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., etcPayment Amount

$

Make check or money order

payable to the Pennsylvania

Department of Revenue

Last NameYour First NameYour Middle Initial

Spouse's Last NameSpouse's First NameMiddle Initial

CityStateZIP CodeTelephone

FormPennsylvania

PA-VPayment Voucher2013

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