Pennsylvania Statement of Financial Condition for Businesses

Statement of Financial Condition for Businesses
Statement of Financial Condition for Businesses (REV-484)
IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING
(ET+) 03-22

REV-484

STATEMENT OF
FINANCIAL CONDITION
FOR BUSINESSES

If additional space is needed, attach separate sheet

SECTION I

Start

BUSINESS INFORMATION

Business Name

Business Phone Number

➜
Business Address
City

County

Type of Ownership (select appropriate oval):

Sole Proprietor

State

ZIP Code

Corporation

Partnership

Other

Preparer’s Name

Preparer’s Title

FEIN

Type of Business

Owner, Partners, Officers, Major Shareholders, etc. Information
NAME AND TITLE

SECTION II

EFFECTIVE DATE

HOME ADDRESS

PHONE NUMBER

TOTAL SHARE
OF INTEREST

SSN

GENERAL FINANCIAL INFORMATION

If sole proprietor, include assets and liabilities of owner.
Latest Filed PA Income Tax Return

Form

Tax Year Ended

Net Income Before Taxes
$

Bank Accounts. (List all types of accounts including payroll and general, saving, certificates of deposit, etc.)
NAME OF INSTITUTION

ADDRESS

TYPE OF ACCOUNT

ACCOUNT
NUMBER

BALANCE

$
$
$
$
TOTAL (Enter in Section III, Line 2) $

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REV-484 (ET+) 03-22

SECTION II

GENERAL FINANCIAL INFORMATION (cont.)

Bank credit available. (Lines of credit, etc.)
NAME OF INSTITUTION

ADDRESS

CREDIT LIMIT

CREDIT
AVAILABLE

AMOUNT OWED

MONTHLY PAYMENTS

$

$

$

$

$

$

$

$

$
$
TOTALS (Enter in Section III, Line 9 or 10 as appropriate.) $

$

$

$

$

Safe Deposit Boxes Rented or Accessed (list all locations, box numbers and contents)
BOX NUMBER

SAFE DEPOSIT BOX LOCATION

CONTENTS

Real Estate Property
REAL PROPERTY DESCRIPTION

TYPE OF OWNERSHIP

ADDRESS (INCLUDE COUNTY AND STATE)

a.
b.
c.
d.
Life Insurance (Owned with business as beneficiary.)
NAME INSURED

COMPANY

POLICY NUMBER

TYPE

FACE VALUE

AVAILABLE LOAN VALUE

$

$

$

$

$

$

$

$

TOTALS (Enter in Section III, Line 4.)

$

Additional information regarding financial condition (Court proceedings, bankruptcies filed or anticipated, transfers of assets for less than full value,
changes in market condition, etc./ include information regarding company participation in trust, estates, retirement plans, etc.)

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REV-484 (ET+) 03-22

GENERAL FINANCIAL INFORMATION (cont.)

SECTION II

Accounts/notes receivable. Include loans to stockholder, officers, partners, etc.
NAME

ADDRESS

AMOUNT DUE

DATE DUE

STATUS

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
TOTALS (Enter in Section III, Line 3.) $

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REV-484 (ET+) 03-22

SECTION III

ASSETS AND LIABILITIES ANALYSIS

(A)
ASSET OR LIABILITY

(C)
CURRENT MARKET
VALUE

(B)
DESCRIPTION

(D)
LIABILITIES
BALANCE DUE

(E)
AMOUNT OF MONTHLY
PAYMENT

1.

Cash on hand

2.

Bank Accounts

3.

Accounts/Notes
receivable

$

$

$

4.

Life Insurance
Loan Value

$

$

$

a.

$

$

$

b.

$

$

$

c.

$

$

$

d.

$

$

$

a.

$

$

$

b.

$

$

$

c.

$

$

$

a.

$

$

$

b.

$

$

$

c.

$

$

$

a.

$

$

$

b.

$

$

$

a.

$

$

$

b.

$

$

$

a.

$

$

$

b.

$

$

$

c.

$

$

$

d.

$

$

$

e.

$

$

$

f.

$

$

$

g.

$

$

$

$

$

$

$

$

$

$

$

$

5.

6.

7.

8.

9.

