Pennsylvania Statement of Financial Condition for Individuals

Statement of Financial Condition for Individuals
Statement of Financial Condition for Individuals (REV-488)
IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING
(ET+) 02-22

REV-488

OFFICIAL USE ONLY

STATEMENT OF
FINANCIAL CONDITION
FOR INDIVIDUALS

If additional space is needed, attach separate sheet
SECTION I

Start

TAXPAYER INFORMATION

MM/DD/YYYY
Date of Birth

Taxpayer’s Name

SSN

➜
Taxpayer’s Street Address
City

County

Spouse’s Name (if applicable)

State
Date of Birth

ZIP Code
SSN

Spouse’s Street Address (if different from above)
City

County

Phone Number

SECTION II

Marital Status

State

ZIP Code

Number of Exemptions Claimed on W-4

EMPLOYMENT INFORMATION

Employer or Business Name
Employer or Business Street Address
City

County

Business Phone Number

Occupation

Paydays

State
Fill In Appropriate Oval
Wage Earner

Partner

ZIP Code

Sole Proprietor

Spouse’s Employer or Business Name
Employer or Business Street Address
City

County

Business Phone Number

SECTION III

Occupation

Paydays

State
Fill In Appropriate Oval
Wage Earner

Partner

ZIP Code

Sole Proprietor

PERSONAL INFORMATION

Name of Next of Kin or Other Reference

Phone Number

Next of Kin or Other Reference Street Address
City

County

State

ZIP Code

Dependents Living in Your Household (exclude husband and wife)
AGE

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RELATIONSHIP

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AGE

PAGE 1

RELATIONSHIP

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REV-488 (ET+) 02-22

SECTION IV

GENERAL FINANCIAL INFORMATION

Latest PA Income Tax Return Filed (Tax Year)

Adjusted Gross Income on Return

Bank Accounts (include Savings and Loans, Credit Unions, IRA and KEOUGH accounts, Certificates of Deposit, etc.)
ADDRESS

NAME OF INSTITUTION

TYPE OF ACCOUNT

ACCOUNT NUMBER

BALANCE

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

$

Bank Charge Cards, Lines of Credit, etc.
TYPE OF ACCOUNT
OR CARD

NAME AND ADDRESS
OF FINANCIAL INSTITUTION

MONTHLY
PAYMENT

AMOUNT OWED

CREDIT AVAILABLE

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

TOTAL (Enter in Section V, Line 8)

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

CREDIT LIMIT

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
NAME OF LIFE INSURANCE COMPANY

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POLICY NUMBER

TYPE

PAGE 2

FACE VALUE

AVAILABLE LOAN VALUE

$

$

$

$

$

$

$

$

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REV-488 (ET+) 02-22

SECTION IV

GENERAL FINANCIAL INFORMATION (cont.)

Additional Information (court proceedings, bankruptcies, repossessions, recent transgers of assets for less than full value, anticipated
increases in income, condition of health, etc., include information on trusts, estates, retirement plans, etc., on which you are a participant
of beneficiary)

SECTION V

ASSET AND LIABILITY ANALYSIS

(A)
ASSET OR LIABILITY

(C)
CURRENT MARKET
VALUE

(B)
DESCRIPTION

(D)
LIABILITIES
BALANCE DUE

(E)
AMOUNT OF MONTHLY
PAYMENT

1.

Cash

2.

Bank Accounts

3.

Stocks, bonds,
investments

$

$

$

4.

Cash or loan value
of insurance

$

$

$

a.

$

$

$

b.

$

$

$

a.

$

$

$

b.

$

$

$

a.

$

$

$

b.

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

5.

6.

7.

8.

9.

Vehicles (model,
year, license)

Real Property

Other Assets

$
$

Bank Revolving
Credit

a.

Other Liabilities
(include judgements,
notes and other
b.
charge accounts)

c.
10. Federal Taxes Owed
11. State Taxes Owed
12. TOTALS

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REV-488 (ET+) 02-22

SECTION VI

INCOME AND EXPENSE ANALYSIS

PART A - INCOME
SOURCE

GROSS

13. Wages/Salary (Taxpayer)
14. Wages/Salary (Spouse) to be completed if you are married even if your spouse is not liable for the tax.
This information is necessary in order for the Department of Revenue to calculate household income and expenses.
15. Interest - Dividends
16. Net business Income (from Form REV-484 or REV-488)
17. Rental Income
18. Pension (Taxpayer) Source:
19. Pension (Spouse) Source:
20. TOTAL

