Form Pa-8453 - Pennsylvania Individual Income Tax Declaration For Electronic Filing - 2004

Declaration Control Number (DCN)

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PA DEPARTMENT OF REVENUE USE ONLY – DO NOT WRITE OR STAPLE IN THIS SPACE

PA-8453

PENNSYLVANIA INDIVIDUAL INCOME TAX

2004

Form

DECLARATION FOR ELECTRONIC FILING

For the year January 1 – December 31, 2004

Your Social Security Number

Spouse’s Social Security Number

Last Name

First Name, Initial & Spouse’s First Name & Initial – Spouse’s last name (only if different)

Print

or

Home Address (Number and Street including Rural Route or P.O. Box)

Type

City, Town, or Post Office

State

Zip Code

The above information must be an exact duplicate of that on the electronic return.

➧

Check

Daytime Telephone Number

S

Single

J

Married, Filing Joint

D

Deceased

Proper

(

)

M

Married, Filing Separate

F

Final Return

Filing Status

P

Part I

Tax Return Information (Whole dollars only)

1. Adjusted PA Taxable Income (Form PA-40, line 11)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.

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2. PA Tax Liability (Form PA-40, line 12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. Total PA Tax Withheld (Form PA-40, line 13) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.

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4. Amount to be Refunded (Form PA-40, line 29) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.

5. Total Payment (Tax Due) (Form PA-40, line 27) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.

Part II

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Direct Deposit of Refund or Electronic Funds Withdrawal of Tax Due (Optional – See instructions.)

The first two numbers of the RTN must

6. Routing transit number (RTN)

be 01 through 12 or 21 through 32.

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7. Depositor account number (DAN)

8. Type of account:

Y

Checking

Savings

9. Debit Date ____________________________

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Part III

Declaration of Taxpayer (Sign only after Part I is Complete)

10.

a.

I consent that my refund be directly deposited as designated in Part II, and declare that the information shown on lines 6 through 8 is correct. If

I have filed a joint return, this is an irrevocable appointment of the other spouse as an agent to receive the refund.

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b.

I do not want direct deposit of my refund or am not receiving a refund.

I authorize (1) the Pennsylvania Department of Revenue and its designated Financial Agents to initiate an Electronic Funds withdrawal entry to

c.

A

my financial institution account designated in the electronic portion of my 2004 Pennsylvania Personal Income Tax Return for payment of my

Pennsylvania taxes owed, and (2) my financial institution to debit the entry to my account. I also authorize 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. Under the terms of this authorization, I can revoke this authorization by notifying the Pennsylvania Department of Revenue no later

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than two business days prior to the payment (settlement) date. I understand that notification must be made in writing by one of the following meth-

ods: E-mail Address: ra-achrevok@state.pa.us or Fax Telephone Number: (717) 772-4193 or (717) 787-2840.

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

I

liable for the tax liability 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 under-

stand my federal return will be rejected.

I declare that under penalties of perjury, I have compared the information on my return with the information I have provided to my electronic return originator and

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the amounts agree with the amounts on my 2004 PA Tax Return (Form PA-40). To the best of my knowledge, my return is true and complete. I consent that my

return and accompanying schedules and statements be sent to the Internal Revenue Service (IRS) by my electronic return originator, and subsequently by the IRS

to the PA Department of Revenue. If I am filing from a home PC, I understand I am required to keep this form and supporting documents for three (3) years

.

➧

➧

Sign

Here

Your signature

Date

Spouse’s signature. If a joint return, BOTH must sign.

Date

Part

IV

Declaration of Electronic Return Originator (ERO) and Paid Preparer (See Instructions.)

I declare that I have received the above taxpayer’s return and that the entries on this form are complete and correct to the best of my knowledge. I have obtained the

taxpayer’s signature on this form before submitting this return to the PA Department of Revenue. I have provided the taxpayer with a copy of all forms and information

to be filed with the IRS and the PA Department of Revenue, and have followed all other requirements described in the IRS Pub. 1345, Handbook for Electronic Filers

of Individual Tax Returns (Tax Year 2004) and requirements specified by the PA Department of Revenue. If I am the preparer, under penalty of perjury, I declare that I

have examined the above taxpayer’s return and accompanying schedules and statements, and to the best of my knowledge, they are true and complete. This decla-

ration is based on all information of which I have knowledge. I understand that I am required to keep this form and the supporting documents for (3) years.

ERO’s signature

Date

Check if also

Check if

EIN

➧

paid preparer

self-employed

ERO’s

➧

Firm’s name (or

Use Only

yours if self-employed)

and address

Daytime Telephone Number (

)

Preparer’s signature

Date

Check if also

Check if

EIN

➧

paid preparer

self-employed

Paid

Preparer’s

➧

Firm’s name (or yours

Use Only

if self-employed)

and address

Daytime Telephone Number (

)

ELECTRONIC RETURN ORIGINATORS (EROs)

TAXPAYERS FILING FROM HOME PCs

AND

KEEP THIS FORM (and the required attachments) FOR THREE YEARS.

Please DO NOT mail this form.