Form Dex 93 - Personal Blank Fax Cover Sheet - Pennsylvania Department Of Revenue
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1DEX 93 (05-12)
PERSONAL INCOME TAX
OFFICIAL USE ONLY
FAX COVER SHEET
Bureau of Individual Taxes
PO BOX 280605
Harrisburg PA 17128-0605
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.
START
Taxpayer Name
(name listed first on return or notice)
Taxpayer SSN/EIN
To:
TYPE MESSAGE HERE
Message:
Reason for Fax (check all boxes that apply):
Required E-File Return Attachments
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)
TYPE OTHER HERE
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.
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