START Declaration Control Number/Submission ID

➜ PA DEPARTMENT OF REVENUE USE ONLY – DO NOT WRITE OR STAPLE IN THIS SPACE

Form PA-8453 PENNSYLVANIA INDIVIDUAL INCOME TAX

DECLARATION FOR ELECTRONIC FILING
2018
(EX) 04-18
For the year Jan. 1 – Dec. 31, 2018
Primary Taxpayer’s Social Security Number Secondary Taxpayer’s Social Security Number

Last Name Primary Taxpayer’s Name, Initial; Secondary Taxpayer’s First Name, Initial; Secondary Taxpayer’s Last Name (only if different)
Print
or Home Address (Number and Street including Rural Route or P.O. Box)
Type
City, Town or Post Office State ZIP Code

The above information must match that on the electronic return exactly.
S £ Single J £ Married, Filing Jointly D £ Deceased
Check

➧ M £ Married, Filing Separately F £ Final Return

Proper Daytime Telephone Number
Filing Status ( ) NO DASHES

Part I Tax Return Information (Enter whole dollars only.) P

1. Adjusted PA taxable income (Form PA-40, Line 11) ...................................... 1.
2.
3.
PA tax liability (Form PA-40, Line 12) . . . . . . . . .
Total PA tax withheld (Form PA-40, Line 13) . . . .
................................
................................
2.
3.
E
4.
5.
Amount to be refunded (Form PA-40, Line 30) . . .
Total payment (tax due) (Form PA-40, Line 28) . .
................................
................................
4.
5.
N
Part II Direct Deposit of Refund or Electronic Funds Withdrawal of Tax Due (Optional – See instructions.) N
The first two numbers of the RTN must
STATE W-2(s), W-2G
and 1099(s) HERE
STAPLE COPY OF

6. Routing transit number (RTN)

7. Depositor account number (DAN)

be 01 through 12 or 21 through 32.
S
8. Type of account: £ Checking £ Savings Y
9 . Debit date MMDDYYYY
Part III Declaration of Taxpayers (Sign only after Part I is complete.)
L
£ a.
10. I consent for my refund to be directly deposited as designated in Part II and declare all information shown on Lines 6 through 8 is correct. I certify the ultimate
destination of the funds is within the U.S. or one of its territories. If I have filed a joint return, this is an irrevocable appointment of the other Taxpayer as V
£ b.
an agent to receive the refund.

£ c.
I am not receiving a refund or I do not want direct deposit of my refund.
I authorize the Pennsylvania Department of Revenue and its designated financial agents to initiate an electronic funds withdrawal entry to my designated
A
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
my payment. I certify the funds for this withdraw are originating from an account within the U.S. or one of its territories. I may revoke this authorization by
notifying the Pennsylvania Department of Revenue no later than two business days prior to the payment (settlement) date. I understand notification must
N
be made in writing by email to [email protected] or fax to 717-772-9310.
If I have filed a balance-due return, I understand that if the PA Department of Revenue does not receive full and timely payment of my tax liability, I will remain liable for the tax and all
applicable interest and penalties. If I have filed a joint federal and state tax return and there is an error on my state return, I understand my federal return will be rejected.
I
I declare under penalties of perjury that I have compared the information on my return with the information I provided to my electronic return originator and the amounts match those
on my 2018 PA Tax Return (PA-40). To the best of my knowledge, my return is true and complete. I authorize my electronic return originator to send my return and accompanying schedules
and statements to the Internal Revenue Service (IRS) and the IRS to subsequently send them to the PA Department of Revenue. In addition, by using a computer system and software to
A
prepare and transmit my return electronically, I consent to the disclosure of all information pertaining to my use of the system and software and to the transmission of my tax return
electronically to the PA Department of Revenue. If I am filing from a home computer, I understand that I am required to keep this form and supporting documents for three years.
MMDDYYYY MMDDYYYY

➧ ➧
Signature of Primary Taxpayer – Please sign after printing Signature of Secondary Taxpayer – Please sign after printing
Sign
Here Primary Taxpayer Date Secondary Taxpayer Date

