Form Rev 484 Fo – Fill Out and Use This PDF

Please verify the federal employer identification number and the Social Security number(s) of the owner(s).

Enter the Business Name, Business Address, County, City, State, ZIP Code and Business Phone Number.

Enter the Preparer's Name, FEIN, Preparer's Title and Type of Business.

If additional space is needed, attach separate sheet.

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.

Under Owner, Partners, Officers, Major Shareholders, etc. Information, enter the Name and Title, Effective Date, Home Address, Phone Number, SSN and Total Share of Interest.

Enter the Latest Filed PA Income Tax Return Form, Tax Year Ended and Net Income Before Taxes. If sole proprietor, include assets and liabilities of owner.

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

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.

For Bank Accounts, list all types of accounts including payroll and general, saving, certificates of deposit, etc., with the Name of Institution, ADDRESS, Type of Account, Account Number and BALANCE.

Enter the TOTAL in Section III, Line 2.

Include all credit cards owned by the business.

For Bank credit available (Lines of credit, etc.), enter the Name of Institution, ADDRESS, Credit Limit, Amount Owed, Credit Available and Monthly Payments.

Enter the TOTALS in Section III, Line 9 or 10 as appropriate.

List all locations, box numbers and contents of Safe Deposit Boxes Rented or Accessed.

For Real Estate Property, enter the Real Property Description, Type of Ownership and Address (Include County and State).

Include all life insurance policies owned by the business, such as Key-Man Life Insurance.

For Life Insurance (Owned with business as beneficiary.), enter the Name Insured, COMPANY, Policy Number, TYPE, Face Value and Available Loan Value.

Enter the TOTALS in Section III, Line 4.

Report any extraordinary situations such as recent transfers of assets, court proceedings and anticipated changes in business income.

Enter 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.).

For Accounts/notes receivable, include loans to stockholder, officers, partners, etc., and enter the NAME, ADDRESS, Amount Due, Date Due and STATUS.

Enter the TOTALS in Section III, Line 3.

This section resembles a balance sheet and should reflect accurate amounts.

For each line, enter the (A) Asset or Liability, (B) DESCRIPTION, (C) Current Market Value, (D) Liabilities Balance Due and (E) Amount of Monthly Payment.

Enter 1. Cash on hand, 2. Bank Accounts, 3. Accounts/Notes receivable, 4. Life Insurance Loan Value, 5. Real Property, 6. Vehicles (model, year, license), 7. Machinery and Equipment (Specify), 8. Merchandise Inventory (Specify), 9. Other Assets (Specify), 10. Other Liabilities (Including notes and judgements), 11. Federal Taxes Owed, 12. State Taxes Owed and 13. TOTALS.

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

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

Report all debts owed by your business. Report all delinquent federal and state business taxes.

Report totals for all entries made in each column.

Must reflect an operating period of 12 months.

Accounting Method Used Report the accounting method of the business (i.e., cash or accrual).

This section must report all sources of income and all business expenses directly attributable to the production of income.

Under Part A - INCOME, enter 14. Gross receipts from sales, services, etc., 15. Gross rental income, 16. Interest, 17. Dividends and 18. Other income (Specify).

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

Depreciation is not deemed an out-of-pocket expense and should not be included in the expense summary.

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

Enter the Net Difference (Line 19 minus Line 31) on Line 32.

Each entry should be verified for accuracy. The department may request supporting documents to substantiate this information.

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. Enter the Print Name, Signature and Date.

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.