Earned Income Tax Return Form Pennsylvania
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1Make checks payable and mail to:
Earned Income Tax Return
Pa. Municipal Service Co
336 Delaware Ave D-A
Oakmont PA 15139-2138
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Mon-Fri 9AM-5PM
Telephone #:
412-828-7955
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Please Complete information below:
Tax Year
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School District
Municipality
Call the number above for your Tax Rate %
Social Security #
Name/Address
Name
Name
Complete for Corrections/Changes: __Self __ Spouse __ Both
Part year Resident Indicate Residency Dates
Your Social Security #
Spouse Social Security #
Month/Day/Year
from ___/___/___ to ___/___/___
Name/Address:
___________________________________
If No Income Reported Indicate Reason
____________________________________________________
___ Retired ___ Unemployed
___ Retired ___ Unemployed
School District/Municipality ______________________________
___ Disabled ___ Deceased
___Disabled ___ Deceased
Other _________________
Other _________________
Effective date of all changes
___/___/___
1. Gross Earned Income.
(Enclose W-2(s), 1099(s))
1. $____________________
1 .$____________________
2. Less: Allowable Non-Reimbursed Employee Business Exp.
2.($____________________)
2.($____________________)
(Submit Pennsylvania Forms UE-1, UE-2 or Federal Form 2106)
3. Taxable Earned Income.
3. $____________________
3. $____________________
(Line 1 minus Line 2)
4. Net Loss from Business, Profession or Farm
(Submit Pa Schedule(s)
4.($____________________)
4.($____________________)
RK-1 and NRK-1 and Federal Schedule(s) C, E, F, K-1, etc.)
5. SubTotal
(Line 3 minus Line 4 ) IF LESS THAN ZERO, ENTER ZERO
5. $____________________
5. $____________________
6. Net Profit from Business, Profession or Farm
(Submit Pa Schedule(s)
6. $____________________
6. $____________________
RK-1 and NRK-1 and Federal Schedule(s) C, E, F, K-1, etc.)
7. TOTAL EARNED INCOME and NET PROFITS
7. $____________________
7. $____________________
(Line 5 plus Line 6)
8. TAX LIABILITY
(Line 7 multiplied by Tax Rate of
)
8. $____________________
8. $____________________
%
9. Employer Payments Withheld by Employer
9.($____________________)
9.($____________________)
(Per W-2)
10. Individual Payments and/or Credits paid as of
(Direct Payments made by you and/or credits from previous year.)
10.($____________________)
10.($____________________)
11. Miscellaneous Credits
(i.e. Out of State, Philadelphia – see
11.($____________________)
11.($____________________)
instructions.)
12. TOTAL PAYMENTS/CREDITS (
12.($____________________)
12.($____________________)
Line 9 plus Line 10 plus Line 11)
13. OVERPAYMENT
(If line 12 greater than line 8) If $1.00 or MORE enter
1.00
amount and check box below (No Refund under $
credit only)
13.$____________________
13.$____________________
Credit to Spouse
Credit to Next Year
Refund
14. TAX DUE
14.$____________________
14.$____________________
(If Line 8 greater than Line 12)
DO NOT REMIT IF LESS THAN $1.00
15. Penalty & Interest
15.$____________________
15.$____________________
16. TOTAL AMOUNT DUE
(Line 14 plus Line 15)
16.$____________________
16.$____________________
I certify the information herein is true, correct and complete.
____________________________________________________________
TOTAL PAID $ __________________________
Your Signature
Date
____________________________________________________________
____________________________ K/M
Spouse’s Signature
Date
Check/Money Order
For Office Use Only
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