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