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Home My WebLink About04-26-07 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 008076 SAURMAN PATRICIA A 431 HERMAN AVE LEMOYNE, PA 17043 ACN ASSESSMENT CONTROL NUMBER AMOUNT ---.---- fold 06153171 $177.16 ESTATE INFORMATION: SSN: 163-07-6635 FILE NUMBER: 2106-1095 DECEDENT NAME: DIERICH ERNEST R DATE OF PAYMENT: 04/26/2007 POSTMARK DATE: 04/23/2007 COUNTY: CUMBERLAND DA TE OF DEATH: 09/18/2006 TOTAL AMOUNT PAID: $177.16 REMARKS: CHECK# 233 SEAL INITIALS: DM RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. Z80601 HARRISBURG, PA 171Z8-0601 -, ~ REY-154J EX AFP, 119-11l ~ INFORMATION NOTICE AND TAXPAYER RESPONSE REVISED NOTICE ~ ~ ~ TYPE OF ACCOUNT EST. OF ERNEST R DIERICH 0 SAVINGS S. S. NO. 162-07-6635 [X] CHECKING DATE OF DEATH 09-18-2006 0 TRUST COUNTY CUMBERLAND 0 CERTIF. REHIT PAYHENT AND FORHS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 7 ....., r.,..- .~. ::~ i) F; I \2: LiD r,1 I' I ,I PATRICIA A SAURMAN 431 HERMAN AVE LEMOYNE PA 17043 FILE ACN DATE NO.21 OU \ 0<:( 5 06153171 10-27-2006 FUL TON BANK has provided the Departaent with the info~at1on 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 infor..tion is incorrect, please obtain written correction froa the financial institution, attach a copy to this fo~, and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Coaaonwealth of Pennsylvania. Questions..y be answered by calling (717) 787-83Z7. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 3622-23353 Date 06-30-2003 Establ1shed Account Balance Percent Taxable A.ount Subject to Tax Rate Potential Tax Due x 18,694.32 50.000 9,347.16 .045 420.62 TAXPAYER RESPONSE Tax x To insure proper credit to your account, two (Z) copies of this notica aust accoapany your payaent to the Register of Wills. Make check payable to: "Register of Wills, Agent". NOTE: If tax payaents are aade within three (3) aonths of the decedent's dete of death, you aay deduct a 5% discount of the tax due. Any inheritanca tax due will becoae delinquent nine (9) aonths after the dete of death. PART m A. 0 The above info~ation and tax due is corrllCt. 1. You aay choose to r..it payaent to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or you aay check box "A" and return this notice to the Register of Wills and an official assassaent will be issued by the PA Departaent of Revenue. B. 0 The above asset has been or will be reported end tax paid with the Pennsylvania Inheritance Tax return to be filed by the decedent's representative. C. l\i( The above inforaation is incorrect and/or debts and deductions were paid by you. ~You aust coaplete PART ~ and/or PART ~ below. [CHECK ] ONE BLOCK ONLY If you indicate a different tax rate, please state your relationship to decedent: PART ~ TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LrNE 1. Date Estabilshed 1 2. Account Balance 2 3. Percent Taxable 3 ~ 4. A~unt Subject to Tax 4_ 5. Debts and Deductions 5_ 6. A.ount Taxable 6 7. Tax Rate 7 8. Tax Due 8 PART I!I DATE I '6 fa 'I '-f, 3::z.. , f~ :2 ~r,~~; I '77.. IIJ DEBTS AND DEDUCTIONS PAID PAYEE DESCRIPTION CLAIMED AMOUNT PAID TOTAL (Enter on Line 5 of Tax Computation) facts I HOME ( WORK ( TELEPHONE Attachement to ACN 06153171 Debts and Deductions Claim for Patricia A. Saurman, 431 Herman Ave., Lemoyne, PA 17043 Fulton Bank Acct. 3622-23353 Check #217 - Burick & Azizkhan Internal Medicine Check #218 - Verizon Check #219 - IMWRF (Susq. Club) Check #220 - Stone & Murray, Funeral Director Check #221 - Millenium Phy. Sys. East Check #222 - Chapel Pointe Check #223 - Quantum Imaging Check #224 - Associated Cardiologists Check #225 - Burick & Azizkhan Internal Medicine Check #226 - Susq. Breast Care Center Check #227 - Burick & Azizkan Internal Medicine Check #228 - Philhaven Check #229 - Belvedere Medical Corp. Check #230 - Holy Spirit Hospital Check #231 - U.S. Treasury TOTAl 09-18-06 09-18-06 09-22-06 09-22-06 10-12-06 10-13-06 10-14-06 10-14-06 10-14-06 10-16-06 11-03-06 11-09-06 11-17-06 12-09-06 04-12-07 Family Physician Telephone Bill Funeral Luncheon Funeral Expenses Medication Nursing Home Care X-ray Heart Consultation Family Physician Dermatologist Family Physician Psychiatric Evaluation Nursing Home Visit Hospital Stay Federal Income Tax $ 44.43 $ 54.68 $ 445.50 $ 2,509.00 $ 197.87 $ 915.00 $ 13.90 $ 27.50 $ 22.28 $ 23.06 $ 100.18 $ 19.12 $ 12.75 $ 952.00 $ 73.00 $ 5,410.27 /oJ. ..,/ o /oJ. (..1 + ,..t. (..1 u., Ct. n C) fool. .~~ - - :- - ::: - - - :::: == ::: - - - - ::: - - - :::: r .~ 7C.~7 ! t-'.J::,. .... . ! ~ w~.., IS -- o~:::!. S ~ s. . JD::l en , d ~ , ~~ c >>3 -<::~ ~('l)t::l ~j . w < f 26 r;'I:?:J;g lf~ "'" ~ ~1~ ~. ~ p.; t;) .:t )> .~ ;;:; ~~i ~ JI. fV N ~ f'.) (.I) n'''I co >< . c" q "'"J ;;:; C} 11 "0 ~ )) H .,.. ''l -0/ ,.. 0<;; , /'0 ~