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COMMlltIIIEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 2B0601
HARRISBURG, PA 17128-0'01
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INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21-oi-04~LI
07116373
04-11-2007
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EST. OF ANN M VALENTINE
S.S. NO. 360-07-4493
DATE OF DEATH 03-12-2007
COUNTY CUMBERLAND
TYPE OF ACCOUNT
D SAVINGS
!iJ CHECKING
o TRUST
D CERTIF.
JUDITH A VALENTINE
5249 STRATHMORE DR
MECHANICSBURG PA 17050-6815
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
INTEGRITY BANK has providad tha Dapart.ant with tha info~ation listad balow which hBS baan usad in
calculating tha potential tax dua. Thair records indicate that at tha daath of tha abova decadant, you wara a joint owner/banaficiary of
this account. If you faal this info~ation is incorract, please obtain written corraction fru. tha finBncial institution, attach a cOPY
to this fo~ and return it to the abova addrass. This account is taxable in accordanca with the Inharitanca TaK LaMS of tha C~onwealth
of Pennsylvania. Questions.. ..,~d blI ealUng (un 1a7--H21.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 201005083 Date 04-29-2004
Account Balanca
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Du.
x
3,765.60
50.000
1,882.80
.045
84.73
TAXPAYER RESPONSE
To insure propar cradit to your account, two
(2) copias of this notica .ust accoapa~ YOUr
payaant to tha Ragistar of Wills. Maka chack
payabla to. "Ragister of Wills, Agant".
Established
x
NOTE. If tax payaants ara .ada within thrae
(3) .onths of the decedent's data of daath,
you _ daduct a' S" discount of tha tax dua.
Any inharitanca:tax dua will, beCoa1kdaUnqUant
nina ,,) ,aonths aftar tha "data Of.diulth. -
Tax
PART
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A. 0 Tha above info~ation and tax dua is correct. '.' '," ."
1. You aay choose to rRit pay.ant to tha Ragistar'i1f Wills with two copies of this notica to obta~n
a discount or avoid intarast, or you aay check box "A" and raturn this notice to the Ragistar of
Wills and an official assass.ant will ba issuad by tha PA Depart.ant of Ravanua.
[CHECK ]
ONE
BLOCK
ONLY
I. DT~a abova ~~sat .ha~,~aan or will ba raportad and tax paid with tha Pannsylva~ia .Inharitanca Tax rat~rn
to be filad by tha dacadant's raprasantativa. ' "'
C. ~ha abova info~ation i~ncorract and/or dabts and daductions wara paid by YOU.
You .ust co.plete PART ~ and/or PART ~ balow.
.-.
0-
ACCOUNTS
PART
[!]
TAX RETURN - COMPUTATION
If you indicate a different tax rate, please state your
relati~n~hlp to decedent:
LINE l. Date Established
2. Account Balance
3. Percent Taxable
4. Amount Subject to Tax
5. Debts and. Deductions
,. A.ount Taxable
7. Tax Rate
8. Tax Due
PART
I!l
OF
1
2
3
4
5
,
7
8
TAX ON JOINT/TRUST
1 /;2t~1o
x
.~() # 006
J *i''S':J1 ~o
~Olo~.G.J
()-
. ott-5""
x
. .DEBTS AND
DATE PAID ~.It.\l.EE, ,
"if.'r/b71111Al.l"2.~'1 Fi~ j
TOTAL (Enter on Line 5
DESCRIP1;ION
~uAlI!J'R.AL ~ Vlc..GtS
~~. >~.
'-:;"::: h
AMOUNT PAID
~ OJ 6'3 # (. I
I
of Tax Co.putation)
.
perjury, I daclare that the facts I
.y owl.due belief.
have reported above are true, correct
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