EFTA01219717.pdf

CUT ALONG DASHED LINES r PA4O1 (743) • Intuit EMPLOYER DEPOSIT STATEMENT OF WITHHOLDING TAX PA DEPARTMENT OF REVENUE ENTITY ID (EIN) ACCOUNT ID INT RATE TAX RATE DEPOSIT PERIOD ENDING DUE DATE 1 TOTAL COMPENSATION SUBJECT TO PA TAX 2 PA WITHHOLDING TAX Only use black or blue ink. Do not use red Ink or pencil. Do Not Make 3 LESS CREDITS Corrections To The PREPRINTED Information On This Form. Use The Change/Correction Form (REV-1705) 4 PLUS INTEREST DEPARTMENT USE ONLY If the payment Is remitted by EFT or PAYMENT credit card. do not Me this PA.501. L DATE DAYTIME TELEPHONE/ EXT SIGNATURE TITLE 00007 EFTA01219717