Pennsylvania e-file Signature authorization
2015
Pa-8879
Form
START
Declaration Control Number/Submission ID
Primary Taxpayer’s Name
Social Security Number
Secondary Taxpayer’s Name
Social Security Number
PaRt i tax Return information – tax year Ending Dec. 31, 2015 (Whole dollars only)
1. Adjusted PA Taxable Income (Form PA-40, Line 11) . . . . . . . . . . . . . . . . . . . . .
1.
2. PA Tax Liability (Form PA-40, Line 12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.
3. Total PA Tax Withheld (Form PA-40, Line 13) . . . . . . . . . . . . . . . . . . . . . . . . . .
3.
4. Refund (Form PA-40, Line 30) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.
5. Total Payment (Tax Due) (Form PA-40, Line 28) . . . . . . . . . . . . . . . . . . . . . . . .
5.
PaRt ii Declaration and Signature authorization of taxpayer
Under penalties of perjury, I declare that I have examined a copy of my electronic individual income tax return and accompanying schedules
and statements of my 2015 PA Tax Return (Form PA-40), and to the best of my knowledge and belief, it is true, correct and complete. In
addition, by using a computer system and software to prepare and transmit my return electronically, I consent to the disclosure of all
information pertaining to my use of the system and software and to the transmission of my tax return electronically to the PA Department of
Revenue. I further declare that the amounts in Part I above are the amounts shown on the copy of my electronic income tax return. If
applicable, I authorize the PA Department of Revenue and its designated financial agents to initiate an electronic funds withdrawal (direct debit)
entry to my designated account for Pennsylvania taxes owed. I also authorize my financial institution to debit the entry to my account and 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 payment. I certify the funds for this withdraw are originating from an account within the United States
or one of its territories. I have selected a personal identification number as my signature for my electronic income tax return and, if applicable,
my electronic funds withdrawal consent.
Primary taxpayer’s Personal identification Number (PiN): (check one box only)
I authorize
to enter my PIN
as my signature on my
tax year 2015 electronically filed income tax return.
I will enter my PIN as my signature on my tax year 2015 electronically filed income tax return.
MMDDYYYY
Signature of Primary Taxpayer – Please sign after printing
Signature
Date
Secondary taxpayer’s PiN: (check one box only)
I authorize
to enter my PIN
as my signature on my
tax year 2015 electronically filed income tax return.
I will enter my PIN as my signature on my tax year 2015 electronically filed income tax return.
MMDDYYYY
Signature of Secondary Taxpayer – Please sign after printing
Signature
Date
Practitioner PiN Program Participants Only – Continue below
PaRt iii Certification and authentication
/
ERO’s EFIN/PIN. Enter your six-digit EFIN followed by your five-digit self-selected PIN
As a participant in the Practitioner PIN Program, I certify the above numeric entry is my PIN, which is my signature on
the tax year 2015 electronically filed income tax return for the taxpayer(s) indicated above. I confirm I am participating
in the Practitioner PIN Program in accordance with the requirements established for this program.
MMDDYYYY
Signature of ERO – Sign after printing
ERO’s signature
Date
ERO must retain this form and the supporting documents for three years.
DO NOt Submit thiS FORm tO thE PENNSylvaNia DEPaRtmENt OF REvENuE.
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