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BUREAU OF INDIVIDUAL TAXES
PO BOX 280601
HARRISBURG PA 17128-0601
I
kEY-1543 E% AFP (08-OB)
PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE
AND FILE N0. 21 08-1167
T~1-~PAYER RESPONSE ACN 09100689
ui,~3C~~ ~,~~ ~~ DATE 01-02-2009
Z~Q9 J~~ ~ ~ F','i
BESSIE V CLOUSE
844 DOUBLING GAP RD
NEWVILLE PA
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eat=~,~',.I'ti~~ ~'~
decQUla,t, 5-IZJ e~'
17241
EST. OF ELMER E CLOUSE
SSN 201-18-3982
DATE OF DEATH 11-03-2008
COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
TYPE OF ACCOUNT
SAVINGS
® CHECKING
TRUST
CERTIF.
ORRSTOWN BANK provided the Department with the information below, which has been used in calculating the
potential tax due. Records indicate that at the death of the above-named decedent, you were a Joint owner/beneficiary of this account.
If you feel the 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. Please call (717) 78?-8327 with questions.
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 101001041 Date 01-01-2001 To ensure proper credit to the account, two
Established copies of this notice must accompany
payment to the Register of Wills. Make check
Account Balance $ 1 , 010 • 73 payable to "Register of Wills, Agent".
Percent Taxable X 50.000
NOTE: If tax payments are made within three
Amount Subject t0 TaX $ 505.37 months of the decedent's date of death,
Tax Rate )( , l rj deduct a 5 vercent discount on the tax due.
Any Inheritance Tax due will become delinquent
Potential Tax Due $ 75 • 81 nine months after the date of death.
PART TAXPAYER RESPONSE
FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT
A. ^ The above information and tax due is correct.
Remit payment to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest, or 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.
C ONE
B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
0 N L Y to be filed by the estate representative.
C. ~ The above informs ion is incorrect and/or debts and deductions were paid.
Complete PART 2~ and/or PART ~ below.
PART If indicating a different tax f~te, please state OFFICIAL U5E ONLY ~ AAF
relationship to decedent: W, PA DEPARTMENT OF REVENUE
TAX RETURN - COMPUTATION OF TAX ON JDINT/TRUST ACCOUNTS PAD
LIME 1. Date Established 1 I
2. Account Balance 2 $ ~
3. Percent Taxable 3 X 3
4. Amount Subject to Tax 4 $ 4
5. Debts and Deductions 5 S
6. Amount Taxable 6 $ 6
7. Tax Rate 7 X ~ 7
8. Tax Due B `~ B
PART DEBTS AND DEDUCTIONS CLAIMED
0
HATE PAID PAYEE DESCRIPTION AMOUNT PAID
TOTAL CEnter on Line 5 or iax (.umpuca uuni
Under penalties of perjury, I declare that the facts I have reported above are true//, correct and
``~~,, complete to the best o my knowledge and belief. // HOME C 7r~ ~ 7~(c' ~Z-~ 3
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TAXPAYER SIGNATU TELEPHONE NUMBER AT