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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
-
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21-b7-Di/O,-/
07116376
04-11-2007
AEV.1543 EX AF'P (09.00)
I - -I'
, ~!:_, >/
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TYPE OF ACCOUNT
o SAVINGS
[i] CHECKING
o TRUST
o CERTIF.
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(,,"
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EST. OF CHARLES WIBLE
5.5. NO. 204-30-7428
DATE OF DEATH 02-25-2007
COUNTY CUMBERLAND
ZELDA WIBLE
LOT 31
82 LINDA DR
MECHANICSBURG PA 17050
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
MEMBERS 1ST FCU has provided the Department with the infor.ation 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 information is incorrect, please obtain written correction from the financial institution, attach a copy
to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth
of PennSYlvania. Questions may be answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 196031-11
08-10-2000
Account Balance
Percent Taxable
Amount Subject to Tax
Tax Rate
Potential Tax Due
PART
[!]
Date
Established
To insure proper credit to your account, two
(2) copies of this notice must accompany your
payment to the Register of Wills. Make check
payable to. "Register of Wills, Agent".
x
922.96
16.667
153.83
.00
.00
TAXPAYER RESPONSE
NOTE. If tax payments are made within three
(3) months of the decedent's date of death,
you may deduct a 5X discount of the tax due.
Any inheritance tax due will become delinquent
nine (9) months after the date of death.
x
[CHECK ]
ONE
BLOCK
ONLY
A. ~ The above information and tax due is correct.
;aw 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest, or you may check box "A" and return this notice to the Register of
Wills and an official assessment will be issued by the PA Department of Revenue.
B. c=J The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
to be filed by the decedent's representative.
C. c=J The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
PART
~
TAX RETURN - COMPUTATION
If yoU indicate a different tax rate, please state YOUI'
relationship to decedent:
LINE l. 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
[!J
DATE PAID PAYEE
OF TAX ON
lctU. 5
2
3 X
4
5
6
7
8
x
JOINT/TRUST
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J53,<;S.3
/5:5 '~3
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ACCOUNTS
DEBTS AND DEDUCTIONS CLAIMED
DESCRIPTION
AMOUNT PAID
.
TOTAL (Enter on Line 5 of Tax Computation)
have repOrted above
Under penalties of perjury, I declare that the facts
complete to the be~t of my knowledge and belief.
'YYJLJ~
AXPAYER SIGNATURE
Cj
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