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Get PA DoR REV-484 FO 2013-2022

Rrent taxes 47. Other (Specify) TOTAL 36. $ TOTAL 48. 49. Net difference (Item 36 minus Item 48) $ $ 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. 50. Signature 51. Date MM/DD/YYYY Signature of Officer Please sign after printing Reset Entire Form RETURN TO PAGE 1 Page 3 PRINT FORM.

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