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BUREAU OF INDIVIDUAL TAXES
PO BOX 280601
WIRRISBUR~: PA 17128-0601
PENNSYLVANIA INHERITANCE T
INFORMATION NOTICE
AND
("ft ~+~TIAXjpAYER RESPONSE
REV-1563 IX
FILE N0. 21 . /(j- ~/~p7
ACN 09179588
DATE 12-15-2009
eta MAR -2 AM I t ~ 59
~.[1'r1~I+\
J
~* DEVON BETZ C'~~"
33 ROYAL PALM DR
MECHANICSBURG PA 17050-7956
EST. OF HAYDN HUGHES
SSN 169-09-9947
DATE OF DEATH LO-25-2009
COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS TD:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
TYPE OF ACCOUNT
SAVINGS
® CHECKING
TRUST
CERTIF.
PNC BANK NA provided the Department with th• information below, which has bean used in calculating the
potential tax due. Records indicate that et th• death of the above-nomad decedent, you wer• a ioint owner/benaficiarv of this account.
If you foal the information is incorrect, please obtain written correction from the financial institution, attach a copy to this fon
snd return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commornrealth of
Pennsylvania. Please call (iii) 76:-Bb27 with questions.
COMPLETE PART 1 BELOW ^ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 000005005567463 Data 09-15-2009
To ensure proper credit to the account, two
Established copies of this notice must accomparo
Account Balance s 44,421.03 payment to the Rsoistar of Wills. Make check
payable to "Register of Wills, Agent".
Percent Taxable X 50.000
Amount Subject to Tax ~ 22, 210.52 NOTE: If tax payments are made within three
months of the decedent's data of death,
Tax Rate
X , 1 5 deduct a 5 percent discount on the tax due.
Potential Tax Due ~ 3, 331 .5$ Any Inheri tango Tax due will become delinquent
nine months after the data of death.
P~r TAXPAYER RESPONSE
1
A. ~ The ebova information and tax due is correct.
Remit payment to the Register of Wills with two copies of this notice to obtain
C CHECK ~ a discount or avoid interest, or check box "A" and return this notice to the Rsoistar of
ONE Wills and an official assessment will b• issued by the PA Department of Revenue.
BLOCK B. ~ Tha ebova asset has boon or will be reported and tax Daid with the Pennsylvania Inheritance Tex return
ONL Y to ba filed by the estate representative.
C. NI Tha ebova inf orma Son is incorrect and/or debts and deductions ware paid.
'yFl' Cwplate PART ~2 and/or PART O below.
PART It Indicating a dlffe rant to rate, pplease state
relationship to deeadont: i~nt [hAF,or -/i'~.,,oQ
TAX RETURN - COMPUTATION OF TAX roN J INT/TRUST ACCOUNTS
~
LINE 1. Data Estsblished 1_ . Q/ ~S
2. Account Balance 2_ $ ~ ~.~'i/a2~. ~ 3
3. Percent Taxable 3 X .~,Q p
4. Amount Subject to Tax 4 ~ _ d /0 ,.3"~
5.
Debts and Deductions
5 p
7
~"~J. Q!~
6. Amount Taxable 6_ ~ /[ y
/. (~ ~~ ~c-~
7. Tax Rate 7_ X s./.~j
8. Tax Due B $~ ~/
PART DEBTS AND DEDUCTIONS CLAIMED
DATE~PA~D PAYEE DESCRIPTION ...,.~...r ..
O P ---- -----
/' f F [C nnuvn~ r•AlU
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r nrw ~ rr-a__
..•-.~ .cn.~r un une 7 oT IaX COmpYtatiOn) f ~'J (7Q
Under penalties of perjury, I declare that the facts I have reported above are true, correct and JJ
complete to the b6Y p 9y kn wledga and belief. HOME ( ~7 ) 6 - fiJ
~~ WORK ( ) 8 -d 7 a~ d W
PAYER SIGNATURE TELEPHONE NUM ER D TE