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COMMONl/EAL TH OF PENNSYLVANIA *
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXE~-n _,..
DEPT. 2B060l '1'- . ,"...n (V-C',
HARRISBURG, PA 17l2B-0601 _.Cv.P.),-:.- Vrl i'v' .
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INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21 07-0371
07123144
05-31-2007
2001 JUl I I AM": 5 9
EST. OF ETHEL PETERSON
S.S. NO. 554-32-9206
DATE OF DEATH 04-14-2007
COUNTY CUMBERLAND
TYPE OF ACCOUNT
Ii] SAVINGS
D CHECKING
D TRUST
D CERTIF.
CLERK OF
ORPHAN'S COURT
CU/\l?["I)' ,,}, WI i~C' , PA
KAREN MARCH
1520 SELTZER CT
MECHANICSBURG PA 17050
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
MEMBERS 1ST FCU has provided the Depart..nt with the infoNlation 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 incorrect, please obtain written correction fro. the financial institution, attach a copy
to this fONl 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. 290021-00
Date 07-31-2006
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
Per-cent Taxable
Amount Subject to Tax
Tax Rate
Potential Tax Due
6,471.12
X 100.00
6,471.12
X .045
291.20
TAXPAYER RESPONSE
NOTE. If tax pay.ents ar-e .ade within thr-ee
(3) .onths of the decadent'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
ONLY
A. c:J The above infoNlation and tax due is correct.
1. You.ay choose to r-e.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 repor-ted and tax paid with the Pennsylvania Inheritance Tax return
~ to be filed by the decedent's representative.
C. c:J The above infor-.ation is incorrect and/or debts and deductions wer-e paid by you.
You .ust co.p1eh PART 0 and/or PART I!] below.
x
If you indicate a differ-ent tax r-ate, please state your-
r-elationship to decedent:
PART
~
TAX RETURN - COMPUTATION
LINE 1. Date Established
2. Account Balance
3. Per-cent Taxable
4. A.ount 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
PART
~
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCR I PTI ON
AMOUNT PAID
I
TOTAL (Enter- on Line 5 of Tax Computation)
.
Under- penalties of per-jur-y, I declar-e that the facts I
~comPl,te to th~est of my knowledge and belief.
CY.~ ~ Ot Et1-.f( J, 1I11'~...;<A J ,j))1..IIJtM J In It H -h. " 'l
TAXPAYER SIGNATURE / PN't; ~
have r-epor-ted above ar-e tr-ue, cor-r-ect
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