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PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE
BUREAU OF INDIVIDUAL TAXES ~ ^ r-• r ' °~-s;°, .,; AND F I L E NO. 21 ~ 7 I o~
PO BOX 280601 ` '_ ,~~F ~~ER RESPONSE ACN
HARRISBURG PA ln2s-o6o1 ~, ,~; 09006174
1rr `i
{ ~~ -<~~ ~.~-: ~~~'~ $.: DATE 10-08-2009
REV-1543 EX AFP COB-08)
~~Q~ ~~~ ~ ~ ~~ ~~~ 2~j TYPE OF ACCOUNT
EST. OF JAMES R PATRICK SAVINGS
~~~~~ ~~. SSN ~ CHECKING
4fiPH ~!t'` ,~ ~. DATE OF DEATH 08-11-2009 ~ TRUST
`' ~'` `~` T COUNTY CUMBERLAND
C~~~.~~-;r-r ~ ~ i~,."~ ~ (~~'~~ n ~ CERTIF.
~~''~ ~~"~ REMIT PAYMENT AND FORMS T0:
SCOTT PATRICK REGISTER OF WILLS
8215 BIRCH RUN ROAD CUMBERLAND CO COURT HOUSE
KNOXVILLE TN 37919 CARLISLE, PA 17013
P SE CU 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) 787-8327 with questions.
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 1174206742-C51 Date 04-28-2004
To ensure proper credit to the account, two
Established copies of this notice must accompany
Account Balance $ 80, 694.21 payment to the Register of Wills. Make check
payable to "Register of Wills, Agent".
Percent Taxable X 33.333
Amount Subject to Tax $ 26, 897.80 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 ~- 1 , 21 0.40 Any Inheritance Tax due will become delinquent
nine months after the date of death.
P~r TAXPAYER RESPONSE
1
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
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 incorrect and/or debts and deductions were paid.
Complete PART 2~ and/or PART ~ 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
PART
0
DATE PAID PAYEE
OF TAX ON JOINT/TRUST ACCOUNTS
1
2 $
3 X
4 $
5
6
7 X
8 $
DEBTS AND DEDUCTIONS CLAIMED
DESCRIPTION
AMOUNT PAID
TOTAL CEnter on Line 5 of Tax Computation) ~
Under penalties of perjury, I declare that the facts I have reported above are true, correct and
c lets to the t of my knowledge and belief.
HOME C$rS ) ~f'10~ ~'7'~
WORK Cg ) _ ~ ~ ~
A AYE SIGNA URE TELEPHONE NUM ER
DATE
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 1 7 1 28-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
REV-1162 EX~11-96)
NO. CD 012178
PATRICK CHARLA C
8215 BIRCH RUN LN
KNOXVILLE, TN 37919
-------- fold
ESTATE INFORMATION: ssN:
FILE NUMBER: 2109-1028
DECEDENT NAME: PATRICK JAMES R
DATE OF PAYMENT: 12/31 /2009
POSTMARK DATE: 1 2/08/2009
COUNTY: CUMBERLAND
DATE OF DEATH: 08/ 1 1 /2009
REMARKS:
CHECK# 7316
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
09006174 ~ $1, 210.40
TOTAL AMOUNT PAID:
INITIALS: JN
$1,210.40
SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS