Statement Of Financial Condition For Individuals Form 2005

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DEPARTMENT OF REVENUE
Statement of Financial Condition for Individuals
(If additional space is needed, attach separate sheet)
REV-488 FO (9-05)
(including county)
1. Taxpayer’s name(s) and address(es)
2. Home phone number
3. Marital status
a. Taxpayer
b. Spouse
4. Social Security
Number(s)
SECTION I – EMPLOYMENT INFORMATION
5. Taxpayer’s employer of business (name and address) or
6. Business phone number
7. Occupation
(Check appropriate box)
8. Paydays
9.
Sole
❑
❑
❑
Wage earner
Partner
Proprietor
10. Spouse’s employer or business (name and address) or
11. Business phone number
12. Occupation
(Check appropriate box)
13. Paydays
14.
Sole
❑
❑
❑
Wage earner
Partner
Proprietor
SECTION II – PERSONAL INFORMATION
15. Name, address and telephone number of next
16. Age and relationship of dependents (exclude 17. Number 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
(tax year)
19. Latest PA income tax return filed
20. Adjusted gross income on return
(include Savings and Loans, Credit Unions, IRA and KEOGH accounts, Certificates of Deposit, etc.)
21. Bank accounts
Name of Institutions
Address
Type of Account
Account Number
Balance
$
(Enter in Item 28)
$
Total
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
$
$
$
$
(Enter in Item 34)
Total
$
$
$
$
(List all locations, box numbers and contents)
23. Safe deposit boxes rented or accessed
(Brief description and type of ownership)
(Include county and state)
24. Real Property
Address
a.
b.
c.
(Name of Company)
25. Life Insurance
Policy Number
Type
Face Value
Available Loan Value
$
$
– Page 1 –

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