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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1543 EX 11FP (09-DO)
INFORMA_AND NOTICE FILE N0. 21 -- ~c~ _ f~~
ACN 08140087
TAXPAYER: RESPONSE DATE 09-04-2008
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JOYCE~P R A GREGOR
1912 FISHER RD
MECHANICSBURG PA 17055
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EST. OP AI~NE~~AMPSON
S.S.,N~O.
~p `~',~~ b'F DEATH 02-27-2008
~~ CUMBERLAND
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TYPE OF ACCOUNT
® SAVINGS
CHECKING
TRUST
CERTIF.
REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
FULTON BANK has provided the Department 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/benefi.ciary of
this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach 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 Commonwealth
of Pennsylvania. Questions may be answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 4415-64684 Date 02-27-2001 To insure proper credit to your account, two
C2) copies of this notice must accompany Your
Established payment to the Register of Wills. Make check
Account Balance 524.64 payable to: "Register of Wills, Agent".
Percent Taxable X 50 • ~~~ NOTE: If tax payments are made within three
Amount Subject to TaX 262 • 32 C3) months of the decedent's date of death,
X 1 5 you may deduct a 59: discount of the tax due.
Tax Rate Any inheritance tax due will become delinquent
Potential TaX Due 39.35 nine (9) months after the date of death.
P~T TAXPAYER RESPONSE
~ FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT BASED ON THIS NOTICE
A. nJ The above information and tax due is correct.
L~J 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
C H E C K Wills and an official assessment will be issued by the PA Department of Revenue.
B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
C ONE
0 N L Y to be filed by the decedent's representative.
C. ~ The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART 2^ and/or PART 3^ below.
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PART If you indicate a different tax rate, please state your
2 relationship to decedent:
TAX RETURN - COMPUTATION
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
&_ Tax Due
OF TAX ON JOINT/TRUST ACCOUNTS
1
2
3 '~
4
5
6
7 Y
8
PAD
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2
3
4
5
6
7
B
OFFiC1AL 1lJ't urytT ~nr+i
PA DEPARTMENT OF REVENUE
DEBTS AND DEDUCTIONS CLAIMED
PART
DATE PAID PAYEE DESCRIPTION
AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation) S
Under penalties of perjury, I declare that the facts I have repor~tyed above are true, correct and
mplete to the best of my knowledge and belief. HOME C /~~ ~G/`/-~`~Z'
WORK C ' ~~ D ~~
%4~ ~ '~'~'~°'_.. ~~ ~ TELEPHONE NUMBER DATE