Form Pa-40esr - Declaration Of Estimated Tax

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TAX YEAR
M
M
D
D
Y
Y
Y
Y
DECLARATION OF ESTIMATED TAX
DATE
FILED:
PA-40ESR (I) (01-12)
FISCAL FILERS ONLY
YOUR SOCIAL SECURITY NUMBER
SPOUSE’S SOCIAL SECURITY NUMBER
READ INSTRUCTIONS BEFORE ENTERING
M
M
D
D
Y
Y
Y
Y
DOLLAR AMOUNTS.
BEGINNING
MAKE CHECKS PAYABLE TO
ADD DASHES
DAYTIME TELEPHONE NUMBER
PA DEPARTMENT OF REVENUE
M
M
D
D
Y
Y
Y
Y
MAIL THIS FORM WITH YOUR PAYMENT TO:
ENDING
PA DEPARTMENT OF REVENUE
PO BOX 280403
LAST NAME
HARRISBURG PA 17128-0403
AMOUNT OF PAYMENT
FIRST NAME
TYPE OF ACCOUNT:
$
I – INDIVIDUAL
P.O. BOX, APT. NO., SUITE, FLOOR, RR NO., ETC.
DECLARATION OF ESTIMATED TAX
STREET ADDRESS
CITY
STATE
ZIP CODE
DEPARTMENT USE ONLY
Reset Entire Form
PRINT FORM

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