Form Rev-484 - Statement Of Financial Condition For Businesses
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3DEPARTMENT OF REVENUE
Statement of Financial Condition for Businesses
If additional space is needed, attach separate sheet.
REV-484 FO (06-13)
1. Name and address of business
Start
2. Business phone number
3. Type of ownership. Check appropriate box.
Sole proprietor
Other (specify)
Corporation
Partnership
4. Preparer’s name and title
5. Federal employer identification number 6. Type of business
7. Information about owner, partners, officers, major shareholders, etc.
Effective
Phone
Social Security
Total Share
Name and Title
Home Address
Date
Number
Number
or Interest
MM/DD/YYYY
SECTION I – GENERAL FINANCIAL INFORMATION
If sole proprietor, include assets and liabilities of owner.
8. Latest filed Pennsylvania income tax return
Form
Tax year ended
Net income before taxes
$
List all types of accounts including payroll and general, saving, certificates of deposit, etc.
9. Bank accounts
Balance
Name of Institutions
Address
Type of Account
Account Number
$
TOTAL
Enter in Item 17.
$
10. Bank credit available
(Lines of credit, etc.)
Credit Limit
Amount Owed
Credit Available
Monthly Payments
Name of Institution
Address
$
$
$
$
TOTALS
$
$
$
Enter in item 24 or 25 as appropriate.
11. Location, box number and contents of all safe deposit boxes rented or accessed
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