Form Pa-40ez - 2000 - Wage Tax Statement Page 2
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1
2PA-40EZ - 2000
0000410027
PA-40EZ (09–00)
PA DEPARTMENT OF REVENUE
OFFICIAL USE ONLY
Pennsylvania Income Tax Return Commonwealth of Pennsylvania
Your Name:
Social Security Number
11. OVERPAYMENT. If Line 9 is more than Line 5, enter the difference here. . . . . . . . . . . . . . . . . . . . .
11.
Enter how you want your overpayment applied. If you only want a refund check, enter the amount from Line 11 on Line 12.
You may not request direct deposit on a paper return. If you want to donate to one or more of the funds listed below, enter the amount on those lines.
The total of Lines 12 through 17 must equal Line 11.
12.
12. Refund -- Amount of Line 11 you want as a check mailed to you. . . . . . . . . . . . . . . . . . . Refund
13. Donation -- Amount of Line 11 you want to donate to the Wild Resource Conservation Fund. . . . . .
13.
14. Donation -- Amount of Line 11 you want to donate to the U.S. Olympic Committee, PA Division.
14.
15. Donation -- Amount of Line 11 you want to donate to the Organ Donor Awareness Trust Fund. .
15.
16. Donation -- Amount of Line 11 you want to donate to the Korea/Vietnam Memorial, Inc. . . . . . . .
16.
17. Donation -- Amount of Line 11 you want to donate to the Breast and Cervical Cancer Research Fund.
17.
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.
Your Signature:
DATE:
Your Occupation:
Spouse’s Signature, if filing jointly:
DATE:
Spouse's Occupation:
PLEASE DO NOT CALL ABOUT YOUR REFUND UNTIL 8 WEEKS AFTER YOU FILE.
PA Schedule W-2S (09-00)
Wage Statement Summary
2 0 0 0
PA DEPARTMENT OF REVENUE
Name(s) as shown on your PA tax return:
Social Security Number:
Instructions. Instead of submitting your Form(s) W-2, or photocopies, you may write the necessary information below. Keep your original Form(s) W-2.
Important. Your PA compensation may be different from your federal wages. Caution. If you believe that the PA amount on a Form W-2 is incorrect, you
must submit your actual Form W-2 with a written explanation from your employer.
You must submit other statements for amounts you are reporting as compensation on your PA tax return.
Information From Each Form W-2.
If you need more space, you may photocopy this schedule or prepare your own schedule in this format.
Number of Form(s) W-2
Include the total on Line 1a
Include the total on Line 6
(a)
(b)
(c)
(d)
• Do not include
local income tax
Employer Identification Number
Federal wages from
PA taxable compensation
PA tax withheld
withheld in
from box B
box 1
from box 17
from box 18
column (d).
$
1.
-
$
$
• Do not include
2.
-
$
$
$
tax withheld to
another state or
$
3.
-
$
$
country in
column (d).
4.
-
$
$
$
$
5.
-
$
$
Caution.
The Department
6.
-
$
$
$
reserves the
right to require
$
7.
-
$
$
your actual
Total.
$
$
Form(s) W-2.
Go back to the beginning of page 1.
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Side 2
Please remember to sign your PA-40EZ. The PA Department of Revenue does not accept electronic signatures.
0000410027
0000410027
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