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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INOIVIOUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
INFORMATION NOTICE
.V --AND
TA'XPAYER RESPONSE
FILE
ACN
DATE
NO. 21 6(,:- lOSi
06135051
07-18-2006
REV-1543 EX AFP [D9-DDl
" r.-"
EST.-Ot/NANCY J LANTZ
S.S. NO. 183-44-0947
DATE OF DEATH 05-25-2006
COUNTY CUMBERLAND
TYPE OF ACCOUNT
[X] SAVINGS
o CHECKING
o TRUST
o CERTIF.
STEPHEN M 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 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 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 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
.00
.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".
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
Tax
NOTE: If tax payments are made within three
(3) months of the decedent's date of death,
you may deduct a SZ discount of the tax due.
Any inheritance tax due will become delinquent
nine (9) months after the date of death.
PART
[!]
A . I'Vt" The
~l.
above information and tax dUB is correct.
You may choose to remit payment to the Register of Wills wi th twc' copies of this notice to obtain
a discount or avoid interest, or you may check box uAn and return this notice to the Register of
Wills and an official assessment will be issued by the PA Oepartmlent 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. [] The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
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
1
PART
~
TAX RETURN - COMPUTATION
If you indicate a different tax rate, please state your
relationship to decedent:
OF TAX ON JOINT/TRUST ACCOUNTS
2
3 X
4
5
6
7 X
8
PART
~
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation)
I
$
perjury, I declare that the facts I
my knowledge and belief.
have reported abo'"e are true, correct
HOME (717) 7t~ 9JJ;:J
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