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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 07- 0415
07125529
06-08-2007
REV"1~43 EX AFP to9.. 00)
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EST. OF MARY E BARRICK
S.S. NO. 186-28-3875
DATE OF DEATH 03-31-2007
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
D CHECKING
o TRUST
!Xl CERTIF.
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ORF;~/'<
LARESA A SNYDER eu! .
203 COLD SPRINGS RD
CARLISLE PA 17013
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
ORRSTOWN BANK has Pl'ovided the Depart.ent with the info,..ation lishd 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.ation is incorl'ect. please obtain written correction fro. 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 Co..onwealth
of Pennsylvania. Questions .ay be answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 4000005405
Date 01-25-2005
Established
To insure proper credit to your account. two
(2) copies of this notice .ust acco.pany your
pay.ent to the Register of Wills. Make check
payable to. "Register of Wills. Agent".
Account Balance
Percent Taxable
Amount Subject to Tax
Tax Rate
Potential Tax Due
50,084.54
X 50.000
25,042.27
X .15
3,756.34
TAXPAYER RESPONSE
NOTE. If tax pay.ents are .ade within three
(3) .onths of the decedent's date of death.
you .ay deduct a 5X discount of the tax due.
Any inheritance tax due will beco.e delinquent
nine (9) .onths after the date of death.
PART
[!]
~ CHECK ]
: ONE
,~BLOCK
I ONLY
A. ~ The above infor.ation and tax due is correct.
1. You.ay choose to re.it pay.ent to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest. or you .ay check box "A" and return this notice to the Register of
Wills and an official assess.ent will be issued by the PA Depart.ent of Revenue.
B. ~ 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. ~ The above infor.etion is incorrect andlor debts and deductions were paid by you.
You .ust co.plete PART ~ andlor PART ~ below.
PART
[!]
TAX RETURN - COMPUTATION
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
OF TAX ON JOINT/TRUST ACCOUNTS
1
2
3
4
5
6
7
8
x
If you indicate a different tax rate, please state your
relationship to decedent:
x
PART
[!]
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUNT PAID
I
TOTAL (Enter on Line 5 of Tax Computation)
.
Under penalties of perjury. I declare that the facts I have reported above are true, correct and
complete to the best of my knowledge and belief. ~ HOME ( )
~ ~ fr:/~ ~ (t ~ WORK (7(2) ?-H' ~
TA PAYER SIGNATURE TELEPHONE NUMBER
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DATE
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