Form Pa-V - Pa Payment Voucher - 2012

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BUREAU OF INDIVIDUAL TAXES
PO BOX 280600
HARRISBURG, PA 17128-0600
PA-40 Payment Voucher (PA-V)
Use the 2012 form PA-V with your payment if you owe tax with your 2012 PA-40, Individual Income Tax Return. Do not use this
voucher for any other purpose. Follow the instructions below.
Social Security Number (SSN)
● SSN - enter your nine-digit SSN with the hyphens.
● SSN - enter your spouse’s nine-digit SSN with the hyphens.
Check Digit
Print the first two letters of the last name of the taxpayer.
Name of Taxpayer and Spouse
● Lines 1 through 4 - print the last name, first name and middle initial of the taxpayer and spouse.
Address
● Lines 5 and 6 – Print the taxpayer’s complete street address. If the address has an apartment, suite or RR number, enter
after the street address.
● Line 7 – Print the name of the city. For foreign addresses, the bottom line of the address should show only the country name,
written in full (no abbreviations) and in capital letters.
● Line 8 – Print the two-digit state abbreviation.
● Line 9 – Print the five-digit ZIP Code.
Taxpayer’s Phone Number
Print the taxpayer’s 10-digit phone number with area code including hyphens.
Payment
Carefully enter the amount of your payment.
Make the check or money order payable to the PA DEPT. OF REVENUE. Please write on your check or money order:
● The last four digits of the primary taxpayer’s SSN;
● "2012 PA-40"; and
● Daytime telephone number of the taxpayer(s).
The department will need the last four digits of your SSN if your check becomes separated from your PA-V. The department will
need the last four digits of your SSN to accurately apply your payment.
t
t
DETACH HERE
2012 PA-V
PA PAYMENT VOUCHER
START
1200910055
PAYMENT AMOUNT
$
Make check or money order
DEPARTMENT USE ONLY
payable to the Pennsylvania
Department of Revenue
PRINT FORM
Reset Entire Form

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