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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
*'
INFORMATION NOTICE
AND
~A*PAYER RESPONSE
FILE NO. 21
ACN 06118855
DATE 04-24-2006
REV-1545 EX AFP (09-00)
r. ~
I'
, ESll"1 OF EVElYN FULFER
S.S. NO. 342-24-3172
DATE OF DEATH 11-05-2005
COUNTY CUMBERLAND
TYPE OF ACCOUNT
D SAVINGS
[X] CHECKING
D TRUST
D CERTIF.
CURTIS W FULFER
609 E KElLER ST
MECHANICSBURG PA 17055
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE. PA 17013
MEMBERS 1ST FCU has provided the Departllent with the information listed below which has been used in
calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of
this account. If you feel this inforllation 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 Laws of the COllmonwealth
of Pennsylvania. Questions lIay be answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 264729-11 Date 05-13-2005
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
5.000.05
100.00
5.000.05
.045
225.00
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 57. discount of the tax due.
Any inheritance tax due will becolle delinquent
nine (9) months after the date of death.
Tax
PART
ill
The above inforllation and tax due is correct.
1. You lIay 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.
[CHECK ]
ONE
BLOCK
ONLY
B. [] 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.
C. [] The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
PART
~
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
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
OF TAX ON JOINT/TRUST ACCOUNTS
1
2
3
4
5
6
7
8
x
x
PAYEE
DESCRIPTION
AMOUNT PAID
I
$
TOTAL (Enter on Line 5 of Tax Computation)
of perjury. I declare that the facts I
of my knowledge and belief. HOME
are true. correct and
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