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COMMOllrlEAL TH OF PENNSYLVANIA .-
DEPARTMENT OF REVENUE _
BUREAU OF INDIVIDUAL TAX~CORrTn rC[':!r';-
DEPT. 280&01 ' '" ~I._... Vi : ,IJ
HARRISBURG, PA 17128-0m!iF(:;i.C;Tf:i:) ':^"i I.
................ "..- , ...' I i ~ - L. ;... ',,;'
1liY-IS43 EX ,;p (19- DO)
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO.21 07-0371
07123148
05-31-2007
CLERK OF
ORPHA~J'S COURT
CUI M-::PY (' in~n P^
,-, ,', '. j L._ '...""._:' /'l.,
EST. OF ETHEL PETERSON
S.S. NO. 554-32-9206
DATE OF DEATH 04-14-2007
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
o CHECKING
o TRUST
[i] CERTIF.
2001 JUL I I AM": 5 9
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.ent 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 infor.ation is incorrect, 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
Account No. 290021-44
IE IE
IE SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Date
Established
01-06-2005
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".
x
55,175.08
100.00
55,175.08
.045
2,482.88
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 becoae delinquent
nine (9) .onths after the date of death.
Account Balance
Percent Taxable
Amount Subject to Tax
Tax Rate
Potential Tax Due
x
PART
ill
[CHECK ]
ONE
BLOCK
ONLY
A. r=J 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 nepart.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. r=J The above infor.ation is incorrect and/or debts and deductions were paid by you.
You .ust co.plate PART 0 and/or PART 0 below.
x
If you indicate a different tax rate, please state your
relationship to decedent:
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
PART
[!]
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation)
.
Under penalties of parjury, I declare that the facts I
comple~e ~9 the ~est of my knowledge and belief.
K E5 fIo.tt 0 t ffk/{/ J ,r6"16-'~ ~ --m /J A A I
'f TAXPAYER SIGNATURE :TH,JAJULA
have reported
HOME (71?
WORK ( )
TELEPHONE NUMBER
above are true, correct and
) 1";d. A./A)~:J.-
7 .t} . () 1
DATE
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