Part IV Declaration of Electronic Return Originator (ERO) and Paid Preparer (See instructions.)
I declare that I have received the above-named taxpayer’s return and that the entries on this form are complete and correct to the best of my knowledge. I obtained the taxpayer’s
signature on this form before submitting this return to the PA Department of Revenue. I provided the taxpayer with a copy of all forms and information to be filed with the IRS and the
PA Department of Revenue and followed all other requirements specified by the PA Department of Revenue and described in the IRS Publication 1345, Handbook for Electronic Filers
of Individual Tax Returns (Tax Year 2018). If I am the preparer, under penalty of perjury, I declare that I examined the above-named taxpayer’s return and accompanying schedules and
statements, and to the best of my knowledge, they are true and complete. I understand that I am required to keep this form and supporting documents for three years.

£ £
ERO’s signature Date MMDDYYYY Check if also Check if EIN/SSN or PTIN
ERO’s
Use ➧ Signature of ERO – Sign after printing paid preparer self-employed

Only Firm’s name (or yours, FIRM NAME AND ADDRESS

if self-employed) and
address ➧ CITY STATE ZIP CODE Daytime Telephone Number ( ) NO DASHES

paid preparer £ self-employed £

Preparer’s signature Date MMDDYYYY Check if also Check if EIN/SSN or PTIN
Paid ➧ Signature of Preparer – Please sign after printing

Preparer’s Firm’s name (or yours, FIRM NAME AND ADDRESS

Use Only if self-employed) and
address ➧ CITY STATE ZIP CODE Daytime Telephone Number ( ) NO DASHES

KEEP THIS FORM AND THE REQUIRED ATTACHMENTS FOR THREE YEARS. Please DO NOT mail this form.
Reset Entire Form TOP OF PAGE NEXT PAGE PRINT
THIS PAGE DOES NOT PRINT
 Pennsylvania Department of Revenue 2018
Instructions for PA-8453
PA-8453 IN (EX) 04-18
Individual Income Tax Declaration for Electronic Filing

