Form Pa-8453-P - Pa S Corporation/partnership Information Return (Pa-20s/pa-65) - Directory Of Corporate Partners (Pa-65 Corp) Tax Declaration For A State E-File Return - 2012

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PA-8453-P (11-12)
PA S Corporation/Partnership Information Return
(PA-20S/PA-65) - Directory of Corporate Partners
2012
PA-8453-P
Form
(PA-65 CORP) Tax Declaration for a State E-File Return
Federal Employer Identification
For calendar year 2012 or tax year beginning
, 2012, ending
, 20___
Number (FEIN)
Name of Entity
Entity Address
City
State
ZIP Code
Revenue ID
Part I
Return Information. Enter whole dollars only.
1. Calculate Adjusted/Apportioned Net Business Income (Loss) (PA-20S/PA-65, Part II, Line 2d)
1.
2. Calculate Adjusted/Apportioned Net Business Income (Loss) (PA-20S/PA-65, Part II, Line 2h)
2.
3. Total Other PA PIT Income (Loss) (PA-20S/PA-65, Part III, Line 9)
3.
4. Total PA Income Tax Withheld (PA-20S/PA-65, Part V, Line 14c)
4.
5. Total Corporate Net Income Tax Withholding For All Nonfiling Corporate Partners For This Entity
(PA-65 Corp, Line 4).
5.
Part II
Declaration of General Partner, Limited Liability Company Member, S Corporation Officer, Authorized Partner or
Representative. Keep a copy of the entity's return.
®
6.
I authorize the PA Department of Revenue and its designated financial institution to initiate an electronic funds withdrawal from the account
designated in the electronic portion of my 2012 PA S Corporation/Partnership Information Return (PA-20S/PA-65) or the Directory of Corporate Partners
(PA-65 Corp) for payment of the state withholding liability owed on this return. 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 to receive confidential information necessary to answer inquiries and
resolve issues related to my payment. I understand that the federal Office of Foreign Assets Control has imposed additional reporting requirements on all
electronic banking transactions that directly involve a financial institution outside of the territorial jurisdiction of the U.S. These transactions are called inter-
national ACH transactions (IAT). I understand that presently the PA Department of Revenue does not support IAT ACH debit transactions. I certify that the
transactions do not directly involve a financial institution outside of the territorial jurisdiction of the U.S. at any point in the process. Under the terms of
this authorization, I understand that I can revoke initiation of electronic funds withdrawal by notifying the PA Department of Revenue no later than two
business days prior to the debit date. I understand that notification must be made by email to ra-achrevok@pa.gov or fax at 717-772-9310.
If I file a balance-due return, I understand that if the PA Department of Revenue does not receive full and timely payment of my withholding liability, I will
remain liable for the withholding liability and all applicable interest and penalties. If I have filed a joint federal and state tax return and there is an error
on my federal return, I understand my state return will be rejected. If any return is rejected or if any other delay in filing occurs, I understand that I will
remain liable for all applicable penalties and interest.
Under penalties of perjury, I declare I am a general partner, limited liability company member, S corporation officer, authorized partner or representative
of the above entity and the information I have given my electronic return originator (ERO) and/or transmitter and the amounts in Part I above agree with
the amounts on the corresponding lines of the entity's 2012 PA S Corporation/Partnership Information Return (PA-20S/PA-65) or the Directory of Corporate
Partners (PA-65 Corp). To the best of my knowledge and belief, the entity’s return is true, correct and complete. I consent to my ERO and/or transmitter
sending the entity’s return and accompanying schedules and statements to the Internal Revenue Service (IRS) and subsequently by the IRS to the
PA Department of Revenue. I also consent to the PA Department of Revenue sending my ERO and/or transmitter through the IRS an acknowledgment of
receipt of transmission and an indication of whether or not the entity’s return is accepted and, if rejected, the reason(s) for the rejection.
Authorized Signature
Date
Title
Social Security Number
Á
SIGN
HERE
Address
City
State
ZIP Code
Part III Declaration of Electronic Return Originator (ERO) and Paid Preparer
I declare I have reviewed the above-named entity’s return and the entries on Form PA-8453-P are complete and correct to the best of my knowledge. I
have obtained the signature of a general partner, limited liability company member, S corporation officer, authorized partner or representative on this form
before submitting the return to the PA Department of Revenue, and I have provided the general partner, limited liability company member, S corporation
officer, authorized partner or representative a copy of all forms and information to be filed with the PA Department of Revenue. I have also followed all
other requirements in IRS Pub. 3112, IRS e-file Application and Participation, and Pub. 4163, Modernized e-File (MeF) Information for Authorized IRS
e-file Providers of Forms 1065/1120S and requirements specified by the PA Department of Revenue. If I am also the preparer, under penalties of perjury
I declare I have examined the above-named entity’s return and accompanying schedules and statements, and to the best of my knowledge they are true,
correct and complete. I understand I am required to keep this form and the supporting documents for three years.
ERO’s Signature
Date
Check if also
Check if
ERO’s PTIN
4
®
®
ERO’S
paid preparer
self-employed
FEIN
USE
4
Firm’s name (or yours
if self-employed),
ONLY
address and ZIP code
Phone Number (
)
Under penalties of perjury, I declare that I have examined the above entity’s return and accompanying schedules and statements, and to the best of
my knowledge and belief they are true, correct and complete.
4
Preparer’s Signature
Date
Check if
Preparer’s PTIN
PAID
®
self-employed
PREPARER’S
4
Firm’s name (or yours
USE
if self-employed),
address and ZIP code
ONLY
Phone Number (
)
The ERO and paid preparer must retain this form and supporting documents for three years.
DO NOT SUBMIT THIS FORM TO THE PA DEPARTMENT OF REVENUE UNLESS REQUESTED.

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