Fillable Form 2021: PA-40 2100110051 )Your Social Security Number (Pennsylvania)

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Form 2021: PA-40 2100110051 )Your Social Security Number (Pennsylvania)

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The Form 2021: PA-40 2100110051 )Your Social Security Number (Pennsylvania) form is 2 pages long and contains:

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  • 12 check-boxes
  • 99 other fields

Country of origin: US
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Residency Status. Fill in only one oval.
R Pennsylvania Resident
N Nonresident
P Part-Year Resident from
___ ___/2021 to ___ ___/2021
CAREFULLY PRINT YOUR SOCIAL SECURITY NUMBER(S) ABOVE
2100110051
2100110051
PA-40 (EX) MOD 06-21 (FI)
PA Department of Revenue
Harrisburg, PA 17129
Taxpayer
Date of death ___ ___/2021
Spouse
Date of death ___ ___/2021
PLEASE PRINT IN BLACK INK. ENTER ONE LETTER OR NUMBER IN EACH BOX. FILL IN OVALS COMPLETELY.
6. Net Income or Loss from Rents, Royalties, Patents or Copyrights. . . . . . . . . . . .
7. Estate or Trust Income. Complete and submit PA Schedule J. . . . . . . . . . . . . . . . . . . . .
8. Gambling and Lottery Winnings. Complete and submit PA Schedule T. . . . . . . . . . . . . .
9. Total PA Taxable Income. Add only the positive income amounts from Lines 1c, 2, 3,
4, 5, 6, 7 and 8. DO NOT ADD any losses reported on Lines 4, 5 or 6. . . . . . . . . . . . . . .
10. Other Deductions. Enter the appropriate code for the type of deduction.
See the instructions for additional information. . . . . . . . . . . . . . . . . . . . . . . . .
LOSS
LOSS
LOSS
1a.
1b.
1c.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11. Adjusted PA Taxable Income. Subtract Line 10 from Line 9. . . . . . . . . . . . . . . . . . . . . .
11.
OVERSEAS
MAIL -
See Foreign
Address Instructions
in PA-40 booklet.
OFFICIAL USE ONLY
Side 1
MI
MI
State ZIP Code
Spouse’s Social Security Number (
even if filing separately
)Your Social Security Number
Spouse’s First Name
Your First Name
City or Post Office
Spouse’s Last Name - Only if different from Last Name above
Second Line of Address
First Line of Address
Last Name Suffix
Suffix
Amended Return.
See the instructions.
Extension. See the instructions.
Filing Status.
S Single
J Married, Filing Jointly
M Married, Filing Separately
F Final Return. Indicate reason:
D
Deceased
Farmers. Fill in this oval if at least
two-thirds of your gross income is
from farming.
Name of school district where you lived
on 12/31/2021
Your occupation Spouse’s occupation
1a. Gross Compensation. Do not include exempt income, such as combat zone pay and
qualifying retirement benefits. See the instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b. Unreimbursed Employee Business Expenses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c. Net Compensation. Subtract Line 1b from Line 1a. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Interest Income. Complete PA Schedule A if required. . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Dividend and Capital Gains Distributions Income. Complete PA Schedule B if required. . .
4. Net Income or Loss from the Operation of a Business, Profession or Farm. . . .
5. Net Gain or Loss from the Sale, Exchange or Disposition of Property. . . . . . . . .
EC
FC
OFFICIAL USE ONLY
PA-40
Pennsylvania Income
Tax Return
Daytime Telephone Number School Code
2021
Country Code
OFFICIAL USE ONLY
START
➜
PRINT
NEXT PAGE
TOP OF PAGE
Reset Entire Form
IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING
2100210059
2100210059
2100210059
PA-40 2021 06-21 (FI)
28.
27. Penalties and Interest. See the instructions for additional
information. Fill in oval if including Form REV-1630/REV-1630A . . . . . .
28. TOTAL PAYMENT DUE. See the instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12. PA Tax Liability. Multiply Line 11 by 3.07 percent (0.0307). . . . . . . . . . . . . . . . . . . . . .
13. Total PA Tax Withheld. See the instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14. Credit from your 2020 PA Income Tax return. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15. 2021 Estimated Installment Payments. Fill in oval if including Form REV-459B.
16. 2021 Extension Payment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17. Nonresident Tax Withheld from your PA Schedule(s) NRK-1. (Nonresidents only) . . . .
18. Total Estimated Payments and Credits. Add Lines 14, 15, 16 and 17. . . . . . . . . . . . .
Tax Forgiveness Credit, submit PA Schedule SP
19a. Filing Status: Unmarried or Married Deceased
Separated
Dependents, Section II, Line 2,
PA Schedule SP. . . . . . . . . . . .
21. Tax Forgiveness Credit from Section IV, Line 16, PA Schedule SP. . . . . . . . . . . . . . .
24. TOTAL PAYMENTS and CREDITS. Add Lines 13, 18, 21, 22 and 23. . . . . . . . . . . . . . .
26. TAX DUE. If the total of Line 12 and Line 25 is more than Line 24,
enter the difference here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29. OVERPAYMENT. If Line 24 is more than the total of Line 12, Line 25 and Line 27
enter the difference here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33. Refund donation line. Enter the organization code and donation amount.
See the instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
34. Refund donation line. Enter the organization code and donation amount.
See the instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31. Credit – Amount of Line 29 you want as a credit to your 2022 estimated account. . . . .
Name(s)
22. Resident Credit. Submit your PA Schedule(s) G-L and/or RK-1.
. . . . . . . . . . . . . . . . .
12.
13.
18.
21.
22.
23. Total Other Credits. Submit your PA Schedule OC.
. . . . . . . . . . . . . . . . . . . . . . . . . . .
23.
24.
26.
29.
31.
32.
33.
Social Security Number (shown first)
14.
15.
16.
17.
30. Refund – Amount of Line 29 you want as a check mailed to you.. . . . . . . . REFUND
The total of Lines 30 through 36 must equal Line 29.
30.
27.
35. Refund donation line. Enter the organization code and donation amount.
See the instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
36. Refund donation line. Enter the organization code and donation amount.
See the instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
34.
35.
36.
19b.
20.
Total Eligibility Income from Section III, Line 11, PA Schedule SP. . .
Side 2
Your Signature Date E-File Opt Out Preparer’s PTIN
See the instructions.
Spouse’s Signature, if filing jointly Preparer’s Name and Telephone Number Firm FEIN
PLEASE DO NOT CALL ABOUT YOUR REFUND UNTIL EIGHT WEEKS AFTER YOU FILE.
  DONATIONS     ESTIMATED TAX PAID  
25. USE TAX. Due on internet, mail order or out-of-state purchases. See the instructions.
25.
SIGNATURE(S). Under penalties of perjury, I (we) declare that I (we) have examined this return, including all accompanying schedules and statements, and to the best of my
(our) belief, they are true, correct, and complete.
32. Refund donation line. Enter the organization code and donation amount.
See the instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OFFICIAL USE ONLY
START
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MM/DD/YY
Please sign after printing.
PLEASE DO NOT CALL ABOUT YOUR REFUND UNTIL EIGHT WEEKS AFTER YOU FILE.
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Form 2021: PA-40 2100110051 )Your Social Security Number (Pennsylvania)

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Completed 3 February 2022

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