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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE NO. 21 06-0879
ACN 06161741
DATE 12-15-2006
REV-l&45 EX AFP 109-001
ROBERT L GOULD
APT 6
111 N ENOLA DR
ENOLA PA 17025
TYPE OF ACCOUNT
EST. OF ROBERT G GOULD 0 SAVINGS
S . S. NO. 187 -16 - 61 77 [XJ CHECKING
DATE OF DEATH 09-20-2006 0 TRUST
COUNTY CUMBERLAND 0 CERTIF.
~~~;
REMIT PA~NT AND F~S TO:
REGISTER OF,1f:l:.1;:t.S .k..
CUMBERLAND CQ -:CPURT I100SE
CARLISLE, PA ~1~3
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CITIZENS BANK OF PA has provided the Department with the information listed below which has ~in used i~
calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a jgiht owner/be~ciary ofe,
this account. If you feel this information is incorrect, please obtain written correction from the financial institution, at~ a copy
to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth
of Pennsylvania. Questions may be ~nswered by ~allins (717) 787-83Z7.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 6106291916 Date 05- 06-2002
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
32,637.21
50.000
16,318.61
.045
734.34
TAXPAYER RESPONSE
To insure proper credit to your account, two
(2) copies of this notice must accompany your
payment to the Register of Wills. Make check
payable to: "Register of Wills, Agent".
x
NOTE: If tax payments are made within three
(3) months of the decedent's date of death,
you may deduct a 5% discount of the tax due.
Any inheritance tax due will become delinquent
nine (9) months after the date of death.
Tax
PART
'11
L.:j
[CHECK ]
ONE
BLOCK
ONLY
A. c:J The above information and tax due is correct.
1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest, or you may check box "An and return this notice to the Register of
Wills and an official assessment will be issued by the PA Department of Revenue.
B. '~~he above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
~o be filed by the decedent's representative.
C. c:J The above information is incorrect and/or debts and deductions ware paid by you.
You must complate PART ~ and/or PART ~ balow.
x
If you indicate a different tax rate, please state your
relationship to decedent:
PART
~
TAX RETURN - COMPUTATION OF
LINE 1. Date Established 1
2. Account Balance 2
3. Percent Taxable 3
4. Amount Subject to Tax 4
5. Debts and Deductions 5
6. Amount Taxable 6
7. Tax Rate 7
8. Tax Due 8
TAX ON JOINT/TRUST ACCOUNTS
x
PART
[!]
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUNT PAID
I
TOTAL (Enter on Line 5 of Tax Computation)
I
$
Under penalties of perjury, I declare that the
complete to the best of~OWledge and belief.
LQ~2?2f:__~ ~{J
facts I have reported above are true, correct and
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