HomeMy WebLinkAbout03-12-07
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
ST AIVISKY JERRY W
420 NE 17TH AVE
BOYNTON BEACH, FL 33435
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ESTATE INFORMATION: SSN: 1 93-30-1145
FILE NUMBER: 2107-0235
DECEDENT NAME: ST AIVISKY JACK A
DA TE OF PAYMENT: 03/12/2007
POSTMARK DATE: 03/06/2007
COUNTY: CUMBERLAND
DATE OF DEATH: 06/29/2006
NO. CD 007890
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
06147902 I $210.97
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TOTAL AMOUNT PAID:
REMARKS:
CHECK# 1180
SEAL
INITIALS: CJ
RECEIVED BY:
REGISTER OF WILLS
$210.97
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
COMMOHlIEALTH OF PENNSYLVANIA
DEPARTIIEHT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG. PA 171lB-0601
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~.~FORMATION NOTICE
G AND
TAXPAYER RESPONSE
NO. 21-01.. a,3S-
06147902
09-15-2006
TYPE OF ACCOUNT
EST. OF JACK A STAIVISKY IiJ SAVINBS
S.S. NO. 193-30-1145 DCHECKINS
DATE OF DEATH 06-29-2006 0 TRUST
COUNTY CUMBERLAND 0 CERTIF.
REHIT PAYHENT AND FORMs TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE. PA 17013
FILE
ACN
DATE
ZOOl ti~iR I 2 Pt-ll 2: 4 1
CLERK OF
ORPH /11' :'(' ('nt 1RT
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~J:'r
JERRY W STAIVISKY
420 NE 17TH AVE
BOYNTON BEACH FL 33435
THE JlJNCy BANK I TRUST CO hils provided the IJePllrt.nt IIlth the InforaUan listed alDll IIhlch hils bH/1 us8d In
ClIlcul.Ung the potBntl.l to du.. Th8lr rllCords Indlc.tB thIIt .t the de.th of the lIboY8 dllClIdtInt. YOU Hr. . joint DlIMr/b8n8flcl.ry of
this lICCount. If yOU #881 this Infor88tlon Is Incorr.ct. pl.... obtllln IIrlttBn corrBctlon frD8 the fln8nCl.l Institution. .ttBch . copy
to this forB III'Id r.tum it to the lIbov. 8ddress. This .ccount Is tIIX1Ibl. In .ccordenoe IIlth the Inh.rlt8nc. T.x L8IIs of the C~lth
ttf.. P.n..ylv..i.......~ ___ IInSHred by -U!ntrti717) 18?-8'"-B-.' __,
COMPLETE PART 1 BELOW... SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 2205004815 o-t. 06-13-2005
Ed_l1s1wd
Account &.1-.
P.rc~t T__1.
AIIount Sub~t to T_
T.x R.t.
Pot~tl.1 T_ au.
x
5.274.07
50.000
2.637.04
.12
316.44
TAXPAYER RESPONSE
To Insur. prop.r cradl t to your IICCOunt. tNo
(l) copl.s of this notlc. BUst .ccoepany your
PII_t to the RlIlIlstBr of II111s. Nllke check
plIYllbl. to: "RlIlIlstBr of NUls. AgBnt".
x
NOTE: If tIIx p._ts IIrB Ade IIlthln thr.
(3) IIOnths of the dIICl1dllnt's dllt. of dIIIIth.
YOU -y deduct. s:c discount of the to du..
Any InhlIrltBnc. tIIx dull 11111 bllCOII. deUnquent
nine (9) lIonthS .fur the dlIItII of de.th.
PART
[!]
A. 0 The above Infor88tlon end till( dull Is corrlli::t.
I. You - ohoos. to rIIIIlt plI_nt to the Reglst.r of Nllls IIlth tNo copl.s of this notl~ to obtllln
II dlllCOUnt or .vold Int.r.st. or yOU _y chllCk box "A" end rBtum this notlc. to the R.glst.r of
NUls lII'Iden officl.l IIS..S....,t 11111 b. Is..ad by the PA DIIp.rtBent of R.venUII.
B. 0 The IIbovII IIS..t h.s Hen or IIUl be report.d end tIIx P11ld IIlth the P.nnsylvanlll InhlIrltllnc. Till( r.turn
to be fUad by the decedent's rllprBSllntllUv..
C. 0 The lIbove Infor_tlon l~ncorrllCt and/or debts end deductions WIIrB pllld by YOU.
You BUst coIIP1.t. PART L.!J lIndIor PART [!] b.1Dll.
[. C~~~K ]
BLOCK
ONLY
If you IndIClIt. . dlff.,..,..t tu r.t.. pl.... st.t. your
raI.Uonshlp to ct.;.-,t:
PART
I!J
TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS
LINE 1. o.t. Est_1lshad 1
2. Account B.1~. 2
3. P.~t T__l. 3 X
4. AIIount SubjM)t to T.x 4
.5. Dabts ~ Deductions 5-
6. Mount Tu_1. 6
7. T_ ht. 7 X
8. Tu~ 8
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~ lD.Q 7
DEBTS AND DEDUCTIONS CLAIMED
PART
I!l
DATE PAID
PAYEE
DESCRIPTION
AMOUNT PAID
I
TOTAL (Ent.r on Ll". 5 of T_ CoIIput.Uon)
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Und.r .....lU.. of ...rjury. I We1.ra th.t thll f.cts I hay. r.port.d 80.. .r. tMM1 corr.ct ~
1.t. to thIl - t of rlYc-k 1.. ~d _l1.f. HOME cSII \ ) ...'?l5-qq~"7lP
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