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COMMONWEALTH OF I'~:NNS\'I.V,\NIA
IJf:PAWT'~IEST OF ItE\''':l\H\E
lIUll~:AU OF Fn:1.II OI'~;II,\TIONS
INH~:ll1T"NC~; TAX IlIVISION
OFFICIAL NOTICE OF INIIERITANCE
TAX APPRAISEMENT ANIl ASSESSMENT
OF ASSETS NOT SIJII.mCT
'1'0 AIlMINISTRATION
~
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REV.523 (10.78)
._---_.-.~-_.._.._---_._------_..._'----_..__._- ------------.--..---
_... _..__________ __..._ ____..____.._.~ ......._____.____________.__._____ ___n_______
1186 LotCbNo~th load
Casp 8111. ~II. 17011
Datd~~ch_.JIL 1_980______________
County Cuablt.!llUld T(~:-rt(i-0.i;7
C t F'I N " !. --}-,---'-Tj fJ
oun y I e o,..,__:.:."--~,__~'____[.___
TO:_
1181an ~. Dolson
Bureau File No,____,____
We have received notice that, as a result of the death oL.!'iJ..1..a,~_~_~l~~_____._,___P,_,_______.___
on 6-n 19.1!-, you camc into ownership of certain property through right of survivorship, which
was formerly owned by the decedent.
Under the Inheritance and Estate Tax Laws of the Commonwealth of Pennsylvania such transfers are taxable
and the liability for the payment of the inheritance tax due is imposed upon you, as transferee.
The property on whicl1 tax is hereby assessed consists of: IlIlllphiD DeP08lt Aecount '1~1-147!l3 111 ~.!I~
Flo~eIlCe E. 01' Hillllrd J. o~ Ilelell._~!....Do.!!OD established 1-10-711.witb bII1llDCe of
9S7.42-1I6 talISb1e At 6:L. Paupb.Ulllep"lIit &,:gCT.Jl'It 115 03 014744 in _8 of Pl_co
I.. Hilll1n! J.. 01' &1_ P. Do18011 ntabl1alted 9-16-77 with balllDce of $14.073.49-
1/6 taxable lit 6~.
appraised by the Commonwealth, as of the date of death, at $ 2.SOS.1S
100 % of this amount is taxable at the rate of 6 %
AMENDED ASSESSMENT
DATE OF ASSESSMENT
TAXABLE AMOUNT
LESS: ALLOWED DEBTS
NET TAXABLE AMOUNT
$
AMOUNT OF TAX DUE
If you pay the above amount within three (3) months of the
date of death of the decedent, or on or before___
19_., you may deduct a discount of
5 % of the amount of tax due, or
i..
" . /
. '
This tax became delinquent nine (9) months after death
(one year if death occurred prior to December 22,1965
and fifteen months if death occurred on or after
December 22,1965 but prior to June 17,1971) and in
addition to the tax, statutory interest at the rate of 6 ~o of
the tax per annum is alsQ.~ue as of~____19_____,.
in the amount of I I ' " ,0 ,: ,I f,,, ;" , II'...' ,
, ' , ",1' <J
-.;. \, '0', '" -'J!' '\...11, I,
* If the tax is not paid'by the above date additional ., '.
interest is due at the rate of 6% per annum until paid
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~.., __.~~..__ ---. -.----.n~--r- .--..... . -.--.-~.------------..--.-~,.
TOTAL AMOUNT DUE S-'!:J~~(:~J,g~,:,,-- S_, -- -------- -
APPRAISED BL_-(lnherT';nce 1:' AiPraiS~),-,,--L ___.ASSESSED BY--~-(A!;~(!::I~li,.CJ,,;,;D;c~~I,/-r:.:~~ -(-=~~n -,-=---=
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INSTRUCTIONS TO TP,XPAYERS
Make checks or money orders payable to:
To Insurc proW'1 nedit to your account
this Official Notice must accompany
your payment. Mail or bring it to,
Ragiater of Willa
Courthouse
NOTE ~A t"'-rt! t"'-Zt~'~t fh, ;' / d" b/ (;Ih'. . -tl b' h Carllialel. d P.'II
.: ny pa y In 10 eres w 0 IS aggneve y IS no Ice lIlay 0 ject t Breto Wit 110 SIX Y ays a er
said notice a-s"provided by Section 1001 of the Inheritance and Estate Tax Act of 1961, 72 P,S 24B5-1001,
RBGISTBR 01" WILLS
17013
receipt of
il':
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If you have already paid tllis tax to an executor, a(hnini~;liator, atlo(rwy, or oilier pl'rsonal reprw;cnlalive of the
decedent for forwarding to the COlTlmonwealth, list below tile dale pard, IInrlle all(\ addll:ss 'Jf 111f; person to whom
you made payment, theIr official title and the amount . '.
