Form Rev-488 Fo - Collection Information Statement For Individuals - Pa Department Of Revenue
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4REV-488 FO (10-99)
DEPARTMENT OF REVENUE
Collection Information Statement for Individuals
NOTE: Complete all blocks except shaded areas. Write “N/A” (not applicabl e ) in the blocks which do not apply. See REV- 4 8 8 A for instructions.
1 . Taxpayer(s) name(s) and address(es)
2 . Home phone number
(
)
3 . Marital status
4 a . Ta x p a y e r’s Social Security Number
b . S p o u s e ’s Social Security Number
Employment Information
SECTION I.
5 . Ta x p a y e r’s employer or business (name and address)
a . How long employed?
b . Business phone number
(
)
c . O c c u p a t i o n
d . Number of dependents claimed for
federal tax purposes:
e . Pay period:
We e k l y
f . ( C h e ck appropriate box )
B i - w e e k l y
M o n t h l y
Wage earner
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Sole proprietor
Payday: _____________ (Mon-Sun)
P a r t n e r
6 . S p o u s e ’s employer or business (name and address)
a . How long employed?
b . Business phone number
(
)
c . O c c u p a t i o n
d . Number of dependents claimed for
federal tax purposes:
e . Pay period:
We e k l y
f . ( C h e ck appropriate box )
B i - w e e k l y
M o n t h l y
Wage earner
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Sole proprietor
Payday: _____________ (Mon-Sun)
P a r t n e r
SECTION II.
Personal Information
7 . Other names or aliases
8 . Previous address(es)
9 . Name, address, and telephone number of
next of kin or other reference
1 0 . Age and relationship of dependents living in your household ( exclude yourself and spouse)
11 . Date of birth
a . Ta x p a y e r
b . S p o u s e
1 2 . Latest filed income
a . Business expense
b . Taxable income
tax return (tax ye a r )
c l a i m e d
General Financial Information
SECTION III.
1 3 . Bank accounts (include savings & loans, credit unions, IRA and retirement plans, certificates of deposit, etc.) Enter bank l o a n s in Item 28.
If more space is needed, use an 8 1/2” X 11” sheet of paper and attach.
Name of Institution
A dd r e s s
Type of Account
Account No.
B a l a n c e
Total (Enter in Item 21)
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Parent category: Financial