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COIItoIIEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVEtIJE
BUREAU OF INDIVIDUAL TAXES
DEPT. ZSD6Dl
HARRISIURGI PA 17128-0601
*'OR
INFORMATION NOTICE
;w--~...' AND
L.!*~-=~,eR RESPONSE
FILE NO. 21 Of 00'3'"2-
ACN 06157541
DATE 11-22-2006
REV-lJiU EX IF,!"t ~r";
~ :.,.
TYPE OF ACCOUNT
2001 JAN r 0 PM lit;'S6 OF ROBERT S RADCLIFFE 0 SAVINGS
S.S. NO. 204...al-3UJO IX] CHECKING
CLERK OF DATE OF DEATH ~7-28-2006, ,,,..,,,0 TRUST
ORPHAN'S CO\j~UNTY CUMBERLAND ~. ',:,,, .::::;<:'~;,~", '....,. ..<.gCERTIF.
CUME~r;!,"',1'""'! CO. P.A. REMIT PAYMENT AND FORMS TO:
'REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CLARANNA B RADCLIffE'"
APT 614
824 LIZBURN RD
CAMP HILL PA 17011
PSECU hu pl"ovided thll Dllpal"t11l1nt with thll infol"ll8tlon listed billow which has been used in
calculating thll potential ux dull. Thllil" I"lICol"ds indicatll that at the death of the above dllCed8l1tl you wal"e a joint ownel"/beneficial"Y of
this account. If you falll this infol"lIBtion is incOl"rllctl plaase obtain wl"itt.., cOl"l"lIction fr~ the financial institution I attach a copy
to this fa... and I"lItul"n it to the above addl"lIss. Thill account is taxablll in accol"dance with 'the Inhal"1tanCll Tax Laws of the COIIIIDnwll81th
of I'eN1sylvlll"lla. Questians _y be an"'l"ttd by _lUng (717) ,787-8$27.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 8602992813 Dat. 06-18-2002
Established
x
3,276.06
16.667
546.02
.00
.00
TAXPAYER RESPONSE
To insul"lI pl"opel" cl"edi t to youl" accountl two
(2) copills of this notice IIUSt BCCOIIpIIf1Y YOUI"
PBYII8I1t to the Registel" of Wills. Malte check
payable to: '"Rllgistel" of Willsl Ag8l1t".
Account Bal~.
P.rcent Taxllbb
AIIount Subject to Tax
Tax Rat.
Potential Tax Due
x
NOTE: If UlC paYllent. al"ll .ade within thl"ee
(3) aonths of the decedent's date of deathl
you ny deduct a S:C discount of the tax due.
Any inhlll"i tanc. talC dull wUl bllCCllle dlIUnqullnt
nine (9) IIOI'Ith.aftel" the date of dllath.
PART
[!]
m:r1:~_t~~L::1\:=i~-~-~:~~::~::::~~%t-JI0\~f.~:t~~~~"-=:~~~i~~~~~~'~~~~~:B1l1jf~::;ililk~[;~--:IH~:'~~~~:~?_ ~ri~~i{~~~~:~~~~:~~-~~ ~ ~:;~~3fr~!~~r~~:~:J~:~~~~~~;~:I~:~-~~~~~~
___"'___~_"~__________",-=--, _'~______",,___ ,_ _~_-u_ _or_~""'-ii!:",*_"Co!!OliI' :ifL;}"",,-'"--"""""'- ,_=_ ____"_ _"""~_ " __ ill* "' ",_"" ,"' _:no_""'""__"'___ ___" ._____j''i._=0'_'ili,''''_*_*____oro~~ _-u__gi;-~""'" _*'_ ClC","",___
_.._M..._...O;;';...._~~'"'__,..__.. _. ..__+'~___ _ ____..__-;-___ __............nr_....:.,....__~ti--__..__ ~..._'i-:.. ;l.l'....H"- ...:..'"\ti.; _...._... ::}!:..-............ _~__......l.t'.. ...._.......... ..:..r.r.:r,..l,..._,.... ., _i-l_.............i.lii..., ____1-r__...._:<;.;, ........~~.....~_....w...;.._"tt.. ..-- --_..~..-.~
A. '-R!. The aboVII infol"lIBUon and tax dull is col"l"ect.
'-t' 1. You lIBY ChoOSll to I"_it paYllllllt to thll Registel" of WUls with two copias of this notica to obtain
a discount 01" avoid intel"astl or you ny check box "A" III1d I"eturn thls notiCll to the Registlll" of
lUll. end an official a..es.ent wUl be issued by the PA Depal"t11811t of Rev8l1Ul1.
B. 0 Tha above asset h.s been 01" wUl be I"epol"ted and tax paid with the Pennsylvania Inh.dtlll'lcII Tax l"etul"n
to be filed by the decadent"s l"epl"lI..ntative.
C. 0 The above infol"lIBUon is incol"l"ect and/al" debts and deductions WlIl"e paid by you.
You IIUst cOlIPlete PART 0 and/Ol" PART ~ billow.
[CHECK ]
ONE
BLOCK
ONLY
PART
[!]
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
If you Indicate a dlff.rent tax rat., pl.as. stat. your
r.lationshlp to decadant:
PART
I!l
TAX RETURN - COMPUTATION OF TAX ON JOINT'TRUST ACCOUNTS
LINE 1. Dat. Established 1
2. Account 8al~ 2
3. P.rcent Taxllbl. 3 X
1ft. AIIount Subject to Tax 1ft
5. Dllbb and DaducUons 5-
6. A.ount Taxab1. 6
7. Tax Rat. 7 X
8. Tax Due 8
~"Y~~
. DESC~It:>>TI.~~.
AMOUNT PAID
I
TOTAL (Ent.r on Un. 5 of Tax CollPUtaUon)
I
.
Under penalti.s of perjury, I declare that the fects
c~l.t. to the best of .y knowledge and belief.
~~ (3 L>~-d"./.# /./~.
~ URE~ ,,-
I have raported above ar. truel corr~t and
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