limit                Owed           Available
                                                                   $             $           $             $

Total (Enter in Item 34)                                           $             $           $             $
23. Safe deposit boxes rented or accessed (List all locations, box numbers and contents)

24.Real Property(Brief description and type of ownership)(Include county andAddressstate)
a.
b.
c.
25. Life Insurance(Name of Company)Policy Number                                         Type                           Face Value                   Available Loan Value
                                                                          $                               $

                                                      – Page 1 –

SECTION III – GENERAL FINANCIAL INFORMATION(continued)
26. Additional Information (Court proceedings, bankruptcies, repossessions, recent transfers of assets for less than full value, anticipated increases
in income, condition of health, etc., include information on trusts, estates, retirement plans, etc., on which you are a participant of beneficiary)

SECTION IV – ASSET AND LIABILITY ANALYSIS
                                                      (c)            (d)                                                                            (e)
            (a)                                             (b)
                                           Current Market            Liabilities                                                                    Amount of
    Asset or Liability                                    Description
                                              Value            Balance Due       Monthly Payment

27. Cash                                   $

28. Bank accounts

29. Stocks, bonds, investments                            $    $

30. Cash or loan value of insurance

31. Vehicles(model, year, license)a.

                          b.

                          c.

32. Real property                   a.

                          b.

                          c.

33. Other assets                    a.

                          b.

                          c.

34. Bank revolving credit

35. Other liabilities               a.
(include judgements, notes
and other charge accounts)b.

                          c.

                          d.

36. Federal taxes owed

37. State taxes owed

38. TOTALS                                 $                $   $

                                    – Page 2 –

SECTION V – INCOME AND EXPENSE ANALYSIS

                             (a) Income                                                                                                                  (b) Necessary Living Expenses

                                                                          47. Rent/House payment                                                       $
                 Source                                                          Gross                          Net
                                                                          48. Groceries                                                                $

                                                                          49. Allowable installment
39. Wage/Salary (Taxpayer)                $                 $                    Payments                     $

40. Wages/Salary (Spouse)                                                 50. Utilities                                                                $

41. Interest - Dividends                                                  51. Transportation                                                           $

42. Net Business Income
                                                                          52. Insurance                                                                $
(from Form REV-484 or REV-488)

43. Rental Income                                                         53. Medical                                                                  $ 

44. Pension(Taxpayer)                                                     54. Estimated tax payments          $
Source:                                                                          (federal-state)

45.Source:Pension(Spouse)                                                 55. Other expenses(specify)$

46. TOTAL                                 $                                   $ TOTAL                         $56. 

Item 40 should be completed if you are married even if your spouse is not liable forNet difference(income less$                                          57. 
the tax. This information is necessary in order for the Department of Revenue to necessary living expenses)
calculate household income and expenses.

CERTIFICATION– Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities and other infor-
mation is true, correct and complete.
58. Your Signature                                                                                            59. Spouse, Attorney or Accountant Signature (POA Attached)             60. Date

                                                        – Page 3 –