Form Rev-488 Fo - Collection Information Statement For Individuals (Page 4 of 4) in pdf

Form Rev-488 Fo - Collection Information Statement For Individuals Page 4

Monthly Income and Expense Analysis

SECTION V.

Total Income

Necessary Living Expenses

(Official use only)

Source

Gross

Claimed

Allowed

42. National Standard Expenses ①

31. Wages/Salaries (Taxpayer)

43. Housing and Utilities ➁

32. Wages/Salaries (Spouse)

44. Transportation ➂

33. Interest – Dividends

34. Net Business income

(from form PA-40 or Schedule C)

45. Health Care

35. Rental Income

46. Taxes (income and FICA)

36 Pension (Taxpayer)

47. Court ordered payments

37. Pension (Spouse)

48. Child/dependent care

38. Child Support

49. Life Insurance

39. Alimony

50. Secured or legally-perfected debts

(specify)

40. Other

51. Other expenses (Specify)

41. Total Income

52. Total Expenses

53. (Official use only) Net difference

(Income less necessary living expenses) $

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.

54. Your Signature

55. Spouse’s signature (if joint return was filed)

56. Date

Notes:

① Clothing and clothing services, food, housekeeping supplies, personal care products and services, and miscellaneous.

➁ Rent or mortgage payment for the taxpayer’s principal residence. Add the average monthly payment for the following expenses if they are not included in the rent or mort-

gage payment: property taxes, homeowner's or renter’s insurance, parking, necessary maintenance and repair, homeowner dues, condominium fees and utilities. Utilities

include gas, electricity, water, fuel oil, coal, bottled gas, trash and garbage collection, wood and other fuels, septic cleaning, and telephone.

➂ Lease or purchase payments, insurance, registration fees, normal maintenance, fuel, public transportation, parking and tolls.

Additional Information or Comments:

PA Department of Revenue Use Only Below This Line

Explain any difference between Item 53 and the deferred payment agreement amount:

Name of enforcement agent or collector

Date

Page 4