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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.
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DATE DAYTIME TELEPHONE/ EXT SIGNATURE TITLE
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EFTA01219715