For use with your 2013 Annual Pennsylvania Tax Return
Your Social Security No.                                            Spouse's Social Security No.
P.O. Box, Apt, Suite, Floor, Rural Route No., etc
Payment Amount
$
Make check or money order
payable to the Pennsylvania
Department of Revenue
Last Name
Your First Name
Your Middle Initial
Spouse's Last Name
Spouse's First Name
Middle Initial
City
State
ZIP Code
Telephone
Form
Pennsylvania
PA-V
Payment Voucher
2013
----------------Page (0) Break----------------