Submission ID

Form

PA D EPARTM ENT OF REVENUE USE ONL Y- D O NOT WRITE OR STAPL E IN TH IS SPACE

PA-8453

PENNSYLVANIA INDIVIDUAL INCOME TAX

DECLARATION FOR ELECTRONIC FILING

2012

For the year Jan. 1 - Dec. 31, 2012

Spouse's Social Security Number

Your Social Security Number

227-11-0301
Print
or
Type

First Name, Initial; Spouse's First Name, Initial; Spouse's Last Name (only if different)

Last Name

CONNER ISAAC J
Home Address (Number and Street including Rural Route or P.O. Box)

1962 JOHNSTON STREET

State

City, Town or Post Office

WILLIAMSPORT
Check The above information must match that on the electronic return exactly.
Proper
S X Single
J
Married, Filing Jointly D
Filing Status
F
M
Married, Filing Separately
Tax Return Information (Enter whole dollars only.)
Part I
1.
2.
3.
4.
5.

Part II
S
T
A
P
L
E
C
O
P
Y

&
OW 1
F 2 0
9
S (s) 9
T
(s)
A W
2
H
T
E G E
R
E

Zip Code

PA
Deceased
Final Return

17701
Daytime Telephone Number

(717) 779-3457

Adjusted PA taxable income (Form PA-40, Line 11)

PA tax liability (Form PA-40, Line 12)
Total PA tax withheld (Form PA-40, Line 13)
Amount to be refunded (Form PA-40, Line 30)
Total payment (tax due) (Form PA-40, Line 28)

26,193
804 E
804

1.
2.
3.
4.
5.

12

Direct Deposit of Refund or Electronic Funds Withdrawal of Tax Due (Optional - See instructions.)
The first two numbers of the RTN must
be 01 through 12 or 21 through 32.

6. Routing transit number (RTN)

0 3 1 3 0 9 1 2 3

7. Depositor account number (DAN)

1 0 0 0 8 3 9 1 7 3 1

8. Type of account:

9. Debit Date

Part III
10.

L
Checking

Savings

02/13/13

8 is correct .
I cert if y t h e ult imat e d est inat ion of t h e f und s is w it h in t h e U.S. or one of it s t errit ories. If I h ave f iled a j oint ret urn, t h is is an irrevocab le
appoint ment of t h e ot h er spouse as an agent t o receive t h e ref und .

Part IV

Your signature

Date

Spouse's signature. If a joint return, BOTH must sign.

Date

Declaration of Electronic Return Originator (ERO) and Paid Preparer (See instructions.)

I d eclare I h ave received t h e ab ove- named t axpayer's ret urn and t h e ent ries on t h is f orm are complet e and correct t o t h e b est of my k now led ge. I ob t ained t h e t axpay er's
signat ure on t h is f orm b ef ore sub mit t ing t h is ret urn t o t h e PA D epart ment of Revenue. I provid ed t h e t axpay er w it h a copy of all f orms and inf ormat ion t o b e f iled w it h t h e IRS
and t h e PA D epart ment of Revenue and f ollow ed all ot h er req uirement s specif ied b y t h e PA D epart ment of Revenue and d escrib ed in t h e IRS Pub licat ion 1345, H and b ook f or
Elect ronic Filers of Ind ivid ual Tax Ret urns (Tax Year 2012). If I am t h e preparer, und er penalt y of perj ury I d eclare I examined t h e ab ove- named t axpay er's ret urn and accompany ing
sch ed ules and st at ement s, and t o t h e b est of my know led ge, t h ey are t rue and complet e. I und erst and t h at I am req uired t o k eep t h is f orm and support ing d ocument s f or
t h ree y ears.

ERO'S
Use
Only

I am not receiving a ref und or I d o not w ant d irect d eposit of my ref und .

I aut h orize t h e Pennsylvania D epart ment of Revenue and it s d esignat ed f inancial agent s t o init iat e an elect ronic f und s w it h d raw al ent ry t o
my d esignat ed account f or Pennsylvania t axes ow ed . I also aut h orize my f inancial inst it ut ion t o d eb it t h e ent ry t o my account and t h e f inancial
inst it ut ions involved in t h e processing of my elect ronic pay ment of t axes t o receive conf id ent ial inf ormat ion necessary t o answ er inq uiries and
resolve issues relat ed t o my payment . I cert if y t h e f und s f or t h is w it h d raw are originat ing f rom an account w it h in t h e U.S. or one of it s t errit ories.
I may revoke t h is aut h orizat ion b y not if ying t h e Pennsy lvania D epart ment of Revenue no lat er t h an t w o b usiness d ay s prior t o t h e pay ment
(set t lement ) d at e. I und erst and not if icat ion must b e mad e in w rit ing b y email t o ra- ach revok @st at e.pa.us or f ax t o 717- 772- 9310.
If I h ave f iled a b alance- d ue ret urn, I und erst and t h at if t h e PA D epart ment of Revenue d oes not receive f ull and t imely pay ment of my t ax liab ilit y , I w ill remain liab le f or t h e t ax
and all applicab le int erest and penalt ies. If I h ave f iled a j oint f ed eral and st at e t ax ret urn and t h ere is an error on my st at e ret urn, I und erst and my f ed eral ret urn w ill b e rej ect ed .
I d eclare und er penalt ies of perj ury compared t h e inf ormat ion on my ret urn w it h t h e inf ormat ion I provid ed t o my elect ronic ret urn originat or and t h e amount s mat ch t h ose on
my 2012 PA Tax Ret urn (PA- 40). To t h e b est of my know led ge, my ret urn is t rue and complet e. I consent my ret urn and accompany ing sch ed ules and st at ement s may b e
sent t o t h e Int ernal Revenue Service (IRS) b y my elect ronic ret urn originat or, and sub seq uent ly b y t h e IRS t o t h e PA D epart ment of Revenue. If I am f iling f rom a h ome
comput er, I und erst and I am req uired t o keep t h is f orm and support ing d ocument s f or t h ree y ears.

Sign
Here

S
Y

Declaration of Taxpayer (Sign only after Part I is complete.)

a. I consent f or my ref und t o b e d irect ly d eposit ed as d esignat ed in Part II and d eclare all inf ormat ion sh ow n on L ines 6 t h rough
b.
c.

ERO's signature
Firm's name (or yours,
if self-employed) and
address
Preparer's signature

Paid
Preparer's
Firm's name (or yours,
Use Only if self-employed) and
address

Date

Check if also
paid preparer

Check if
self-employed

EIN/SSN or PTIN

Daytime Telephone Number

Date

Check if also
paid preparer

Check if
self-employed

EIN/SSN or PTIN

Daytime Telephone Number

KEEP THIS FORM AND THE REQUIRED ATTACHMENTS FOR THREE YEARS.

Please DO NOT mail this form.

I
A