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PA S CORPORATION/PARTNERSHIP INFORMATION RETURN

2011

PA-8453-P

(PA-20S/PA-65) - DIRECTORY OF CORPORATE PARTNERS

Form

(PA-65 CORP) TAX DECLARATION FOR A STATE E-FILE RETURN

Federal Employer Identification

For calendar year 2011 or tax year beginning

, 2011, ending

, 20___

Number (FEIN)

Name of Entity

Entity Address

City

State

ZIP Code

PA Account ID Number

PART I

RETURN INFORMATION (Whole dollars only)

1. Calculate Adjusted/Apportioned Net Business Income (Loss) (Form PA-20S/PA-65, Part II, Line 2d)

2. Calculate Adjusted/Apportioned Net Business Income (Loss) (Form PA-20S/PA-65, Part II, Line 2h)

3. Total Other PA PIT Income (Loss) (Form PA-20S/PA-65, Part III, Line 9)

4. Total PA Income Tax Withheld (Form PA-20S/PA-65, Part V, Line 14c)

5. Total Corporate Net Income Tax Withholding For All Nonfiling Corporate Partners For This Entity

(Form PA-65 Corp, Line 4).

PART II DECLARATION OF GENERAL PARTNER, LIMITED LIABILITY COMPANY MEMBER, S CORPORATION OFFICER,

AUTHORIZED PARTNER OR REPRESENTATIVE. (See instructions.) Keep a copy of the entity's return.

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 2011 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 international 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 2011 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

SIGN

HERE

Address

City

State

ZIP Code

PART III DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER (See instructions.)

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 seven years.

ERO’s Signature

Date

Check if also

Check if

ERO’s PTIN

ERO’S

paid preparer

self-employed

FEIN

USE