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Primary Taxpayer’s Last Name Secondary Taxpayer’s First Name, Initial Part III Declaration of Taxpayers (Sign only after Part I is complete.) 10. I I am not receiving a refund or I do not want direct deposit of my refund. Primary Taxpayer Date Secondary Taxpayer Date Part IV Declaration of Electronic Return Originator (ERO) and Paid Preparer (See instructions.) ➧ Sign Here ERO’s Use Only ERO’s signature Date EIN/SSN or PTIN Daytime Telephone Number ( ) Part II Direct Deposit of Refund or Electronic Funds Withdrawal of Tax Due (Optional – See instructions.) 6. Routing transit number (RTN) 7. Depositor account number (DAN) 8. Type of account: Checking Savings 9 . Debit date Declaration Control Number/Submission ID Form PA-8453 2013 PENNSYLVANIA INDIVIDUAL INCOME TAX DECLARATION FOR ELECTRONIC FILING Primary Taxpayer’s Social Security Number Secondary Taxpayer’s Social Security Number Home Address (Number and Street including Rural Route or P.O. Box) City, Town or Post Office State ZIP Code Part I Tax Return Information (Enter whole dollars only.) For the year Jan. 1 – Dec. 31, 2013 Check Proper S Single J Married, Filing Jointly D Deceased Daytime Telephone Number Filing Status M Married, Filing Separately F Print or Type KEEP THIS FORM AND THE REQUIRED ATTACHMENTS FOR THREE YEARS. Please DO NOT mail this form. ➧ ➧ The first two numbers of the RTN must be 01 through 12 or 21 through 32. ➧ Check if also paid preparer Check if self-employed Firm’s name (or yours, if self-employed) and address ➧ ➧ ➧ Paid Preparer’s Use Only Check if self-employed Firm’s name (or yours, if self-employed) and address STAPLE COPY OF STATE W-2(s), W-2G and 1099(s) HERE P E N N S Y L V A N I A PA DEPARTMENT OF REVENUE USE ONLY – DO NOT WRITE OR STAPLE IN THIS SPACE The above information must match that on the electronic return exactly. a. b. c. Preparer’s signature Date EIN/SSN or PTIN Daytime Telephone Number ( ) Check if also paid preparer 2. PA tax liability (Form PA-40, Line 12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. 3. Total PA tax withheld (Form PA-40, Line 13) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. 4. Amount to be refunded (Form PA-40, Line 30) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. 5. Total payment (tax due) (Form PA-40, Line 28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 1. Adjusted PA taxable income (Form PA-40, Line 11) PA Tax Return (PA-40). To the best of my knowledge, my return is true and complete. I consent my return and accompanying schedules and statements may be sent to the Internal I declare I have received the above-named taxpayer’s return and the entries on this form are complete and correct to the best of my knowledge. I obtained the taxpayer’s signature on this form before submitting this return to the PA Department of Revenue. I provided the taxpayer with a copy of all forms and information to be filed with the IRS and the PA Department of Revenue and followed all other requirements specified by the PA Department of Revenue and described in the IRS Publication 1345, Handbook for Electronic Filers of Individual Tax Returns (Tax Year 2013). If I am the preparer, under penalty of perjury I declare I examined the above-named taxpayer’s return and accompanying schedules and statements, and to the best of my knowledge, they are true and complete. I understand I am required to keep this form and supporting documents for three years. Primary Taxpayer’s First Name, Initial Secondary Taxpayer’s Last Name (only if different) Final Return consent for my refund to be directly deposited as designated in Part II and declare all information shown on Lines 6 through 8 is correct. I certify the ultimate destination of the funds is within the U.S. or one of its territories. If I have filed a joint return, this is an irrevocable appointment of the other Taxpayer as an agent to receive the refund. I authorize the Pennsylvania Department of Revenue and its designated financial agents to initiate an electronic funds withdrawal entry to my designated account for Pennsylvania taxes owed. I also authorize my financial institution to debit the entry to my account and 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. I certify the funds for this withdraw are originating from an account within the U.S. or one of its territories. I may revoke this authorization by notifying the Pennsylvania Department of Revenue no later than two business days prior to the payment (settlement) date. I understand notification must be made in writing by email to ra-achrevok@state.pa.us or fax to 717-772-9310. If I have filed a balance-due return, I understand that if the PA Department of Revenue does not receive full and timely payment of my tax liability, I will remain liable for the tax and all applicable interest and penalties. If I have filed a joint federal and state tax return and there is an error on my state return, I understand my federal return will be rejected. I declare under penalties of perjury compared the information on my return with the information I provided to my electronic return originator and the amounts match those on my 2013 RevenueService (IRS) by my electronic return originator, and subsequently by the IRS to the PA Department of Revenue. If I am filing from a home computer, I understand I am required to keep this form and supporting documents for three years. ----------------Page (0) Break----------------