Form Rev-276 (I) - Application For Extensionof Time To File
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1REV-276 (I)
0007010028
Application for Extensionof Time to File
REV-276 EX (09–00)
OFFICIALUSE ONLY
PA DEPARTMENT OF REVENUE
Print the first two (2) letters of the last name if for individual or a PA-41.
DO NOT STAPLE
Print the first two (2) letters of the first name if a PA-65 or PA-40NRC.
PA-40, PA-41, PA-40NRC, PA-65
If PA-65 or PA-40 NRC, enter the partnership name starting with the first box of the “Last Name” and
A P P L I C AT I O N F O RE X T E N S I O NO FT I M E TO F I L E
continue until you have used all the space available (if needed). If you do not have enough space for
(See reverse for filing instructions. Be sure to answer all questions.)
PLEASE PRINT OR TYPE A L L I N F O R M AT I O N
the complete partnership name, do not use the address lines.
Your Social Security Number
Spouse’s Social Security Number
Employer Identification Number
-
-
-
-
-
First Name
MI
Last Name
Fill in the oval if filing in Pennsylvania for the first time
First Time PA Filer
TYPE OF RETURN
Spouse’s Last Name - Only if different from last name above
Spouse’s First Name
MI
Fill in the oval for the kind of PAReturn you will file
PA-40 or PA-40EZ Individual Tax Return
PA-40NRC Consolidated Nonresident Tax Return
P .O . Box, Apt. No., Suite, Floor, RR No, etc.
PA-41 Fiduciary Income Tax Return
PA-65 Partnership Information Return
Street Number and Name
If filing a PA-41 or PA-65, indicate your taxable year
/ /
Calendar Ye a r
Fiscal Y e a r, beginning
AMOUNT OFYOUR PAYMENT
City or Post Office
State
ZIP Code
$
Daytime Telephone Number
Ta x p a y e r’s S i g n a t u r e
D a t e
-
-
S p o u s e ’s Signature
D a t e
An extension of time until
is requested to file the PA return of the above named taxpayer for the taxable year
month
date
year
beginning
and ending
.
month
date
year
month
date
year
(See instructions regarding type and length of extension.)
Has an extension of time to file been previously granted for this taxable year?
Ye s
N o
Fiscal Year Filer
Ye s
N o
IF YOU ARE SUBMITTING A PAYMENT WITH THIS A P P L I C ATION, COMPLETE THE “AMOUNT OF YOUR PAYMENT” BLOCK ABOVE. IF
YOU RECEIVED A PREPRINTED PA-V PAYMENT VOUCHER WITH YOUR TAX BOOKLET, SUBMIT THE VOUCHER ALONG WITH Y O U R
PAYMENT AND THIS A P P L I C AT I O N .
State in detail the reason the taxpayer needs an extension. (Use additional sheet if necessary):
S I G N ATURE A N D V E R I F I C AT I O N
If Prepared by Taxpayer. – Under penalties of perjury, I declare that to the best of my knowledge and belief, the statements made herein are true and correct.
If Prepared by Someone Other Than Taxpayer. – Under penalties of perjury, I declare that to the best of my knowledge and belief, the statements made
herein are true and correct, that I am authorized by the taxpayer to prepare this application, and that I am:
A member in good standing of the bar of the highest court of (specify jurisdiction)
A public accountant duly qualified to practice in (specify jurisdiction)
A person enrolled to practice before the Internal Revenue Service.
A duly authorized agent holding a power of attorney. (The power of attorney need not be submitted unless requested.)
A person standing in close personal or business relationship to the taxpayer who is unable to sign this application because of illness, absence,
or other good cause. My relationship to the taxpayer and the reason(s) why the taxpayer is unable to sign this application are:
Relationship:
Reason(s):
SIGNATUREOFPREPAREROTHERTHAN TAXPAYER
DATE
PAYMENT OF TA X R E Q U I R E D
An extension of time to file an income tax return does not extend the time for full payment of the tax, nor does it preclude the assessment of penal-
ty and interest for underpayment of tax due. You M U S T PAY I N F U L L on or before the original due date the amount reasonably estimated as your
Pennsylvania tax due.
Remittances should be made payable to the PA Dept. of Revenue and submitted with this application and your preprinted PA-V Payment Vo u c h e r
on or before the original due date of the tax return.
P L E A S E P R I N T O R T Y P E A L L I N F O R M ATION. In the event correspondence regarding this application is to be returned to the taxpayer
at an address other than shown above, or to an agent acting for the taxpayer, please complete the section below:
NAME:
TELEPHONE NUMBER:
(
)
ADDRESS:
CITY:
STATE:
ZIPCODE:
EC
0007010028
0007010028
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