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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280'01
HARRISBURG. PA 17128-0'01
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2007 JUL I I AM II: 59
CLERK OF
C&I}fH~,N',S,r;C9~~R1A
KAREN MARCH
1520 SELTZER CT
MECHANICSBURG PA 17050
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21 07-0371
07123147
05-31-2007
EST. OF ETHEL PETERSON
S.S. NO. 554-32-9206
DATE OF DEATH 04-14-2007
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
o CHECK I NG
o TRUST
[i] CERTIF.
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 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 info~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 C~.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. 290021-41
Account Balance
Percent Taxable
Amount SUbject to Tax
Tax Rate
Potential Tax Due
PART
ill
Date 09-12-2006
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".
20,627.52
X 100.00
20,627.52
X .045
928.24
TAXPAYER RESPONSE
NOTE. If tax pay.ents are .ade within three
(3) .onths of the decedent's date of death.
you .ay deduct a 5% discount of the tax due.
Any inheritance tax due will bec~e delinquent
nine (9) .onths after the date of death.
A. c:l 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.
[CHECK ]
ONE
BLOCK
ONLY
8. lia 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:l The above infor.ation is incorrect and/or debts and deductions were paid by you.
You .ust co.plete PART ~ and/or PART ~ below.
PART
I!l
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
OF TAX ON JOINT/TRUST ACCOUNTS
1
2
3 X
4
5
6
7 X
8
DESCR I PTI ON
AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation)
.
Under penalties of perjury, I declare that the facts I
l,::/ comp~e to thel'P.est of my. knowledlle and belief.
f'J ~>> '" Efh4tIJdl/l1f)'5,,",,~/ J J. .
L1 Y 'BAd ( !!-!:.( 1/1/1 i:!!:!:t.
. TAXPAYER SIGNATURE
have reported above are true. correct
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