Fillable Printable Personal Income Tax Fax Cover Sheet (DEX 93)

Personal Income Tax Fax Cover Sheet (DEX 93)

NOTE: Please include only one taxpayer’s information and one tax year per fax. Do not highlight information

on any sheets included with the fax. Failure to follow these instructions will result in delays in processing or payment

of refunds.

Taxpayer Name (name listed first on return or notice)

Taxpayer SSN/EIN

To:

Message:

Reason for Fax (check all boxes that apply):

Required E-File Return A

ttachments

Military orders and other information (fax: 717-772-4193 or 717-787-2840)

Other states’ returns and federal Form 1116 (fax: 717-705-6651)

Response to Department Notice

Request for Information (fax: 717-783-5823)

Other: Clarify documents faxed and reason for fax (fax to the number on the notice you are responding to)

Sender Information:

Name of Sender

Telephone Number

Number of pages sent including fax cover sheet:

This message is intended only for the use of the individual or entity to which it is addressed, and may contain information that is privileged,

confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient or the employees or

agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution or copying

of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone, and

return the original message to us at the above address via the U.S. Postal Service. Thank you.

Bureau of Individual Taxes

PO BOX 280605

Harrisburg PA 17128-0605

PERSONAL INCOME TAX

FAX COVER SHEET

DEX 93 (05-12)

OFFICIAL USE ONLY

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