ETATSFO

227-11-0301

CONNER ISAAC J

1962 JOHNSTON STREET

17701PAWILLIAMSPORT

X(717) 779-3457

26,193804804

12

0 3 1 3 0 9 1 2 3

1 0 0 0 8 3 9 1 7 3 1

X

02/13/13

X

PATS

EL

COPY

ERO'SUseOnly

Printor

Type

W2(s)

G2W

9(s)

&109

HE

ER

signature on th is f orm bef ore submit t ing th is return to th e PA D epartment of Revenue. I provided th e taxpayer w ith a copy of all f orms and inf ormat ion to be f iled w ith th e IRS and th e PA D epartment of Revenue and f ollow ed all oth er requirements specif ied by th e PA D epartment of Revenue and described in th e IRS Publicat ion 1345, H andbook f or

computer, I understand I am required to keep th is f orm and support ing documents f or th ree years.

I declare I h ave received th e above- named taxpayer's return and th e ent ries on th is f orm are complete and correct to th e best of my know ledge. I obtained th e taxpayer's

Elect ronic Filers of Ind ividual Tax Returns (Tax Year 2012). If I am th e preparer, under penalty of perjury I declare I examined th e above- named taxpayer's return and accompanying

(set t lement ) date. I understand not if icat ion must be made in w rit ing by email to ra- ach revok@state.pa.us or f ax to 717- 772- 9310.

PA D EPARTM ENT OF REVENUE USE ONLY- D O NOT WRITE OR STAPLE IN TH IS SPACE

sch edules and statements, and to th e best of my know ledge, th ey are t rue and complete. I understand th at I am required to keep th is f orm and support ing documents f or th ree years.

sent to th e Internal Revenue Service (IRS) by my elect ronic return originator, and subsequent ly by th e IRS to th e PA D epartment of Revenue. If I am f iling f rom a h ome

I am not receiving a ref und or I do not w ant d irect deposit of my ref und.

inst itut ions involved in th e processing of my elect ronic payment of taxes to receive conf ident ial inf ormat ion necessary to answ er inquiries and

I consent f or my ref und to be d irect ly deposited as designated in Part II and declare all inf ormat ion sh ow n on L ines 6 th rough 8 is correct .I cert if y th e ult imate dest inat ion of th e f unds is w ith in th e U.S. or one of it s territories. If I h ave f iled a joint return, th is is an irrevocable

I declare under penalt ies of perjury compared th e inf ormat ion on my return w ith th e inf ormat ion I provided to my elect ronic return originator and th e amounts match th ose on my 2012 PA Tax Return (PA- 40). To th e best of my know ledge, my return is t rue and complete. I consent my return and accompanying sch edules and statements may be

If I h ave f iled a balance- due return, I understand th at if th e PA D epartment of Revenue does not receive f ull and t imely payment of my tax liab ilit y , I w ill remain liab le f or th e tax and all applicable interest and penalt ies. If I h ave f iled a joint f ederal and state tax return and th ere is an error on my state return, I understand my f ederal return w ill be rejected.

I auth orize th e Pennsylvania D epartment of Revenue and it s designated f inancial agents to init iate an elect ronic f unds w ith draw al ent ry tomy designated account f or Pennsylvania taxes ow ed. I also auth orize my f inancial inst itut ion to debit th e ent ry to my account and th e f inancial

I may revoke th is auth orizat ion by not if y ing th e Pennsylvania D epartment of Revenue no later th an tw o business days prior to th e payment

appointment of th e oth er spouse as an agent to receive th e ref und.

resolve issues related to my payment . I cert if y th e f unds f or th is w ith draw are originat ing f rom an account w ith in th e U.S. or one of it s territories.

5.

3.4.

Final Return

2.

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

Last Name

1.

3.

Total payment (tax due) (Form PA-40, Line 28)

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)

Adjusted PA taxable income (Form PA-40, Line 11)2.

4.

1.

5.

City, Town or Post Office

self-employed

Form

if self-employed) and

EIN/SSN or PTIN

address

paid preparerCheck ifDate Check if also

Zip Code

Married, Filing Separately Single Daytime Telephone NumberMarried, Filing Jointly

Your Social Security Number

State

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

Spouse's Social Security Number

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

self-employedCheck if

paid preparerEIN/SSN or PTINERO's signature Date Check if also

(See instructions.)

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

addressif self-employed) and Firm's name (or yours,

Firm's name (or yours,

a.

b.c.

9. Debit Date

Submission ID

Preparer's signature

Daytime Telephone Number

Please DO NOT mail this form.KEEP THIS FORM AND THE REQUIRED ATTACHMENTS FOR THREE YEARS.

Daytime Telephone Number

Date

CheckingType of account:8. Savings

6. Routing transit number (RTN)

Deceased

Depositor account number (DAN)

10.

Your signature

7.

Filing Status

Direct Deposit of Refund or Electronic Funds Withdrawal of Tax Due (Optional - See instructions.)

F

Check Proper

The above information must match that on the electronic return exactly.

Sign

The first two numbers of the RTN must

Paid

D

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

be 01 through 12 or 21 through 32.

Tax Return Information (Enter whole dollars only.)

HereDeclaration of Electronic Return Originator (ERO) and Paid Preparer

MS

Preparer's

J

Use Only

Part III

Part IV

Part II

Part I

DECLARATION FOR ELECTRONIC FILINGPENNSYLVANIA INDIVIDUAL INCOME TAXPA-8453 2012

NSY

PEN

NIA

LVA