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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
ACN
DATE
NO.21 DLP - ~3
06124284
05-25-2006
REY-15~3 EX AFP <O9-00l
EST. OF JOHN H HESS
S.S. NO. 181-07-7308
DATE OF DEATH 03-07-2006
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
[i] CHECKING
o TRUST
o CERTIF.
BARBARA A SHADE
6911 CHATHAM DR
HBG PA 17111
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS -~
CUMBERLAND C~COURT ~~USE
CARLISLE, PA . 17013 ,~,
_, I
PNC BANK has provided the Department with the information listed below which has 'been us"'" -in ,
calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner~bsneficiarY'Qf
this account. If you feel this information is incorrect, please obtain written correction from the financial ingtitution;wttach a-cOp~
to this form and return it to the abova address. This account is taxable in accordance with the Inheritanc~ Tax Laws of iha CO"~~alth
o~ PennsYlvania. Questions may be answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCtIONS
Account No. 5070089226 Date 03-10-2003
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
11,186.07
50.000
5,593.04
.15
838.96
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".
Tax
x
NOTE: If tax payments are made within three
(3) months of the decedent's date of death,
you may deduct a 57. discount of the tax due.
Any inheritance tax due will become delinquent
nine (9) months after the date of death.
PART
ill
A.
[ CHECK ]
ONE
BLOCK B.
ONLY
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 "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.
[J The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
If yoU indicate a different tax rate, please state your
relationship to decedent:
PART
~
TAX RETURN - COMPUTATION
LINE 1. Date Established
2. Account Balance
3. Percent Taxable
4. Amount Subject to Tax
5. Debts and Deductions
6. Amount Taxable
7. Tax Rate
8. Tax Due
PART
~
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
OF
1
2
3
4
5
6
7
8
x
TAX ON JOINT/TRUST ACCOUNTS
x
PAYEE
DESCRIPTION
AMOUNT PAID
I
TOTAL (Enter on Line 5 of Tax Computation)
perjury, I declare that the facts I
ledge and belief.
I
$
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