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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG. PA 17128-0601
* INFORMATION NOTICE
,r1.r/"", (~,-' f'of'" " AND
...n: lJ) vt~:XPAVER RESPONSE
:'''~I~ t""';:""
REV-1543 EX ."pi fJ!(:oQi
FILE
ACN
DATE
NO.
21 01 S9u
07123128 I
05-31-2007
TYPE OF
ACCOUNT
Iil SAVINGS
o CHECKING
o TRUST
o CERTIF.
2001 JUN 20 AM llESt-S OF CYNTHIA DAVIS
S.S. NO. 040-42-3539
ClERK OF DATE OF DEATH 04-12-2007
ORPHAN'S COUR-'::OUNTY CUMBERLAND
CUM8ERLf.\ND CO, PA
JAMES DAVIS
3929 BROOKRIDGE DR
MECHANICSBURG PA 17050
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
MEMBERS 1 ST FCU has p..ovided the Depa..teent with the info...ation listed below which has been used in
calculating the potential tax due. Thei.. ..eco..ds indicate that at the death of the above decedent. you we..e a joint owne../beneficiary of
this account. If you feel this info..eation is inco....ect. please obtain w..itten co....ection f..om the financial institution, attach a copy
to this fo..e and ..etu..n it to the above add..ess. This account is taxable in acco..dance with the Inhe..itance Tax Laws of the Coeeonwealth
of Pennsylvania. Questions eay be answe..ed by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 181555-00
Date
Established
02-01-1999
To insu..e p..ope.. c..edit to you.. account. two
(2) copies of this notice eust accoepany you..
payeent to the Registe.. of Wills. Make check
payable to: "Registe.. of Wills, Agent".
Account Balance
Percent Taxable
Amount Subject to Tax
Tax Rate
Potential Tax Due
PART
[!]
x
1,121.93
16.667
186.99
.00
.00
TAXPAVER RESPONSE
NOTE: If tax payeents a..e eade within th..ee
(3) months of the decedent's date of death,
you eay deduct a 5X discount of the tax due.
Any ~nhe..itance tax due will becoee delinquent
nine (9) eonths afte.. the date of death.
x
A. ~The above info..eation and tax due is co....ect.
~. You eay choose to ..eeit payeent to the Registe.. of Wills with two copies of this notice to obtain
a discount 0" avoid inte..est. 0.. you eay check box "A" and ..etu..n this notice to the Registe.. of
Wills and an official assessment will be issued by the PA Depa..teent of Revenue.
[CHECK ]
ONE
BLOCK
ONLY
B. c=l The above asset has been 0" will be ..epo..ted and tax paid with the Pennsylvania Inhe..itance Tax ..etu..n
to be filed by the decedent's ..ep..esentative.
C. c=l The above info..eation is inco....ect and/o.. debts and deductions we..e paid by you.
You eust coeplete PART ~ and/o.. PART ~ below.
OF TAX ON JOINT/TRUST ACCOUNTS
1
2
3 X
4
5
6
7 X
8
PART
[!I
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
TOTAL (Enter on Line 5 of Tax Computation)
.
of perjury, I declare that the facts I
of my knowledge and belief.
have reported above are true, correct and
(", > 13 ~-'1 ~3E.
WORK {,f1 >7'b-O;JJ( 'lft"??1
TELEPHONE NUMBER
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