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PENNSYLVANIA CORPORATION TAX

2014

DECLARATION FOR A STATE e-file REPORT

Form PA-8453-C

Employer Identification

Number

For calendar year 2014 or tax year beginning

, 2014, ending

, 20___

Name of Corporation

Address

City

State

ZIP

Revenue ID Number

PART I TAX REPORT INFORMATION (Whole dollars only.)

1. Total Book Income (Form RCT-101, Section A, Line 2)

2. Capital Stock/Foreign Franchise Tax (Form RCT-101, Section A, Line 18)

3. Income or Loss from Federal Return on a Separate Company Basis (Form RCT-101, Section C, Line 1)

4. PA Taxable Income or Loss (Form RCT-101, Section C, Line 12)

5. Corporate Net Income Tax (Form RCT-101, Section C, Line 13)

PART II DECLARATION OF OFFICER (See instructions.) Keep a copy of the corporation's tax report (RCT-101).

6a.

I consent that the corporation's refund check can be mailed directly to the address provided on the RCT-101.

6b.

I do not want a refund mailed to the corporation, or the corporation is not receiving a refund.

6c.

I authorize (1) the PA Department of Revenue and its designated financial institution to initiate an electronic funds withdrawal entry to my

financial institution account designated in the electronic portion of my 2014 Pennsylvania Corporate Tax Report for payment of my state

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. I can revoke this authorization by notifying the PA Department of Revenue no later than two business days prior to the

payment date. I understand notification must be made by calling 717-783-6277.

If I filed a balance-due report, I understand if the PA Department of Revenue does not receive full and timely payment of my tax liability, I remain

liable for the tax due and all applicable interest and penalties. If I filed a joint federal and state tax return/report and there is an error on my federal

return, I understand my state report will be rejected.

Under penalties of perjury, I declare I am an officer of the above-named corporation and the information I provided to my electronic return originator

(ERO) and/or transmitter and the amounts in Part I above agree with the amounts on the corresponding lines of the corporation's 2014 Pennsylvania

Corporate Tax Report. To the best of my knowledge and belief, the corporation's report is true, correct and complete. I consent to my ERO and/or

transmitter sending the corporation's report and accompanying schedules and statements to the Internal Revenue Service (IRS) and subsequently by

the IRS to the PA Department of Revenue. I also consent to the PA Department of Revenue sending my ERO and/or transmitter, through the IRS, an

acknowledgment of receipt of transmission, an indication of whether or not the corporation's report is accepted and, if rejected, the reason(s) for

rejection.

Signature of Officer

Date

Title

Social Security number

SIGN

HERE

Address

City

State

ZIP

PART III DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER (See instructions.)

I declare I have reviewed the above-named corporation's report, and the entries on Form PA 8453-C are complete and correct to the best of my

knowledge. I obtained the corporate officer's signature on this form before submitting the report to the PA Department of Revenue, provided the

corporate officer a copy of all forms and information to be filed with the PA Department of Revenue and followed all other requirements specified by

the PA Department of Revenue and in IRS Pub. 3112, IRS e-file Application and Participation, and Pub. 4163, Modernized e-File (MeF) Information

for Authorized IRS e-file Providers of Forms 1120/1120S. If I am also the preparer, under penalties of perjury, I declare I examined the above-named

corporation's report, accompanying schedules and statements, and to the best of my knowledge they are true, correct and complete. I understand I

am required to keep this form and the supporting documents for three years.

ERO’s Signature

Date

Check if also

Check if

ERO’s SSN or PTIN

paid preparer

self-employed

ERO’S

EIN

USE

Firm’s name (or yours

ONLY

if self-employed),

address and ZIP code

Telephone Number

Under penalties of perjury, I declare I examined the above-named corporation's report, accompanying schedules and statements, and to the best of

my knowledge and belief they are true, correct and complete.

Preparer’s Signature

Date

Check if

Preparer’s SSN or PTIN

self-employed

PAID

PREPARER’S

Firm’s name (or yours

USE

if self-employed),

ONLY

address and ZIP code

Telephone Number

ELECTRONIC RETURN ORIGINATORS (EROs) AND PAID PREPARERS ARE REQUIRED TO KEEP THIS FORM AND REQUIRED ATTACHMENTS FOR

THREE YEARS.

Form Pa-8453-C - Pennsylvania Corporation Tax Declaration For A State E-File Report - 2014

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