Form Rev-488 Fo - Collection Information Statement For Individuals - Pa Department Of Revenue Page 3
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4SECTION IV.
Assets and Liabilities
Current
C u r r e n t
E q u i t y
Amount of
Name and Add r e s s
Date of
D e s c r i p t i o n
M a r k e t
A m o u n t
i n
M o n t h ly
o f
D a t e
F i n a l
Va l u e
O w e d
A s s e t
Pay m e n t s
Lien/Note Holder/Lender
P l e d ge d
Pay m e n t
2 0 . Cash
2 1 . Bank accounts (from Item 13)
2 2 . Securities (from Item 18)
2 3 . Cash or loan value of insurance
2 4 . Vehicles (model, ye a r, license tag #)
a.
b.
c.
2 5 . Real Property
a .
(from Section III.
b .
Item 16)
c .
2 6 . Other A s s e t s
a.
b.
c.
d.
e.
2 7 . Bank revolving credit (from Item 14)
2 8 . Other Liabilities
a .
(including bank
b .
loans, judgments, c .
n o t e s, and
d .
charge accounts
e .
not entered in
f .
Item 14.)
g .
2 9 . State/Federal taxes owed ( p rior ye a r s )
3 0 . To t a l s
$
$
Official Use Only Below This Line
Financial Ve r i f i c a t i o n / A n a ly s i s
Date Info r m a t i o n
Date Pro p e rt y
Estimated Forc e d
I t e m
or Encumbrance Verified
I n s p e c t e d
Sale Equity
Personal Residence
Other Real Property
Ve h i c l e s
Other Personal Property
State Employment (Husband and W i fe )
Income Tax Return
Wage Statements (Husband and W i fe )
Sources of Income/Credit
E x p e n s e s
Other A s s e t s / L i a b i l i t i e s
Page 3
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