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Section 4: Payment Options A. Refund: A. Paying Tax Due by Check - If you agree, enter your five-digit self-selected PIN below. A self-selected five-digit personal identification number (PIN) will serve as your electronic signature on your tax return. If you are filing with a spouse, you must each enter your five-digit PIN. If filing a joint return on behalf of one or more deceased taxpayers, you must enter both PINs. Primary Taxpayer Section 2: Additional Information Needed to E-file Your Pennsylvania Return ......................... ......................... Section 3: Refund Options If you would like to have your refund directly deposited into your bank account, enter the information below. If you are paying with a check, print Form PA-V Payment Voucher, and mail it with your check to the Pennsylvania Department of Revenue. See Instructions for more information. B. Electronic Funds Withdrawal of Tax Due I authorize (1) The Pennsylvania Department of Revenue and its designated financial agents to initiate an electronic funds withdrawal (automatic withdrawal) entry to my financial institution account designated above for payment of my Pennsylvania taxes owed, and (2) my financial institution to debit the entry to my account. I also authorize the financial institutions involved in the processing of my electronic payment of taxes to receive confidential information necessary to answer inquiries and resolve issues related to my payment. Under the terms of this authorization, I can revoke authorization by notifying the Pennsylvania Department of Revenue no later than two business days prior to the payment date. I understand that notification must be made in writing by one of the following methods: Routing Transit Number Type Checking Requested payment Date Bank Account Number or Savings Taxpayer's Daytime Phone Number Secondary Taxpayer E-mail address (for confirmation e-mail) Re-enter e-mail address (must match) Routing Transit Number Type Checking Bank Account Number or Savings I authorize the Department of Revenue to direct deposit my refund as designated herein. If I have filed a joint return, this is an irrevocable appointment of the other spouse as an agent to receive the refund. Required Information For Electronic Filing -Complete All 4 Sections Below Will the fund go to an account outside the U.S.? Section1: E-Signature ..................... G ..................... G . G G G G G . G ............... ............... Under penalties of perjury, I/we declare that I/we have examined this return, including all accompanying schedules and statements, and to the best of my/our belief, they are true, correct and complete. box below, you will receive a check. Will the fund come from an account outside the U.S.? Email to: ra-achrevok@pa.gov, or Fax to: 717-772-4193 All fields are required. If you do not enter all required direct deposit information and check the authorization withdraw the amount of your tax payment from your bank account: Filling out the information below authorizes the Department of Revenue and its designated financial agents to electronically Yes No Yes No ----------------Page (0) Break----------------