and wife use different last names, by electronic funds withdrawal by

FILING OF FORM PA-8453 please separate the names. For completing Part II.
If a taxpayer elects not to use the example, Paul A. Smith and Joan A.
Weston would be Smith, Paul A. and Line 6 - The routing transit number
federal self-select PIN or a return is (RTN) must contain nine digits. If the
filed without a federal return, electronic Joan A. Weston.
RTN does not begin with 01 through
return originators (EROs) and trans- The address on this form must match 12, or 21 through 32, the direct
mitters must retain completed Forms the address on the electronically filed deposit or electronic funds withdrawal
PA-8453 and supporting documents PA-40. request will be rejected.
for three years after the due date of
the return or the date the return was Line 7 - The depositor account
filed electronically, whichever is later. PART I – TAX RETURN number (DAN) may contain up to 17
EROs and transmitters must make the INFORMATION alphanumeric characters. Include
documents available to the PA hyphens but omit spaces and special
Department of Revenue upon request. Line 1 - Enter adjusted PA taxable symbols. If fewer than 17 characters,
Do not mail Form PA-8453 and income from Line 11, Form PA-40. enter the number from left to right and
attachments to the PA Department of Line 2 - Enter PA tax liability from leave the unused boxes blank.
Revenue unless requested. Line 12, Form PA-40. Line 8 - Check the appropriate box.
NOTE: If an ERO or transmitter Line 3 - Enter total PA tax withheld
closes its business, it must mail Line 9 - Debit Date - Enter the date
from Line 13, Form PA-40. the taxpayer wants the payment
all forms to the following address with
a letter of explanation. Line 4 - Enter the amount to be electronically withdrawn, on or before
refunded from Line 30, Form PA-40. April 15, 2019.
PA DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES Line 5 - Enter total payment (tax due), NOTE: The account cannot
ELECTRONIC FILING SECTION from Line 28, Form PA-40. include the name of any other
PO BOX 280507 person unless the taxpayer’s filing
Taxpayers are responsible for status on the return is “married filing
HARRISBURG PA 17128-0507 submitting payment due to the PA jointly” or “married filing separately,”
Any taxpayer filing electronically from Department of Revenue by April 15, and the taxpayer’s spouse is the other
a home computer must keep the 2019. name listed on the account.
signed Form PA-8453 and supporting Payment may be sent along with
documents for three years after the Some financial institutions do not
Form PA-40 V. If Form PA-40 V was permit the deposit of a joint refund
due date of the return or the date the not received, it may be completed
return was filed electronically, which- in an individual account. The PA
online, printed and mailed to the Department of Revenue is not
ever is later. Taxpayers must make the department with payment. Check or
documents available to the PA responsible when a financial
money order should be made payable institution refuses a direct deposit.
Department of Revenue upon request. to the PA Dept. of Revenue. The last
Do not mail Form PA-8453 and four digits of the taxpayer’s Social To be eligible for direct deposit or
attachments to the PA Department of Security number, “2018 PA-V” and electronic funds withdrawal, taxpayers
Revenue unless requested. daytime telephone number should be must provide proof of account owner-
written on the payment. ship to the ERO. An acceptable proof
LINE INSTRUCTIONS of account ownership is a check, form,
PA DEPT. OF REVENUE report or other statement generated
FORM 8453 PAYMENT ENCLOSED by the financial institution that has the
Submission ID - The Submission ID 1 REVENUE PLACE taxpayer’s name, RTN and DAN
is a 20-digit number assigned by the HARRISBURG PA 17129-0001 preprinted on it.
ERO to a taxpayer’s return.
For accounts payable through a
Name, Address and Social Security
PART II – DIRECT DEPOSIT financial institution other than the one
Number Print or type the taxpayer’s OF REFUND OR at which the account is located, the
name (last name first) and complete ELECTRONIC FUNDS taxpayer must provide a document,
address including ZIP code. In the WITHDRAWAL such as an account statement or
spaces provided, enter the taxpayer’s identification card, showing the RTN
Social Security number and that of the Taxpayers may elect to have refunds of the bank or institution where the
spouse, if applicable. If a husband directly deposited or payments made account is located. A deposit slip

www.revenue.pa.gov PA-8453 1
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should not be used to verify RTN or the debit date. Written requests to the ERO must have the taxpayer
DAN because it can contain internal revoke the electronic funds withdrawal complete and sign a corrected Form
routing numbers that are not part of must include the taxpayer’s name, PA-8453.
the RTN. address, Social Security number,
RTN, DAN and payment amount. PART IV – DECLARATION
If there is any doubt about the correct Written requests can be faxed to
RTN, the taxpayer should contact the 717-772-9310 or emailed to OF ELECTRONIC RETURN
financial institution for assistance. [email protected]. ORIGINATOR (ERO)
NOTE: Some financial institutions After a return has been prepared and AND PREPARER
may not accept direct deposits before the return is transmitted, the
into accounts payable through The ERO must sign this form and
taxpayer (or both taxpayers, if filing keep it with the required attachments
another bank or financial institution, jointly) must verify the information on
including credit unions. for three years.
the return and sign and date the
completed Form PA-8453. If you are A preparer must sign the Form PA-8453
PART III – DECLARATION responsible for the affairs of a minor, in the space for Preparer. If the
OF TAXPAYER disabled person, or a decedent who preparer is also the ERO, do not
could not prepare his or her own PA complete the Preparer Section;
Line 10 - All filers must check one of tax return, you must sign to file a valid instead, check the box labeled “Check
the boxes. tax return. The ERO must provide the if also paid preparer.”
taxpayer with a copy of this form.
NOTE: Taxpayers may revoke
the electronic funds withdrawal If the ERO makes changes to the
authorization by notifying the PA electronic return after the Form
Department of Revenue in writing no PA-8453 has been signed by the
later than two business days prior to taxpayer, but before it is transmitted,

2 PA-8453 www.revenue.pa.gov
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