Form Pa-8879 - Pennsylvania E-File Signature Authorization

Pennsylvania e-file Signature Authorization

2013

PA-8879

Form

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, 2013 (Whole dollars only)

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

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

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

4. Refund (Form PA-40, Line 30) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Total Payment (Tax Due) (Form PA-40, Line 28) . . . . . . . . . . . . . . . . . . . . . . . .

PART II Declaration and Signature Authorization of Taxpayer

Under penalties of perjury, I declare I have examined a copy of my electronic individual income tax return and accompanying schedules and

statements of my 2013 PA Tax Return (Form PA-40), and to the best of my knowledge and belief, it is true, correct and complete. 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 2013 electronically filed income tax return.

I will enter my PIN as my signature on my tax year 2013 electronically filed income tax return.

Signature

Date

Secondary Taxpayer’s PIN: (check one box only)

I authorize

to enter my PIN

as my signature on my

tax year 2013 electronically filed income tax return.

I will enter my PIN as my signature on my tax year 2013 electronically filed income tax return.

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 2013 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.

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.

Form Pa-8879 - Pennsylvania E-File Signature Authorization - 2013

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