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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
*'!
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE NO. 21- 07 - CJtb
ACN 07140000
DATE 10-09-2007
REV-15tf'~EX A1!'co9.m
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EST. OF GEORGE D GULDEN
S.S. NO. 174-20-0793
DATE OF DEATH 07-25-2007
COUNTY CUMBERLAND
TYPE OF ACCOUNT
D SAVINGS
[i] CHECKING
D TRUST
D CERTIF.
2007 q('"j 2l
LVI J PN /: l'f2
HELEN T GULDEN
18' N BtlTLCR ~
llT uQLLY SPCE p~ 170'5
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REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
PNC BANK has provided the Depart.ent with the information 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 ioint 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 ~elling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 5140185302
Date 04-01-1963
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".
Account Balance
Percent Taxable
Amount Subject to Tax
Tax Rate
Potential Tax Due
11,618.63
X 16.667
1,936.48
X .00
.00
TAXPAYER RESPONSE
NOTE: If tax pay.ents are .ade within three
(3) .onths of the decedent's date of death,
YOU .ay deduct a 5Y. discount of the tax due.
Any inheritance tax due will beco.e delinquent
nine (9) .onths after the date of death.
PART
[!J
[CHECK ]
ONE
BLOCK
ONLY
A. fV"I The above information 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 Department of Revenue.
B. c=J 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.plete PART ~ and/or PART ~ below.
t;;lHE l- UBt. E3tBblished
2. Account Balance 2
3. Percent Taxable 3
4. Amount Subject to Tax 4
5. Debts and Deductions 5
6. Amount Taxable 6
7. Tax Rate 7
8. Tax Due 8
PART
[!]
DATE PAID PAYEE
x
PART
[!]
TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS
If you indicate a different tax rate, please state your
relationship to decedent:
x
DEBTS AND DEDUCTIONS CLAIMED
DESCRIPTION
AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation)
.
Under penalties of perjury, I declare that the facts
complete to the best of my knowledge and belief.
~~~ :J L~~/
TAXPAYER SIGNATURE
have reported above are true, correct and
(7/7) ~~-~5b/
)
NUMBER
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