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COMMONWEALTH OF PENNSYLVANIA " ..
DEPARTMENT OF REVENUE !-I,:rn,..,'''I r-
BUREAU OF INDIVIDUAL TAXES' 'A J,1i)l{i n
DEPT. 280601 -" \A
HARRISBURG. PA 17128-0601 tli (,c: ",' ,
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REV-1S43 Elf AFP <09" 00)
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21 07-0371
07123150
05-31-2007
AM fI: 59
CLERK OF
9~t:~\tIj's caUR
cu. 'I 'I'" "rr, '\ T
~'.." !I' ',,0 r)/
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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
Iil 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 Depert.ent with the inforaation 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 fora 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 b. answ.,.ed bY calling (7l7) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 290021-47
Date
Established
08-02-2006
To insure prope,. credit to your account. two
(2) copies of this notice .ust acco.pany your
pay.ent to the Registe,. of Wills. Make check
payable to. "Register of Wills, Agent".
x
5,349.20
100.00
5,349.20
.045
240.71
TAXPAYER RESPONSE
NOTE. If tax pay.ents are .ade within th,.ee
(3) .onths of the decedent's date of death.
you .ay deduct a 5X discount of the tax due.
Any inhe,.itance tax due will beco.e delinquent
nine (9) .onths after the date of death.
Account Balance
Percent Taxable
AMount Subject to Tax
Tax Rate
Potential Tax Due
x
PART
[!]
[CHECK ]
ONE
BLOCK
ONLY
A. 0 The above infor.ation and tax due is cor,.ect.
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 Depa,.t.ent of Revenue.
B. ~ The ebove asset has been or will be repo,.ted and tax paid with the Pennsylvania Inheritance Tax return
)CW to be filed by the decedent's representative.
C. 0 The above infor.ation is incorrect and/or debts and deductions were paid by you.
You .ust co.plete PART 0 and/or PART 0 below.
x
If you indicate a different tax rate, please state your
relationship to decedent:
PART
I!I
TAX RETURN - COMPUTATION
LINE 1. Date Established
2. Account Balance
3. Percent 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
DESCRIPTION
AMOUNT PAID
I
TOTAL (Enter on Line 5 of Tax Computation>
.
Under penalties of perjury, I
rf~Tplete to th~ b..lst of
I?t o.fl"'1B ofet4sf J ~r6il"~",
TAXPAYER SIGNATURE
facts I have reported above are true, correct
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