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COMMONWEAL TH OF PENNSYLVANIA *'
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES p~rn,jQ['\,t:f1 Ul\!,:
DEPT. 280601 ' "_'J\." i .i'__LJ ',!
HARRISBURG. PA 17128-0601 RCr:'CT'p (',[ \,~t, , '
-V"'","'l ._.1 j .....:~ ) / ;, !
Rn-lil4'S' EX OFP C09-'0)
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO.21 07-0371
07123143
05-31-2007
2007 JUL I' AM": 5 9
EST. OF ETHEL PETERSON
5.5. NO. 554-32-9206
DATE OF DEATH 04-14-2007
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
o CHECKING
o TRUST
!iJ CERTIF.
CLERK OF
ORPHAN'S COURT
CUMre~;'_/I\!~) CO 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 Departaent with the info~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 inforaation is incorrect, please obtain written correction froa 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 Coa.onwealth
~f Pennsylvania. Questions aay be anr~ered by calling (717) 787-8327.
COMPLETE PART 1 BELOW . * . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 290021-48
Date
Established
08-02-2006
To insure proper cradit to your account, two
(2) copies of this notice .ust accoapany your
pay.ent to the Register of Wills. Make check
payable to: "Register of Wills. Agent".
x
23,571.38
100.00
23,571.38
.045
1,060.71
TAXPAYER RESPONSE
NOTE: If tax payaents are aade within three
(3) aonths of the decedent's date of death,
you .ay deduct a 5X discount of the tax due.
Any inheritance tax due will beco.e delinquent
nine (9) aonths after the date of death.
Account Balance
Percent Taxable
Amount Subject to Tax
Tax Rate
Potential Tax Due
x
PART
[!]
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[CHECK ]
ONE
BLOCK
ONLY
A. E:l The above inforaation and tax due is correct.
1. You aay choose to re.it payaent to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest, or you aay check box "A" and return this notice to the Register of
Wills and an official assessaent will be issued by the PA Oepartaent 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. E:l The above inforaation is incorrect and/or debts and deductions were paid by you.
You aust coaplete PART 0 and/or PART 0 below.
x
If you indicate a different tax rate, please state your
relationship to decedent:
PART
l!l
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
!!l
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUNT PAID
I
TOTAL (Enter on Line 5 of Tax Computation)
.
Under penalties of perjury, I declare that the facts
~' cO.Pletl!l.i~~( ~e .j)est of 1Iy' kno edge and belief.
R d;.Tl1 ot e'f"fS J, Y6'1l1/{fJ"
TAXPAYER SIGNATURE
have reported above are true, correct
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