HomeMy WebLinkAbout06-25-09REV-1162 EX111-96)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
CLOUSER DOUGLAS G
1875 TOWN HILL ROAD
YORK SPRINGS, PA 17372
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
ACN
ASSESSMENT
CONTROL
NUMBER
fold
ESTATE INFORMATION: ssN: ~s4-2s-5o4s
FILE NUMBER: 2109-0204
DECEDENT NAME: CLOUSER DAVID H
DATE OF PAYMENT: 06/25/2009
POSTMARK DATE: 06/24/2009
COUNTY: CUMBERLAND
DATE OF DEATH: 02/ 20/ 2009
AMOUNT
09117554 ~ 5305.58
TOTAL AMOUNT PAID:
REMARKS:
SEAL
CHECK# 7735
INITIALS: AJW
RECEIVED BY:
5305.58
GLENDA EARNER STRASBAUGH
REGISTER OF WILLS
NO. CD 01 1402
REGISTER OF WILLS
PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE
AND FILE N0. 21 09-0204
BUREAU OF INDIVIDUAL TAXES ACN 09117554
PD Box zao6ol TAXPAYER RESPONSE
HARRISBURG PA 17128-0601 DATE 03-19-2009
REV-1543 EX AFP (08-087
TYPE OF ACCOUNT
EST. OF DAVID H CLOUSER SAVINGS
CHECKING
5SN 184-26-5048 N _.
DATE OF DEATH 02-20-2009 ~ *RF1ST
COUNTY CUMBERLANDGp G CE[dTIF.
REMIT PAYMENT AND FORMS T0: t~} O C..~ ~ ` _
'
DOUGLAS CLOUSER ~- ~~ ~
j
REGISTER OF WILLS ~,~'t•~'t ~
CUMBERLAND CO COURT HOU~E~n~7 u C -,
1875 TOWNHILL ROAD
YORK SPRINGS PA 17372 CARLISLE, PA 17013 <y~~ ~ ~ _?
:'Y Cr
MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the
re a joint owner/beneficiary of this account.
potential tax due. Records indicate that at the death of the above-named decedent, Yau we
tion from the financial institution, attach a copy to this form
If you feel the information is incorrect, please obtain written correc
t is taxable in accordance with the Inheritance Tax laws of the Commonwealth of
and return it to the above address. Thi s accoun
Pennsylvania. Please call i7I7i 7is/-x327 witn questions.
ELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
COMPLETE PART 1 B
Account No. 1 1 3054-42 Date 08-11-2004 To ensure proper credit to the account, two
copies of this notice must accompany
Established
payment to the Register of Wills. Make check
ce
l
B $ 81 , 491.13 payable to "Register of Wills, Agent".
an
a
Account
Percent Taxable X 8.333
NOTE: If tax payments are made within three
Amount Subject to Tax $ 6 , 790 • 66 months of the decedent's date of death,
deduct a 5 percent discount on the tax due.
Tax Rate X . 0 4 5
Any Inheritance Tax due will become delinquent
$ 305.58 nine months after the date of death.
Potential Tax DUe
TAXPAYER RESPONSE
PART FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX A55ES5MENT
A. ~he above information and talc 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
CHECK 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 estate representative.
C. ~ The above informs >.on is incorrect and/or debts and deductions were paid.
Complete PART 2~ and/or PART ~ below.
PART If indicating a different tax rate, Please state OFFICIAL USE ONLY ~ AAF
relationship to decedent: PA DEPARTMENT OF REVENUE -
TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD
1
LINE 1. Date Established 1
2 $ 2
2. Account Balance X
3. Percent Taxable 3 3
4. Amount Subject to Tax 4 '~ 4
5. Debts and Deductions 5 5
6. Amount Taxable 6 $ 6
~ X 7
7. Tax Rate
8. Tax Due $ $ $
DEBTS AND DEDUCTIONS CLAIMED
PART
PAYEE DESCRIPTION AMOUNT PAID
DATE PAID
TOTAL CEnter on Line 5 of Tax Computation) ~
Under penalties of perjury, I declare that the facts I have reported above are tr/~ue, correct and
complete t~6\the best of mY kn~p,~+ledge and belief. HOME C /j7 ~ ~rS ~ y~(~~
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