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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 2110601
HARRISBURG, PA 171211-0601
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INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE NO. 21 06-0836
ACN 06154030
DATE 10-25-2006
2006 DEe -4 PM 3: 28
EST. OF DEAN C KEITER
S.S. NO. 162-20-8724
DATE OF DEATH 09-19-2006
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
IX] CHECKING
o TRUST
o CERTIF.
CLERK OF
ORPHAN'S COURT
CUVncDi i, ',"-, ,-"(j At
I. '._._'.__ :'. "I.' .."..,,_. j'
DEBRA RILEY
645 KNIGHTBRIDGE DR
HAGERSTOWN MD 21740
REHIT PAYHENT AND FORHS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
HEHSERS 1ST Feu has Pl"ovided the Depal"tllBnt with the infol"BaUon listed below which has bean used in
calculating the potential tax due. Theil" I"ecol"ds indicate that at the death of the above decedent, yoU wel"e a joint ownel"/beneficial"Y of
this account. If YOU feel this infol"Bation is incol"l"ect, please obtain wl"itten COl"l"ection fl"OB the financial institution, attach a copy
to this fOI"B and I"etul"n it to the above addl"ess. This account is taxabla in accol"dance with the Inhel"itance Tax Laws of the CO.Bonwealth
of Pennsylvania. Questions Bey be answel"ed by callIng (717) 787-8~Z7.
COMPLETE PART 1 BELOW · . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 160332-11 Date 08-17-2001
Established
Account Salance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
2,067.22
50.000
1,033.61
.045
46.51
TAXPAYER RESPONSE
To insul"e pl"opel" cl"edit to YOUI" account, two
(2) copies of this notice BUSt acc~pany yoUI"
paYBent to the Registel" of Wills. Make check
payable to: "Registel" of Wills, Agent".
Tax
x
NOTE: If tax paYBants al"e Bade within thl"ee
(3) Bonths of the decedent.s date of death,
YOU aay deduct a S7. discount of the tax due.
Any inhel"itance tax due will becoBe delinquent
nine (9) Bonths aftel" the date of death.
PART
[!]
A.
[ CHECK ]
ONE
BLOCK B.
ONLY
c.
If yoU indicate a different tax rate, please state your
relationship to decedent:
R71 The above infol"Bation and tax due is COl"l"ect.
~l. You Bay choose to I"BBit paYBent to the Registel" of Wills with two copies of this notice to obtain
a discount 01" avoid intel"est, 01" YOU Bay check box "A" and I"etul"n this notice to the Registel" of
Wills and an official assesSBent will be issued by the PA Depal"t.ent of Revenue.
c=J The above asset has been 01" will be I"epol"ted and tax paid with the Pennsylvania Inhel"itance Tax I"etul"n
to be filed by the decedent's I"epl"esentative.
c=J The above infol"lIBtion is incol"l"ect and/ol" debts and deductions wel"e paid by YOU.
You BUSt coaplete PART ~ and/ol" PART ~ below.
PART
[!1
TAX RETURN - COMPUTATION OF
LINE 1. Date Established 1
2. Account Salance 2
3. Percent Taxable 3
4. AIIount Subject to Tax 4
5. Debts and Deductions 5
6. A.ount Taxable 6
7. Tax Rate 7
8. Tax Due 8
PART
f!]
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
TAX ON JOINT/TRUST ACCOUNTS
x
x
PAYEE
DESCRIPTION
AMOUNT PAID
perjury, I declare that the facts I
knowledge and belief. HOME
and
Ii/ai-Jab
DATE