Form Pa-8453 - Pennsylvania Individual Income Tax Declaration For Electronic Filing - 2015

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Declaration Control Number/Submission ID

START

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

Form

PA-8453

PENNSYLVANIA INDIVIDUAL INCOME TAX

2015

DECLARATION FOR ELECTRONIC FILING

For the year Jan. 1 – Dec. 31, 2015

Primary Taxpayer’s Social Security Number

Secondary Taxpayer’s Social Security Number

Last Name

Primary Taxpayer’s Name, Initial; Secondary Taxpayer’s First Name, Initial; Secondary Taxpayer’s Last Name (only if different)

Type

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

City, Town or Post Office

State

ZIP Code

The above information must match that on the electronic return exactly.

Check

➧

Single

Married, Filing Jointly

Deceased

Daytime Telephone Number

Proper

Married, Filing Separately

Final Return

(

)

Filing Status

NO DASHES

Tax Return Information (Enter whole dollars only.)

Part I

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. Amount to be refunded (Form PA-40, Line 30) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.

5. Total payment (tax due) (Form PA-40, Line 28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.

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

Part II

The first two numbers of the RTN must

6. Routing transit number (RTN)

be 01 through 12 or 21 through 32.

7. Depositor account number (DAN)

8. Type of account:

Checking

Savings

Debit date

MMDDYYYY

Declaration of Taxpayers (Sign only after Part I is complete.)

Part III

10.

consent for my refund to be directly deposited as designated in Part II and declare all information shown on Lines 6 through 8 is correct. I certify the ultimate

destination of the funds is within the U.S. or one of its territories. If I have filed a joint return, this is an irrevocable appointment of the other Taxpayer as

an agent to receive the refund.

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

I authorize the Pennsylvania Department of Revenue and its designated financial agents to initiate an electronic funds withdrawal 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

my payment. I certify the funds for this withdraw are originating from an account within the U.S. or one of its territories. I may revoke this authorization by

notifying the Pennsylvania Department of Revenue no later than two business days prior to the payment (settlement) date. I understand notification must

be made in writing by email to ra-achrevok@pa.gov or fax to 717-772-9310.

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 liable for the tax 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 understand my federal return will be rejected.

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

on my 2015 PA Tax Return (PA-40). To the best of my knowledge, my return is true and complete. I authorize my electronic return originator to send my return and accompanying schedules

and statements to the Internal Revenue Service (IRS) and the IRS to subsequently send them to the PA Department of Revenue. 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. If I am filing from a home computer, I understand that I am required to keep this form and supporting documents for three years.

➧

MMDDYYYY

Sign

Here

Signature of Primary Taxpayer – Please sign after printing

Signature of Secondary Taxpayer – Please sign after printing

Primary Taxpayer

Date

Secondary Taxpayer

Date

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

Part

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

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

PA Department of Revenue and followed all other requirements specified by the PA Department of Revenue and described in the IRS Publication 1345, Handbook for Electronic Filers

of Individual Tax Returns (Tax Year 2015). If I am the preparer, under penalty of perjury, I declare that I examined the above-named taxpayer’s return and accompanying schedules and

statements, and to the best of my knowledge, they are true and complete. I understand that I am required to keep this form and supporting documents for three years.

ERO’s

Check if

ERO’s signature

Date

Check if also

EIN/SSN or PTIN

self-employed

Use

➧

MMDDYYYY

paid preparer

Only