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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
'*
FILE
ACN
DATE
NO. 21 Cfl DC\.<6S
07140164
10-09-2007
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
REV-1Sli3 EX AFP (09-00)
TYPE OF
ACCOUNT
o SAVINGS
[i] CHECKING
o TRUST
o C-ERTIF.
EST. OF STEPHANIE A RANGE
S.S. NO. 162-48-09~~ ~3
DATE OF DEATH 07-27-~ ~
~'-~ -'n C'~l
COUNTY CUMBERLAND::o''i'J c
'0 ;~ =T~~, C) ---9,
REMIT PAY~~~ND F~MS TO:
REGISTER OF:W'lJ..1-"S - -
CUMBERLAND CP~COURT HOUSE
CARLISLE, P~:?PpI3~
DENNIS RANGE
1007 CHARLES ST
MECHANICSBURG PA 17055
N
+:-
MEMBERS 1 ST FCU 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 joint owner/beneficiary of
this account. If you feel this information is incorrect, please obtain written correction fro.. the financial institution, attach a copy
to this for.. and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Co....onwealth
uf P~nn~llvania. Qucsti~ns may he an5worad by calling (717) 787.8327.
Account No. 204497 -11
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account Balance
Percent Taxable
Amount Subject to Tax
Tax Rate
Potential Tax Due
PART
[!]
Date 08-17-2004
Established
To insure proper credit to your account, two
(2) copies of this notice must accompany your
pay..ent to the Register of Wills. Make check
payable to: "Register of Wills, Agent".
1,488.20
X 16.667
248.04
X .00
.00
TAXPAYER RESPONSE
NOTE: If tax payments are made 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 become delinquent
nine (9) ..onths after the date of death.
A. c=J The above information and tax due is correct.
1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest, or you may check box "A" and return this notice to the Register of
Wills and an official assessment will be issued by the PA Department of Revenue.
[CHECK ]
ONE
BLOCK
ONLY
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. c=J The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
PART
~
TAX
If you indicate a different tax rate, please state your
relationship to decedent:
RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS
I
2
3 X
4
5
6
7 X
8
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
DESCR I PTI ON
AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation)
.
have reported above are true, correct and
Under penalties of perjury, I declare that the facts
complete to the best~ my knowledge and belief.
a. ~ - ~L-- J"7"'
TAYPAV~P <::Tr.:....ATIIP~ /
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