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PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE
BUREAU OF INDIVIDUAL TAXES ~o^'~ ti~ AND FILE N0. 21'~U"~~~~
PO BOX 288681 '~~ ~' ~~Y'-~'~"~~ee~(pAYER RESPONSE ACN 10112557
HARRISBURG PA 17128-0681 - "' ~`' _ -' ~ ,~'{~-
~' "~ `~- ,,~ ~~' •~''' DATE 03-05-2010
REV-1543 E% AFf4 t~`19Y ~,
2Qt0 APR 19 PIS 1 ~ 29
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TYPE OF ACCOUNT
SAVINGS
® CHECKING
TRUST
CERTIF.
MARIE G OCKER
10994 MORGAN DR
SHIPPENSBURG PA 17257
EST. OF MINERVA l_ GROCE
SSN 206-32-1599
DATE OF DEATH 01-31-2010
COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
ORRSTOWN BANK 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, atkach a copy to this form
and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of th• Commonwealth of
Pennsylvania. Please call (717) 787-8327 with questions.
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTIRUCTIONS
Vn1C
BLOCK
0 N L Y 8. ~ The above asset has been
to be filed by the estate or will be reported and tax paid with the Pennsylvania Inheritance Tax return
representative.
C. ~ The above informs ion is
FFFTTT Complete PART ~2 and/or incorrect and/or debts and deductions were paid.
PART 3~ below.
PART If indicating a different to~{
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ase state
ate, ~ m "~` ' ~+
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relationship to decedent: ;•+-~~~T~~ ~
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TAX RE TURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS E r'~'~~sy~~
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~M•~~ar
LINE 1. Date Established ~}
1 f `7 ~' ~
,
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P`~'r'1','~~a ~~ ew
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2. Account Balance 2 ~ ~
1~0.~ y
~
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3. Percent Taxable T
3 X SO • Ott
rw~
~
1
4. Amount Subject to Tax ~^
4 $ 7 ~~~ ~ ~-- t~
~ f'
~ ~y +
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5. Debts and Deductions 5 c
~
6. Amount Taxable 6~~~~y,~
7. Tax Rate 7 X
8. Tax Due 8 ~ ~~ oZ.2
PART DEBTS AND DEDUCTIONS CLAIMED
DATE PAID PAYEE nFSCRTpr7nu wMnuuT Dwrn
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. unur ~~» . ,.rte ti ~ Qom. ~ ,
TOTAL CEnter on Line 5 of Tax Computation) 6
1"1 VI~C 19U rID CR ~ UAIC
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