Primary Taxpayer’s Last Name
Secondary Taxpayer’s First Name, Initial
Part III
Declaration of Taxpayers
(Sign only after Part I is complete.)
10.
I
I am not receiving a refund or I do not want direct deposit of my refund.
Primary Taxpayer                        Date                 Secondary Taxpayer                               Date
Part 
IV
Declaration of Electronic Return Originator (ERO) and Paid Preparer 
(See instructions.)
➧
Sign
Here
ERO’s
Use
Only
ERO’s signature                         Date                                                 EIN/SSN or PTIN
Daytime Telephone Number (           )
Part II
Direct Deposit of Refund or Electronic Funds Withdrawal of Tax Due
(Optional – See instructions.)
6. Routing transit number (RTN) 
7. Depositor account number (DAN) 
8. Type of account:
Checking
Savings
9
.
Debit date
Declaration Control Number/Submission ID
Form 
PA-8453
2013
PENNSYLVANIA INDIVIDUAL INCOME TAX 
DECLARATION FOR ELECTRONIC FILING
Primary Taxpayer’s Social Security Number                               Secondary Taxpayer’s Social Security Number
Home Address (Number and Street including Rural Route or P.O. Box)
City, Town or Post Office
State                       ZIP Code
Part I
Tax Return Information 
(Enter whole dollars only.)
For the year Jan. 1 – Dec. 31, 2013
Check
Proper
S
Single
J
Married, Filing Jointly
D
Deceased           Daytime Telephone Number
Filing Status
M
Married, Filing Separately
F
Print
or
Type
KEEP THIS FORM AND THE REQUIRED ATTACHMENTS FOR THREE YEARS.                Please DO NOT mail this form.
➧
➧
The first two numbers of the RTN must
be 01 through 12 or 21 through 32.
➧
Check if also
paid preparer  
Check if 
self-employed  
Firm’s name (or yours,
if self-employed) and
address
➧
➧
➧
Paid
Preparer’s
Use Only
Check if
self-employed  
Firm’s name (or yours,
if self-employed) and
address
STAPLE COPY OF
STATE W-2(s), W-2G
and 1099(s) HERE
P
E
N
N
S
Y
L
V
A
N
I
A
PA DEPARTMENT OF REVENUE USE ONLY – DO NOT WRITE OR STAPLE IN THIS SPACE
The above information must match that on the electronic return exactly.
a.
b.
c.
Preparer’s signature                      Date                                                 EIN/SSN or PTIN
Daytime Telephone Number (           )
Check if also
paid preparer  
2. PA tax liability (Form PA-40, Line 12)  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.
3. Total PA tax withheld (Form PA-40, Line 13)  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.
4. Amount to be refunded (Form PA-40, Line 30) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.
5. Total payment (tax due) (Form PA-40, Line 28)  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.
 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.
1. Adjusted PA taxable income (Form PA-40, Line 11) 
PA Tax Return (PA-40). To the best of my knowledge, my return is true and complete. I consent my return and accompanying schedules and statements may be sent to the Internal 
I declare I have received the above-named taxpayer’s return and 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 2013). If I am the preparer, under penalty of perjury I declare 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 I am required to keep this form and supporting documents for three years.
Primary Taxpayer’s First Name, Initial 
Secondary Taxpayer’s Last Name (only if different)
Final Return
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 an agent to receive the refund.
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 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 ra-achrevok@state.pa.us 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 declare under penalties of perjury compared the information on my return with the information I provided to my electronic return originator and the amounts match those on my 
2013 RevenueService (IRS) by my electronic return originator, and subsequently by the IRS to the PA Department of Revenue. If I am filing from a home computer, I understand I 
am required to keep this form and supporting documents for three years.
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