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COKKONWEALTH OF PENNSYLVANIA
OEPARTKENT OF REVENUEr. ,.
BUREAU OF INOIVIDUAL'TAxES
DEPT. 2B0601 '
HARRISBURG, PA 171~. 0601
'*
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21 06-1163
07108416
03-02-2007
:r71.~i: '.' I 0
., ".( J
Pi'! 12: L! I
TYPE OF ACCOUNT
D SAVINGS
[Xl CHECKING
D TRUST
D CERTIF.
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REV-1545 EX /lFP (09-00>
EST. OF SUSAN C BREWER
S.S. NO. 181-38-9086
DATE OF DEATH 11-13-2006
COUNTY CUMBERLAND
RICHARD YARLET
1195 KINGSLEY RD
CAMP HILL PA 17011
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
MEMBERS 1ST FCU has p..ovid.d the D.p...t t "th th ..
calculating the pot.nti.l tax du.. Th.i.. ...co..ds indic.t. that a:.~h.w~ · info...atlon l,st.d b.low which h.s boon us.d in
this account. If you f..l this info....tien is inco.....ct pl..s. bt i .a:~tOf tho .bov. d.c.dont, you w.... a joint own.../b.n.ficiary of
to this fo... and "".t..u_"_~"i_t__t_o tho ...v. .dd...ss. This ~ccount i: t:X:b~: in.:c~:~~:~ct.iownitfh""th.th. financi.l institution, attach a copy
"'l'-: D......"":'.'H..._.=~ _... ___ ~_ ____.,__...f "_0. __.... 3._ ,_._.. ___ ____ Inheritanc. Ta L.,. of the Co..ontl.81th
. ......_..........._.;11. ......~~......,.... ...... ... QI.~".I.... ..,. .........~II. "'.....~ ..... ...~'&...
COMPLETE PART 1 IELOW
Account No. 268664-11
Account Balance
Percent Taxable
AMount Subject to Tax
Tax Rate
Potential Tax Due
PART
[!]
. .
. SEE REVEISE SIDE FOR FILINC AND PAYMENT INSTRUCTIONS
Date 07-28-2005
Established
To insu... p..op... c...dit to you.. account, two
{2l copi.s of this notic. .ust .cco.p.ny you..
pay..nt to the R.gist... of Wills. K.k. ch.ck
p.yabl. to. "R.gist... of Wills. Ag.nt".
x
3,291.19
50.000
1,645.60
.15
246.84
TAXPAYER RESPONSE
NOTE. If tax p.y..nts .... .ad. within th....
{3l .onths of the d.c.d.nt's date of d.ath,
you .ay d.duct a 5X discount of the tax du..
Any inh...itanc. tax due will b.co.. d.linqu.nt
nino {9l .onths aft... the d.t. of d.ath.
x
Th. .bov. info...ation and tax due is cor...ct.
1. You.ay choos. to ....it pay..nt to the R.gist... of Wills with two copi.s of this notic. to obt.in
. discount 0.. .void int....st, 0.. you .ay ch.ck box "A" .nd ...tu..n this notic. to the R.gist... of
Wills .nd an offici.l .ss.ss..nt will b. issu.d by tho PA D.p...t..nt of R.v.nu..
[CHECK ]
ONE
BLOCK
ONLY
B. c:J Th. .bov. .ss.t h.s b..n 0" will b. ...po..t.d .nd tax paid with the P.nnsylvani. Inh...it.nc. Tax ...tu..n
to b. fil.d by tho d.c.d.nt's ...p...s.ntativ..
C. c=l Th. .bov. info....tion is inco.....ct .nd/or d.bts .nd d.ductions w.... paid by you.
You .ust co.ploto PART 0 .nd/o.. PART ~ b.low.
OF TAX ON JOINT/TRUST ACCOUNTS
1
2
3 X
4
5
6
7 X
8
PART
~
TAX RETURN - COMPUTATION
If you indicate a different tax rate, please state your
relationship to decedent:
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
PART
[!]
DATE PAID PAYEE
DEBTS AND DEDUCTIONS CLAIMED
DESCRIPTION
AMOUNT PAID
I
TOTAL (Enter on Line 5 of Tax Computation)
.
IIDr:
perjury, I declare that the facts I
my k wledge and b.lief.
have reported above are true, correct and. ~
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