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COMMONWEAL TH OF PENNSYLVANIA *'
DEPARTMENT OF REVEN~r-.:(..'('.'! r._.,.!"'.'r-...11 f'\[C.;0 ,.. ,~,.-
BUREAU OF INDIVIDUALr.'T~! 'Lil-l) \.XI 'Ut: t.-
DEPT. 280.601 'v"n ,"'Tr-,', "
HARRISBURG, PA 17128fllth)!Ln "''',
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO.21 07-0371
07123149
05-31-2007
2001 JUL I r AM": 5 9
REV-1543 EX MP (D'-DR>
CLERK OF
ORPHAN'S COURT
CUt\':FPjl/:C' CO, PA
EST. OF ETHEL PETERSON
5.5. NO. 554-32-9206
DATE OF DEATH 04-14-2007
COUNTY CUMBERLAND
TYPE OF ACCOUNT
D SAVINGS
D CHECKING
D TRUST
Ii] CERTIF.
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 info...aUon listed below which has baan 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 raturn it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Co..onwea1th
of Pennsylvania. Questions.ay be answered by calling (717) 787-1327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 290021-46
Account Balance
Percent Taxable
Amount Subject to Tax
Tax Rate
Potential Tax Due
PART
ill
Date 08-02-2006
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 tOI "Register of Wills, Agent".
55,629.85
X 100.00
55,629.85
X .045
2,503.34
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 becoae delinquent
nine (9) .onths after the date of death.
[CHECK ]
ONE
BLOCK
ONLY
A. c: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 Depart.ent of Revenue.
B. 181 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 infor.ation is incorrect and/or debts and deductions were paid by you.
You .ust co.p1ete PART ~ and/or PART ~ below.
OF TAX ON JOINT/TRUST ACCOUNTS
1
2
3 X
4
5
6
7 X
8
PART
~
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)
.
Under penalties of perjury, I declare that the facts I
tfomPletef~t~r be~ of my knowledge and belief.
(3'1 c;~1z.ttr (1 ~,~ J;rt'tr~<(JfLJJ//-I)1f1uj ~iLH~
TAXPAYER SIGNATURE ~ '
have reported above are true, correc~
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