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Home My WebLink About07-21-09COMMONWEALTH OF PENNSYLVANIA REV-1162EX111-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT N0. CD 01 1515 HOUSEMAN DEBRA A 1204 MITCHELL DRIVE MECHANICSBURG, PA 17050 ACN ASSESSMENT AMOUNT CONTROL NUMBER fold ESTATE INFORMATION: ssrv: '1a4-2s-5048 FILE NUMBER: 2109-0204 DECEDENT NAME: CLOUSER DAVID H DATE OF PAYMENT: 07/21 /2009 POSTMARK DATE: 07/20/2009 COUNTY: CUMBERLAND DATE OF DEATH: 02/20/2009 09117550 ~ 5320.91 09117553 ~ 5305.58 09117547 ~ 5321.07 TOTAL AMOUNT PAID: REMARKS: 5947.56 CHECK# 666 INITIALS: JN SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS t BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 _ _ REV-1543 E%~AFP~(OB-093' PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE AND TAXPAYER RESPONSE FILE N0. 21 09-0204 ACN 09117550 DATE 03-19-2009 Z~~~ JAL 2 i ~~` fG~ 30 C~~~r~ (fir= a~~H~~~s (, ,~T cure,. ~ , ~~ ! ~~. i V~. i `~'~' '~' `~~ '~'~' PA. DEBRA HOUSERMAN 1204 MITCHELL DRIVE MECHANICSBURG PA 17050 EST. OF DAVID H CLOUSER SSN 184-26-5048 DATE OF DEATH 02-20-2009 COIINTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU 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 point 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 Pennsv i~r ania. Please eaii i717i 707-0327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 113054-41 Date 02-05-1990 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 85,579.74 payment to the Register of Wills. Make check Percent Taxable payable to "Register of Wills, Agent". X 8.333 AmOUnt Subject to TaX $ 7, 131 .36 NOTE: If tax payments are made within three Tax Rate months of the decedent's date of death, X .045 deduct a 5 percent discount on the tax due. Potential Tax Due $ 320.91 Any Inheritance Tax due will become delinquent nine months after the date of death. PART 1 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 CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of C 0 N E ~ 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 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrIe~c-t~ and/or debts and deductions were paid. Complete PART 2~ and/or PART IJ below. PART If indicating a different tax rate, please state DFfICIAL USE ONLY relationship to decedent:- ~ AAF PA DEPARTMENT OF REVENUE TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Date Established 1 1 2. Account Balance 2 $ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 +~ 4 5. Debts and Deductions 5 - ~ 6. Amount Taxable 6 $ 6 7. Tax Rate 7 X 7 8. Tax Due B $ 8 Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. HOME C ~/ 7 ~ / !( `~GL~~ TAXPAYER SIGNATURE TELEPHONE NUMBER -1DA1TLE v1 PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTTC]N wun(,.,r .,. r,. r - PENNSYLVANIA INHERITANCE TAX MEMBERS 1ST FCU 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 khe 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 thr Commonwealth of Pennsylvania. Please tail (717) 7BY-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 113054-42 Date 08-11-2004 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 81 491.13 payment to the Register of Wills. Make check ~ payable to "Register of Wills, Agent". Percent Taxable X 8.333 Amount Subject t0 Tax $ 6, 790.66 NOTE: If tax payments are made within three months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Potential Tax Due $ 305.58 Any Inheritance Tax due will become delinquent nine months after the date of death. P~r TAXPAYER RESPONSE 1 FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT: INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE N0. 21 09-0204 PO BOX 280601 - HARRISBURG PA 171za-oc01 ~"AXRAYER .RESPONSE ACN 09117553 REY-1543 EX AFP (OB-OB) ~~ DATE 0 3 - 19 - 2 0 0 9 ~~~~ ~~'~ ~ ~ ~~ S .. OF DAVID H CLOUSER TYPE OF ACCOUNT E!(7 ~~ ~ SAVINGS $$~~ 184-26-5048 ~ CHECKING G'«(~~,4-;~ DATE OF DEATH 02-20-2009 TRUST r'OARPHj1,~`I'c~ ~C~~~ OUNTY CUMBERLAND ~ CERTIF. CUAT~'~,,.r, '~+"~ ~ 'EMIT PAYMENT AND FORMS T0: .,t r .`t.'ro.'J h!~} f DEBRA HOUSERMAN R~GISTER OF WILLS 1204 MITCHELL DRIVE CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17050 CARLISLE, PA 17013 A. IYI The above information and tax due is correct. ~[3 Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of 0 N E 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 T 0 N L Y to be filed by the estate representative. ax return C. ~ The above information is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3LJ below. PART If indicating a different tax rate, please state 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 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS pA~ 1 1 2 $ 2 3 X 3 4 $ 4 5 - 5 6 $ 6 7 X ~ 8 $ 8 OFFICIAL USE ONLY ~ AAF PA DEPARTMENT OF REVENUE rnrti DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE nFC(`Rrarrnu _........_ ____ - - - -•• ui iax (,O mpuLaLlOn) $ Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. ~ HOME ( "~(7 ~ '7~1~ -- 7D ~~/ ~ /1Ai, ~iV~-'. TAXP~R SIGNATURE WORK ( ~-~ - TELEPHONE NUMBER DATE y ~ _ PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE N0. 21 09-0204 PO BOX 280601 HARRISBURG PA ln2a-0601 ' 'TAXPAYER RESPONSE ACN 09117547 aEV-is~s~scaracoe-as~~. ~ DATE 03-19-2009 CLE~~s~; Lr ORPHF~J'S ~u.~!)Ri DEBRA HOUSERMAN 1204 MITCHELL DRIVE MECHANICSBURG PA 17050 EST. OF DAVID H CLOUSER SSN 184-26-5048 DATE OF DEATH o2-20-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU 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. rlease call t)t ii iui-b32i witn questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 113054-40 Date 12-14-2005 To ensure vroper credit to the account, two Established copies of this notice must accompany Account Balance $ 85, 622.33 Payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Percent Taxable X 8.333 Amount Subject to TaX $ 7, 134.91 NOTE: If tax payments are made within three months of the decedent's date of death, TaX Rate X . 045 deduct a 5 percent discount on the tax due. Potential Tax Due ~` 321.07 Any Inheritance Tax due will become delinquent nine months after the date of death. PaT TAXPAYER RESPONSE 1 FAILURE TD 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 C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of 0 N E ~ Wills and an official assessment will be issued by the PA Department of Revenue. BLOC K 0 N L Y g, ~ The above asset has been or will be reported and tax paid with the Penns lv y ania Inherit T to be filed by the estate representative. ance ax return C. ~ The above information is incorrect, and/or debts and deductions Complete PART ~2 and/ 3 PAR were paid. or T LJ below. PART If indicating a different tax rate, please state 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 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS pqD 1 2 3 4 $ X $ 1 2 3 4 5 6 7 8 $ X $ 5 6 ~ 8 OFFICIAL USE ONLY ~ AAF PA DEPARTMENT OF REVENUE rcuc i 0 DATE PAID PAYEE DEBTS AND DEDUCTIONS CLAIMED DESCRIPTION AMOUNT PAID TOTAL (Enter on Line 5 of Tax Computation) g Under penalties of perjury, I declare that the facts I have reported above are true, correct and c mplet to the best~of my knowledge and belief. J~ HOME C ~/7 )~` ~l~ G~`1 ~ '~-'~ WORK ( ) T XPAYER SI NA URE ~I---%j TELEPHONE NUMBER DATE