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REV-488A FO (03-12)

INSTRUCTIONS FOR

COMPLETING STATEMENT

OF FINANCIAL CONDITION

Bureau of Collections and Taxpayer Services

FOR INDIVIDUALS

PO BOX 281041

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 36 and 37: 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 39 and 40: 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.

Form Rev-488a Fo - Instructions For Completing Statement Of Financial Condition For Individuals (Rev-488a)

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