Real Property

Vehicles (model,
year, license)

Machinery and
Equipment (Specify)

Merchandise
Inventory (Specify)

Other Assets
(Specify)

10. Other Liabilities
(Including notes
and judgements)

$
$

11. Federal Taxes Owed
12. State Taxes Owed
13. TOTALS

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REV-484 (ET+) 03-22

SECTION IV

INCOME AND EXPENSE ANALYSIS

The following information applies to income and expenses
during the period
to

Accounting Method Used

PART A - INCOME
14. Gross receipts from sales, services, etc.

$

15. Gross rental income

$

16. Interest

$

17. Dividends

$

18. Other income (Specify)

$
$
$
$
$
$
$
$
$
$

19. TOTAL

$

PART B - EXPENSES
20. Materials purchased

$

21. Net wages and sales

$

22. Rent

$

23. Installment payments

$

24. Supplies

$

25. Utilities/Telephone

$

26. Gasoline/Oil

$

27. Repairs and maintenance

$

28. Insurance

$

29. Current taxes

$

30. Other (Specify)

$
$
$

31. TOTAL

$

32. Net Difference (Line 19 minus Line 31)

SECTION V

$

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.
Print Name

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Instructions for REV-484

Statement of Financial Condition for Businesses

REV-484 IN (ET+) 03-22

GENERAL INFORMATION
The Statement of Financial Condition for Businesses provides
the Pennsylvania Department of Revenue with credit and
statistical information that will be utilized in evaluating the
financial position of your business. Every item of the financial
statement must be completed and should reflect accurate
statements and amounts. If an item is not applicable to your
business, insert N/A. An incomplete Statement of Financial
Condition for Businesses will not be considered.
The Statement of Financial Condition for Businesses is
presented in five sections. Instructions have been
provided only for items requiring further clarification. Most
of the requested items are self-explanatory and need no
further interpretation.

LIFE INSURANCE
Include all life insurance policies owned by the business,
such as Key-Man Life Insurance.
ADDITIONAL INFORMATION
REGARDING FINANCIAL CONDITION
Report any extraordinary situations such as recent transfers
of assets, court proceedings and anticipated changes in
business income.

SECTION III
ASSETS AND LIABILITIES ANALYSIS

LINES 1-13
This section resembles a balance sheet and should reflect
accurate amounts.

LINE INSTRUCTIONS

LINE 1

SECTION I

Report actual cash on hand, not cash in banks or other
financial institutions.

BUSINESS INFORMATION
Please verify the federal employer identification number
and the Social Security number(s) of the owner(s).
Information about owner, partners, officers, major
shareholders, etc. must be completed for any type of
ownership indicated. A sole proprietorship must report the
individual owner’s name, partnership must report all
partners and/or general partner’s names, and corporations
must report the names of all corporate officers.
Attachments may be used as necessary

SECTION II
GENERAL FINANCIAL INFORMATION

LINE 6
Report the current market value of business vehicles as
determined in an automobile “blue book” or by other property
valuation sources.

LINE 10
Report all debts owed by your business.

LINES 11 AND 12
Report all delinquent federal and state business taxes.

LINE 13

All information recorded in this section should be verified for
accuracy. The department may conduct an inquiry to
substantiate this information.

Report totals for all entries made in each column.

If the business is a partnership, the Statement of Financial
Condition for Businesses must be completed for partnership
assets and liabilities, and a separate Statement of Financial
Condition for Individuals must be completed for each
general partner.

INCOME AND EXPENSE ANALYSIS

BANK CREDIT AVAILABLE
Include all credit cards owned by the business.
www.revenue.pa.gov
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SECTION IV
LINES 14-32
This section must report all sources of income and all
business expenses directly attributable to the production of
income. Depreciation is not deemed an out-of-pocket
expense and should not be included in the expense
summary. Additional lines have been provided for reporting
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income and/or expense items not already itemized in
Section III. Each entry should be verified for accuracy. The
department may request supporting documents to
substantiate this information.
REPORTING PERIOD
Must reflect an operating period of 12 months.
ACCOUNTING METHOD USED
Report the accounting method of the business (i.e., cash
or accrual).

SECTION V
CERTIFICATION
Signature certifies that statements and entries contained in
the Statement of Financial Condition and/or accompanying
schedules are correct to the best knowledge and belief of
the undersigned.
Must provide signature by a duly authorized representative,
owner, partner or corporate officer along with the applicable
date the signatures were affixed.

LINE 19
Report total income from all income sources listed under
Lines 14-18.

LINE 31
Report total expenses from all liability sources listed under
Lines 20-30.

2

REV-484

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