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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG. PA 17128-0601
REV-1162 EX( 11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
CRUTCHER KAREN
809 NESBIT DRIVE
CARLISLE, PA 17013
n___n_ fold
ESTATE INFORMATION: SSN: 383-28-9592
FILE NUMBER: 2107-1038
DECEDENT NAME: MOODY CARL C
DATE OF PAYMENT: 11/13/2007
POSTMARK DATE: 11/13/2007
COUNTY: CUMBERLAND
DATE OF DEATH: 08/27/2007
NO. CD 008960
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
07144055 I $206.38
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS:
CHECK# 41 03
SEAL
INITIALS: AJW
RECEIVED BY:
REGISTER OF WILLS
$206.38
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
COHHONWEAl TH 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
07144055
10-18-2007
REV-1S43 EX AFP (09-00>
(j) KAREN
809 NESBIT
CARLISLE
CRUTCHER
DR
EST. OF CARL C MOODY
5.5. NO. 383-28-9592
DATE OF DEATH 08-27-2007
COUNTY CUMBERLAND
TYPE OF ACCOUNT
[i] SAVINGS
o CHECKING
o TRUST
o CERTIF.
PA 17013
REMIT PAY~NT AND FO~MS TO:
REGISTER OF:wt,.W..S ~
CUMBERLAND Ccr~URT UnuSE
CARLISLE, PAl-~7;JIJ3
c,...~;
MEMBERS 1 ST FCU has provided the Department with the information listed below which has been used in
calculating the potential tax due. Theil' records indicate that at the death of the above decedent, YOU were e-~oi.t owner~neficial'Y of
this account. If you feel this information is incorrect, please obtain written correction from the financial 1nstitution, attach a COpy
to this fol'll and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of ~~ COIIllonwealth
of Pennsylvania. Questions may be answered by calling (717) 187-8327.
COMPLETE PART 1 BELOW
Account No. 308803-00
Account Balance
Percent Taxable
Amount Subject to Tax
Tax Rate
Potential Tax Due
PART
l!]
IE IE
IE SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Date
Established
06-27-2007
To insure propel' credit to your account, two
(2) copies of this notice must accompany YOUI'
payment to the Register of Wills. Make check
payable tOI "Register of Wills, Agent".
x
9,655.12
50.000
4,827.56
.045
217.24
TAXPAYER RESPONSE
NOTEI If tax payments are .ade within three
(3) months of the decedent's date of death,
you may deduct a 5X discount of the tax due.
Any inheritance tax due will become delinquent
nine (9) months after the date of death.
x
A. r: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 01' avoid interest, 01' 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
8. r:J The above asset has been 01' will be reported and tax paid with the PennSYlvania Inheritance Tax return
to be filed by the decedent's representative.
C. r:J The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
OF TAX ON JOINT/TRUST ACCOUNTS
1
2
3 X
4
5
(;
7 X
8
PART
~
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
DEBTS AND DEDUCTIONS CLAIMED
DESCRIPTION
AMOUNT PAID
.
and
TOTAL CEnter on Line 5 of Tax Computation)
facts I
Under penalties of perjury, I declare that the
~/Ple~e to the best./! my ~nO~ledge and belief.
~~~
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