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 2017
(EX) 05-17 DECLARATION FOR ELECTRONIC FILING
For the year Jan. 1 – Dec. 31, 2017
Primary Taxpayer’s Social Security Number Secondary Taxpayer’s Social Security Number
Print Last Name
413-77-0450
Primary Taxpayer’s Name, Initial; Secondary Taxpayer’s First Name, Initial; Secondary Taxpayer’s Last Name (only if different)
or WANG ALEX L
Type 124 HIGHPOINT AVENUE APT 1
Home Address (Number and Street including Rural Route or P.O. Box)
City, Town or Post Office State ZIP Code
WEEHAWKEN, NJ 07086
Check
The above information must match that on the electronic return exactly.
➧
Proper S £
X Single J £ Married, Filing Jointly D £ Deceased Daytime Telephone Number
P
Filing Status M £ Married, Filing Separately F £ Final Return (646) 716-2203
Tax Return Information (Enter whole dollars only.)
E
Part I
1. Adjusted PA taxable income (Form PA-40, Line 11) ...................................... 1. 1,122
2. PA tax liability (Form PA-40, Line 12) . . . . . . . . . ................................ 2.
N
34
3. Total PA tax withheld (Form PA-40, Line 13) . . . . ................................ 3. 17
4. Amount to be refunded (Form PA-40, Line 30) . . . ................................ 4.
N
5. Total payment (tax due) (Form PA-40, Line 28) . . ................................ 5. 17
Direct Deposit of Refund or Electronic Funds Withdrawal of Tax Due (Optional – See instructions.)
S
Part II
The first two numbers of the RTN must
6. Routing transit number (RTN) be 01 through 12 or 21 through 32.
STATE W-2(s), W-2G
and 1099(s) HERE
STAPLE COPY OF
031176110
Y
7. Depositor account number (DAN) 36036651400
8. Type of account: £
X Checking £ Savings
9 . Debit date
L
04/16/2018
V
Part III Declaration of Taxpayers (Sign only after Part I is complete.)
10. £ a. 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
A
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
an agent to receive the refund.
£ b. I am not receiving a refund or I do not want direct deposit of my refund.
N
X c.
£ I authorize the Pennsylvania Department of Revenue and its designated financial agents to initiate an electronic funds withdrawal 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
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
I
notifying the Pennsylvania Department of Revenue no later than two business days prior to the payment (settlement) date. I understand notification must
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
A
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 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 2017 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
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.
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 2017). 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.
Check if
ERO’s ERO’s signature Date Check if also
£ self-employed £
EIN/SSN or PTIN
Use ➧ SELF-PREPARED paid preparer
Only
➧
Firm’s name (or yours,
if self-employed) and
address Daytime Telephone Number ( )
Preparer’s signature Date Check if also Check if EIN/SSN or PTIN
➧ SELF-PREPARED paid preparer £ self-employed £
Paid
➧
Preparer’s Firm’s name (or yours,
if self-employed) and
Use Only address
Daytime Telephone Number ( )
KEEP THIS FORM AND THE REQUIRED ATTACHMENTS FOR THREE YEARS. Please DO NOT mail this form.