NET

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

PART B - NECESSARY LIVING EXPENSES
21. Rent/House Payment

$

22. Groceries

$

23. Allowable Installment Payments

$

24. Utilities

$

25. Transportation

$

26. Insurance

$

27. Medical

$

28. Estimated Tax Payments (federal-state)

$

29. Other Expenses (specify)

$

30. TOTAL

$

31. Net Difference (income less necessary living expenses)

SECTION VII

$

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.
MM/DD/YYYY
Print Name
Signature
Date

SIGN AFTER PRINTING

Spouse, Attorney or Accountant Print Name

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Spouse, Attorney or Accountant Signature (POA Attached)

SIGN AFTER PRINTING

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Instructions for REV-488

Statement of Financial Condition for Individuals

REV-488 IN (ET+) 02-22

GENERAL INFORMATION
The Statement of Financial Condition for Individuals
provides the Pennsylvania Department of Revenue with
credit and statistical information that will be utilized in
evaluating an individual’s financial status. Every line of the
financial statement must be completed and should reflect
accurate information and amounts. If a line is not applicable
to you, respond "N/A". An incomplete Statement of Financial
Condition for Individuals will not be considered.
The Statement of Financial Condition for Individuals is
presented in six sections. Instructions are provided only for
lines requiring clarification. Most of the requested items are
self-explanatory and need no further interpretation.

LINE INSTRUCTIONS
SECTION I
TAXPAYER INFORMATION
Please verify the Social Security numbers reported.

SECTION II
EMPLOYMENT INFORMATION
This section should report all full-time and/or part-time
employers that currently make payment(s) to you in the form
of wages, salaries and/or commissions for services
performed. You may provide attachments if necessary.

SECTION III
PERSONAL INFORMATION
Provide personal and household information regarding you,
your spouse and/or your dependents.

SECTION IV
GENERAL FINANCIAL INFORMATION
All information furnished in this section should be verified
for accuracy. The department may conduct an inquiry to
substantiate this information.
BANK CHARGE CARD
Include any line of credit available to you from a company credit
union.
REAL PROPERTY
Report all business real estate holdings as well as your
personal residence.
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Report insurance information as verified through your
insurance agent.
ADDITIONAL INFORMATION
Report any extraordinary situations, such as recent transfers
of assets, court proceedings and anticipated changes in
employment.

SECTION V
ASSET AND LIABILITY ANALYSIS
This section resembles a balance sheet and should reflect
accurate amounts for assets owned and debts owed.

LINE 1
CASH
Report actual cash on hand, not cash in banks or other
financial institutions.

LINE 5
VEHICLES
Report the current market value of your vehicle(s) as
determined in an automobile blue book or by other property
valuation sources.

LINE 7
Report other assets such as furniture, recreational vehicles,
recreational or hobby tools, machinery and equipment and
miscellaneous household assets.

LINE 9
Report all other liabilities and debts owed for medical bills,
dental bills and educational expenses, including any formal
promissory note, loan arrangement or financial obligation
currently assigned to you.

LINES 10 - 11
FEDERAL/STATE TAXES OWED
Report all delinquent federal and state taxes.

LINE 12
TOTALS
Report totals for all entries made in each column.
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REV-488

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SECTION VI

LINE 23

MONTHLY INCOME AND EXPENSE ANALYSIS
Report all sources of income, both gross and net, earned
and/or received on a monthly basis and all sources of
necessary living expenses paid and/or incurred on a monthly
basis. Additional lines have been provided for reporting
income and/or expense items not already itemized in
Section V. Each entry should be verified for accuracy. The
department may request supportive documents to
substantiate this information.

Report allowable installment payments, the minimum
payments on secured or legally perfected debts (car
payments, judgments, etc.). Do not include payments on
encumbered assets (boats, recreational vehicle, etc.),
which are not necessary living expenses.

LINES 13 - 14
WAGES/SALARY
Report gross and net income figures obtained from all of
your wage statements. If you are paid on a weekly basis,
multiply your weekly gross and net salary by 4.3 to arrive at
your monthly gross and net income.

LINE 20
TOTAL INCOME
Report total income, both gross and net, from all income
sources identified under Items 13-19.

LINE 30
TOTAL
Report total expenses from all liability sources identified
under Lines 21-29.

SECTION VII
CERTIFICATION
Signature by you, your spouse or your attorney/accountant
(POA attached), certifies that statements and entries
contained in the Statement of Financial Condition for
individuals and/or accompanying schedules are correct to
the best knowledge and belief of the undersigned.
Provide your signature along with the date your signature
was posted. If a joint income tax return was filed, your
spouse’s signature must also be provided.

LINES 21 - 29
NECESSARY LIVING EXPENSES
Report accurate amounts for expenses verified by
examining your checkbook for the last six months.

2

REV-488

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