Form Pa 162Vr PDF Details

Pennsylvania residents who are age 62 or older may soon be required to file a new form with the state, Form Pa 162Vr. This form will be used to track individuals' income and estate information, and it is expected that the information collected on this form will help the state better assess and levy taxes on residents' estates. The deadline for filing this form is December 31st of each year. Residents who do not file this form by the deadline may face penalties. More information about Form Pa 162Vr can be found on the Pennsylvania Department of Revenue's website.

QuestionAnswer
Form NameForm Pa 162Vr
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 162, 162vr, pa 162vr pdf, pa162 vr

Form Preview Example

COMMONWEALTHOFPENNSYLVANIA

DEPARTMENTOFPUBLICWELFARE

OFFICE OF INCOME MAINTENANCE

Dear

Because you have applied for/or receive PUBLIC ASSISTANCE benefits, your social security number and the social security numbers of the people in your household have been used to obtain information from other government agencies.

The information we have received follows:

SOURCE:

 

 

 

 

INCOMETYPE

 

AMOUNT: $

 

 

 

 

PAIDTO:

 

 

 

 

 

 

 

 

 

 

 

 

PERIOD:

 

 

 

 

SOCIALSECURITYNUMBER:

 

 

 

 

 

 

 

PAID BY:

 

 

 

 

 

 

 

 

FREQUENCY:

 

 

CLAIM /ACCOUNTNUMBER:

 

 

 

 

 

 

 

CONTINUED ON BACK

 

 

 

 

 

 

 

This information was not reported when you applied for public assistance or it conflicts with information you gave to your eligibility worker. In order for us to determine if this information is correct and/or affects your public assistance benefits, you must provide additional verification. Verification which may be acceptable includes

Be sure to put your name, address and record number on the information you provide.

Please mail this information by

/

/

to the office shown above.

Attention

Please bring this information to the COUNTYASSISTANCE OFFICE at the above address on

 

 

 

at

 

 

 

 

.

 

This information is required

so

we can

determine

your continued eligibility for benefits. If

you have any questions concerning

this

 

request,

or need

help to get verification, please call your

eligibility worker immediately at

 

 

 

 

 

 

. Thank you.

Worker’s Signature

Date

CO

RECORD NO.

CAT

 

 

 

DIST

CS LD

CLIENT

CASE RECORD

PA162VR - 12/07

SOURCE:

 

 

 

 

 

 

INCOMETYPE

 

 

AMOUNT: $

 

 

 

 

PAIDTO:

 

 

 

 

 

PERIOD:

 

 

 

 

SOCIALSECURITYNUMBER:

 

 

 

 

 

 

 

 

 

PAID BY:

 

 

 

 

 

 

 

 

 

 

 

FREQUENCY:

 

CLAIM /ACCOUNTNUMBER:

 

 

 

 

 

 

 

 

 

SOURCE:

 

 

 

 

 

 

INCOMETYPE

 

 

AMOUNT: $

 

 

 

 

PAIDTO:

 

 

PERIOD:

 

 

 

 

SOCIALSECURITYNUMBER:

 

 

 

 

 

 

 

PAID BY:

 

 

 

 

 

 

 

 

 

 

 

FREQUENCY:

 

CLAIM /ACCOUNTNUMBER:

 

 

 

 

 

SOURCE:

 

 

 

 

 

 

INCOMETYPE

 

 

AMOUNT: $

 

 

 

 

PAIDTO:

 

 

PERIOD:

 

 

 

 

SOCIALSECURITYNUMBER:

 

 

PAID BY:

 

 

 

 

 

 

 

 

 

 

 

FREQUENCY:

 

CLAIM /ACCOUNTNUMBER:

 

 

SOURCE:

 

 

 

 

 

 

INCOMETYPE

 

 

AMOUNT: $

 

 

 

 

PAIDTO:

 

 

PERIOD:

 

 

 

 

SOCIALSECURITYNUMBER:

 

 

PAID BY:

 

 

 

 

 

 

 

 

 

 

 

FREQUENCY:

 

CLAIM /ACCOUNTNUMBER:

 

 

SOURCE:

 

 

 

 

 

 

INCOMETYPE

 

 

AMOUNT: $

 

 

 

 

PAIDTO:

 

 

 

 

 

 

 

 

PERIOD:

 

 

 

 

SOCIALSECURITYNUMBER:

 

 

 

 

 

 

 

 

PAID BY:

 

 

 

 

 

 

 

 

 

 

 

FREQUENCY:

 

CLAIM /ACCOUNTNUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMENTS: