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Form Rev-488 Fo - Collection Information Statement For Individuals - Pa Department Of Revenue Page 4

SECTION V.

Monthly Income and Expense Analysis

Total Income

N e c e s s a ry Living Expenses

(Official use only)

S o u rc e

G ro s s

C l a i m e d

A l l ow e d

3 1 . Wages/Salaries ( Ta x p aye r )

4 2 . National Standard Expenses

3 2 . Wages/Salaries ( S p o u s e )

4 3 . Housing and Utilities

3 3 . Interest – Dividends

4 4 . Transportation

3 4 . Net Business income

(from form PA-40 or Schedule C)

4 5 . Health Care

3 5 . Rental Income

4 6 . Taxes (income and FICA)

3 6 Pension ( Ta x p aye r )

4 7 . Court ordered payments

3 7 . Pension ( S p o u s e )

4 8 . Child/dependent care

3 8 . Child Support

4 9 . Life Insurance

39. A l i m o n y

5 0 . Secured or legally-perfected debts

(specify)

4 0 . O t h e r

5 1 . Other expenses ( S p e c i f y )

4 1 . Total Income

5 2 . Total Expenses

5 3 . (Official use only) Net diff e r e n c e

(Income less necessary living expenses)

C e rt i f i c a t i o n : Under penalties of perjury, I declare that to the best of my know l e d ge and belief this

statement of assets, l i a b i l i t i e s , and other information is true, c o r r e c t , and complete.

5 4 . Your Signature

5 5 . S p o u s e ’s signature (if joint return was filed)

56. Date

N o t e s :

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

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.

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

Additional Information or Comments:

PA Department of Rev e nue Use Only Below This Line

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

Name of enforcement agent or collector

D a t e

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