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enter your five digit PIN. If filing a joint return on behalf of one or more deceased Section 1: E - Signature A self - selected five - digit personal identification number (PIN) will serve as your - taxpayers, you must enter both PINs. 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. If you agree, enter your five - digit self - selected PIN below. Primary Taxpayer Secondary Taxpayer Section 2: Additional Information Needed to e - File your Pennsylvania Return E m ail addre ss (for confirmation email) Re - enter email address (must match) electronic signature on your tax return. If you are filing with a spouse, you must each ----------------Page (0) Break---------------- Section 3: Refund Options /Payment Options A. Refund : If you would like to receive your refund directly deposited into your bank account, enter the information below . All fields are required. Routing Transit Number Bank Account Number Checking 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 s pouse as an agent to receive the refund. If you do not enter all required direct deposit information and check the authorization box above , you will receive a check. Section 4: Payment Options A. Paying Tax Due by Check : If you are paying with a check, print Form D - 40P, Payment Voucher, and mail it with your check to the Pennsylvania Department of Revenue A. If you are paying the tax due by check , print form PA - V and make the check or money order payable to: PA Department of Revenue Payment Enclosed 1 Reve nue Place Harrisburg PA 17129 - 0001 Include “ 2013 PA - 40 ” and the last four digits of the primary taxpayer’s Social Security number on the check. If paying without form PA - V, mail your check to the above address with “ 2013 PA - 40 ” and the complete Social Security number of the primary taxpayer noted on your check. If you pay by money order or check that does not include your name and address, include your name, address and the full Social Security number of the primary taxpayer on the che ck or money order along with “ 2013 PA - 40 ” . B. B. Electronic Funds Withdrawal of Tax Due: Filling out the information below authorizes the Department of Revenue and its designated financial agents to electronically withdraw the amount of your tax payment f rom your bank account: Routing Transit Number Bank Account Number Checking or Savings Requested Payment Date Taxpayer’s Daytime Phone Number I authorize (1) The Pennsylvania Department of Revenue and its designated financial agents to initiate an el ectronic 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 Formatted: List Paragraph, Numbered + Level: 1 + Numbering Style: A, B, C, ... + Start at: 1 + Alignment: Left + Aligned at: 0.25" + Indent at: 0.5" Formatted: Indent: First line: 0.5" Formatted: Indent: Left: 0.75", No bullets or numbering Formatted: Normal, Indent: Left: 0.5", No bullets or numbering ----------------Page (1) Break---------------- account. I also authorize the financial instit utions 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: Email to ra - achrevok@pa. gov , or Fax to717 - 772 - 4193 I understand that if the Pennsylvania Department of Revenue does not receive full and timely payment of my tax liability, I will remain liable for the tax liability and all applicable interest, penalties and return item charges . NOTE : In some instances, your account will be debited on the business banking day following your authorization . C. The Federal Office of Foreign Assets Control is imposing additional reporting requirements on electronic banking transactions directly involving a financial institution outside of the territorial jurisdiction of the U.S . These transactions are called i nter national ACH t ransactions (IAT). Presently, the Pennsylvania Department of Revenue does not support IAT ACH Debit Transactions. Please select the appropriate answer to the following question. Will the funds for this payment come from a bank account outside of the U.S. ? Yes or No ----------------Page (2) Break----------------