Date Paid
Name and Address of f'ayue
Official fit,,:
Amount Palll
Under certain circumstances, II, alter the dale of de,111I uf II,,; lb,,,der,\. fud [Jl:lJor.,llIy P~\IlJ 11111(:ral expenses
or other just debts of the decedellt. with funds derived Irorn tire properly IlUrein taxed, ~;l1Cll anlOunl:; expended
by you may qualify as deductions against lire gross value of IIle property In tile computatioll of tax due, If any
such expenditures meet all of the three following lests, it is recommenderl ilia I yuu itemize the payments below,
execute the affidavit, and return this notice. The Regisler of Wills will examine 1110 debts claimed and allow those
which he determines to be proper, The tax will then be recompuled ami YOl' will receive all iimended assessment
of tax.
THE THREE TESTS WHICH MUST BE MET ARE THAT:
1, You were personally legally responsible for these debts, and
2, You actually paid these debts and can furnish proof of such payment, if required, and
3. These same debts are not also claimed, for tax purposes, by an executor, administrator or other
personal representative of tllO decedent Iiandling the administration of IIle general estate of the
decedent or any other transferee.
Date Paid
SCHEDULE OF DEBTS
___~,_~__..._.m___"_'''_.__'___' ,.-,.-----.-..--.-- ....-. ..----.
Name of Payee ' Description of Obli[Jation
___u~--=- -~~~=0==~==L~~-~-=----- ____,__-u - '
-Anlount Paid
--'-- ---_.~-- ---~_._-------_..-~_.._-.-. ---.----- .-----....---
-----..------ ._-------_._~--- -~_._--_.__._------~._._--_.__.. -------...--.----
=l=-=--==:-:=:-===-=-..:.=====---=- ----,
--------'--,'--------'----------'------------' ------------
_--1_'_____.._ --- ,- ---------- ---------'
--~J--~ ~E-I~:-==~~~-~=---i- -~-=- =
._____._l~_._..__.____. _. ..J___....____.. _. . - .1.------- ---------
-----~
TOTAL $
-------------------..-...---.
-(attach sepaiiiesheetifrequJredjU
COMMONWEALTH OF PENNSYLVANIA)
COUNTY OF _____________.1
SS:
1,________liereby certify t1lat the foregoing is a just and true statement of funeral expenses
and otlier debts of the decedent,______________________, for whicli I was legally responsible and which
I did pay oul of the property Ilerein taxed, I further certify, tllat to tlw best of my knowledge and belief, these
same debts '/Iill not be claimed by any Diller person, for inhcrltallc') tax purpuse:;
SWORN AND SUBSCRIBED BEFORE ME THIS
19
___ o,wor
SIOl1dlur~ 01 Tawa,'cr
REPORT OF REGISTER or WILLS
I. the undersigned, duly elected Register of Wills in and lor the above county, do respectfUlly report that I ilave
allowed deductions listed above in tile total amount of S______.____..__________ ,,__u_____
Date of AppfGval:..._.._
!l('Ols:~r I'll Wills
,
4. petitioner, upon learning the facts of decedent's physical
condition and medical history subsequent to decedent's death, notified
the owner and beneficiary of said policy, Dauphin Deposit Bank and
Trust Company, of Harrisburg, Pennsylvania, and decedent's said widow,
that it was rescinding and canceling said policy and denying the
said beneficiary's claim for benefits under the policy. However,
petitioner desires to seek an Order of Court declaring that said
policy has been rescinded and cancelled as of the date of its incep-
tion by reason of the decedent's misrepresentations in the application
for such insurance and, in order to do so, petitioner desires to name
decedent's personal respresentative as one of the defendants in the
legal action being instituted for that purpose.
5. Petitioner is unable to obtain a Court Order, as above,
against decedent's personal representative until such representative
is duly appointed.
6. Petitioner has requested decedent's widow, the said
Helen Dolson, as the person primarily entitled, to take out Letters
of Administration but she has neglected and refused to do so.
7. Petitioner has requested George B. Faller, Esquire, of
Carlisle, pennsylvania, to serve as Administrator of the decedent's
estate, in the event decedent's said widow persists in her refusal
by failing to respond to the Citation to be issued hereunder.
Petitioner's said nominee has agreed to serve in such capacity, if
necessary.
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