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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
INFORMATION NOTICE
AND
TAXPj:\VJSR RESPONSE
FILE
ACN
DATE
NO. 21 Of....:, U6CI
06135050
07-18-2006
REV-154! EX AFP <09-00)
EST. Of "tfl\NCY J LA,NTZ
8.S. NO. 183-44-0947
DATE OF DEATH 05-25-2006
COUNTY CUMBERLAND
TYPE OF ACCOUNT
[X] SAVINGS
o CHECKING
o TRUST
o CERTIF .
ELIZABETH R LANTZ
6 PATTON RD
MECHANICSBURG PA 17055
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
BELCO has provided the Department with the information listed belclw which has been used in
calculating the potential tax due. Their records indicate that at the death of the above decedent, YCIU were a joint owner/beneficiary of
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 Inh.,ritance Tax Laws of the Commonwealth
of Pennsylvania. Questions may be answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 725670 Date 04-15-1994
Established
x
1,736.80
16.667
289.47
.045
13.03
TAXPAYER RESPONSE
To insure prclIper 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".
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
NOTE: If ta>< payments are made within three
(3) months oiF the decedent's date of death,
you may deduc:t 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. RI The
1.
above information and tax due is correct.
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 Departmlent of Revenue.
[CHECK ]
ONE
BLOCK
ONLY
B. [] The above asset has been or will be reported and tax paid with the Pe,nnsylvania Inheritance Tax return
to be filed by the decedent's representative.
C. 0 The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
LINE 1. Dais 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 X
4
5
6
7 X
8
PART
[3J
TAX RETURN - COMPUTATION
If you indicate a different tax rate, please state your
relationship to decedent:
PART
[!]
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUNT PAID
TOTAL (Enter on Line 5 of Tax ComputatiClnJ
I
$
of perjury, I declare that the facts I have reported abllve are true, correct and
of my knowledge and belief.
( 7/7) 7{,(p t(~J
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