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PENNSYLVANIA INHERITANCE T
INFORMATION NOTICE
r- ~- ,
~~~ ~ F [~~ AND
BUREAU OF INDIVIDUAL TAXES ~` ~.
PD sox 2eo6o1 ''` ir.~i~ j ''" TAXPAYER RESPONSE
HARRISBURG PA 17128-0681 `Wig s,;;,, .
REV-1543 EX IIFP COB-0e)
~~~ ~~
ABED CO.: PA
DOLORES E DLUZESKI
6038 WILLIAM DR
MECHANICSBURG PA 17055
EST. OF STANLEY J DLUZESKI
SSN 165-20-6131
DATE OF DEATH 12-16-2009
COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
TYPE OF ACCOUNT
SAVINGS
® CHECKING
TRUST
CERTIF.
WACHOVIA BK NA 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 ]oint 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 accoun# .is *_axable in accordance with the Inheritance lax laws of the Commonwealth of
Pennsylvania. Please call C717) 787-8327 with questions.
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 1014149089618 Date 12-03-1996 To ensure proper credit to the account, two
Established copies of this notice must accompany
Account Balance 323.89 payment to the Register of Wills. Make check
payable to "Register of Wills, Agent".
Percent Taxable X 50.000
Amount Subject to Tax ~ 161.95 NOTE: If tax payments are ^ade within three
months of the decedent's date of death,
TaX Rate X ~ 11j deduct a 5 percent discount on the tax due.
Potential Tax Due
~` 24.29 Any Inheritance Tax due will become delinquent
nine months after the date of death.
P~T
~ TAXPAYER RESPONSE
.~
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
Wills and an official assessment will be issued by return this notice to the Register of
the PA Department of Revenue.
C ONE
BLOCK 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 revresentative.
C. ~ The above informs ion is incorrect and/or debts and deductions were paid.
Complete PART 2~ and/or PART 3~ below.
PART If indicating a different tax rate, please state =
relationship to decedent: SO DrteP. '.~ s~ ~
et ' :.»•:
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
1
2 +~`
3 X
4 $
5
6
7 X c~ p
8 $ • d~
~- IOIAL cEnter on Line 5 of Tax Computation) 8
Un er en lties of erj ry, I declare that the facts I have reported above are ru , correct and
p e b my knowledge a belief. HOME )
WORK ( ) ~
~ AYER SIGN TELEPHONE NUMBER E
FILE N0. 21- ~O-d3Ie7
ACN 10115044
DATE 03-16-2010
PART DEBTS AND DEDUCTIONS CLAIMED
a
DATE PAID PAYEE DESCRIPTION AMOUNT PAID