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COMMONWEALTH OF PENNSVLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. l8D601
HARRISBURG, PA 171l6-0601
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE NO.
ACN
DATE
210Cp- I3J;;<'
06124963
06-02-2006
REV-15~5 EX AFP (09-00)
TYPE OF
ACCOUNT
o SAVINGS
[XJ CHECKING
o TRUST
o CERTIF .
CRYSTAL JSTen!1{ S 1::;
5251 STRATHMORE DR
MECHANICSBURG PA 17050
EST. OF GERTRUDE I COLLINS
S.S. NO. 199-07-1999
DATE OF DEATH 01-08-2006
COUNTY CUMBERLAND
()rne r 1<01
REHIT PAYHENT AND FORHS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
_,"l
"'.. ._-~
HEHBERS 1ST FCU has provided the Department with the inforMation listed below which has been used ~n
calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/~eficiary
this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy
to this form and return it to the above address. This account is taxable in accordance with the Inheritance 'Tax'tallS' of the ,CommolfWElam
of PennsYlvania. Questions may he answergd by calli~~ (7171 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 179403-11 Date 10-17-1998
Established
")
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
2,677.95
50.000
1,338.98
.045
60.25
TAXPAYER RESPONSE
To insure proper credit to your aCcOll[lt, two
(l) copies of this notice must acco~~ny 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
[!]
A.
[ CHECK ]
ONE
BLOCK B.
ONLY
c.
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 "A" and return this notice to the Register of
Wills and an official assessment will be issued by the PA Department of Revenue.
[] The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
to be filed by the decedent.s representative.
~ The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
PART
@]
TAX RETURN - COMPUTATION OF
LINE 1. Date Established 1
2. Account Balance 2
3. Percent Taxable 3
4. Amount Subject to Tax 4
S. Debts and Deductions S
6. Amount Taxable 6
7. Tax Rate 7
8. Tax Due 8
x
TAX ON JOINT/TRUST ACCOUNTS
I /')- I '7 - C) 7
~::;:) ED 7'7. <7'5-
~ 0 7.:>
/~3~'<}Y
/33~-~;~
Q!;>
~
If you indicate a different tax rate, please state your
relationship to decedent:
x
PART
@J
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
on Line 5 of Tax
declare that the facts I
belief.
, .~