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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 171 2B-0601
REV-' '62 EX(' '-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
REST AGNO NANCY
POBOX 396
LEWISBERRY, PA 17339
-------. fold
ESTATE INFORMATION: SSN: 205-62-2415
FILE NUMBER: 2107-1023
DECEDENT NAME: REST AGNO SARA L
DA TE OF PAYMENT: 11/09/2007
POSTMARK DATE: 11/09/2007
COUNTY: CUMBERLAND
DATE OF DEATH: 07/03/2007
NO. CD 008943
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
07144147 I $23.95
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TOTAL AMOUNT PAID:
REMARKS:
CHECK# 5161
SEAL
INITIALS: AJW
RECEIVED BY:
REGISTER OF WILLS
$23.95
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO.21 01 \oa~
07144147
10-19-2007
REV-lSli3 EX AFP (09-00>
EST. OF SARA L RESTAGNO
S.S. NO. 205-62-2415
DATE OF DEATH 07-03-2007
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
o CHECKING
o TRUST
[Xl CERTIF.
NANCY P RESTAGNO
PO BOX 396
LEWISBERRY PA 17339
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
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MEMBERS 1ST FCU has provided the Departaaent with the information listed below which has' be:..i1 used; In
calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a j~int'<owner)ieneficiary of
this account. If you feel this information is incorrect, please obtain written correction frOM the financial institu~ion,~tach a COpY
to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Coaamonwealth
of Pennsylvania. Questions may be answered by calling (717) 787-8327. ~' ,
COMPLETE PART 1 BELOW. . . SEE REVERSE SIDE FOR FILING AND PAYMENT I,N$TRUCTIDNS
Account No. 228093-40
Date 03-28-2006
Established
,,,,,,
To insure proper credit to your ac~nt, two
(2) copies of this notice must accompany your
payment 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
1,064.25
X 50.000
532.13
X .045
23.95
TAXPAYER RESPONSE
NOTE, If tax paYMents are made within three
(3) months of the decedent's date of death,
YOU may deduct a 5% discount of the tax due.
Any inheritance tax due will beCOMe delinquent
nine (9) Months after the date of death.
PART
[!]
[CHECK ]
ONE
BLOCK
ONLY
A. r\YThe 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.
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=l The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART 0 and/or PART 0 below.
If you indicate a different tax rate, please state your
relationship to decedent:
x
PART
~
TAX
RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS
LINE 1- Date Established
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
DEBTS AND DEDUCTIONS CLAIMED
DESCRIPTION
AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation)
$
perjury, I declare that the facts I
knOWledge and belief.
have rep\l.llt d
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