STREET ADDRESS P.O. BOX, APT. NO., SUITE, FLOOR, RR NO., ETC. NAME FIDUCIARY / PARTNERSHIP NAME EMPLOYER IDENTIFICATION NUMBER PA-40ESR (F/C) (04-14)
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CITY

TAX YEAR

DAYTIME TELEPHONE NUMBER
FILED: DATE

ADD DASHES MMDD YY YY

STATE

ZIP CODE

TYPE OF ACCOUNT: MUST MARK HARRISBURG PA 17128-0403 PO BOX 280403 PA DEPARTMENT OF REVENUE MAIL THIS FORM WITH YOUR PAYMENT TO: PA DEPARTMENT OF REVENUE MAKE CHECKS DOLLAR AMOUNTS. READ INSTRUCTIONS BEFORE ENTERING

C – (PARTNERSHIP, ASSOCIATION F – FIDUCIARY (ESTATE or TRUST) PAYABLE TO
or PA S CORPORATION)
(FILL IN OVAL) FOR FIDUCIARIES, PARTNERSHIPS & OR ESTIMATED WITHHOLDING TAX DECLARATION OF ESTIMATED TAX
OTHER PASS THROUGH ENTITIES

ENDING BEGINNING
$

ss ,, OR ESTIMATED WITHHOLDING TAX DECLARATION OF ESTIMATED TAX ss ,,
MMDD YY YY MMDD YY YY
AMOUNT OF PAYMENT
DEPARTMENT USE ONLY FISCAL FILERS ONLY

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