HomeMy WebLinkAbout04-30-10COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0801
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
N0. CD 012676
JANTE-CLAPPSY PA~TRICIA A
5500 F GLOUCESTER STREET
MECHANICSBURG, IPA 17055
fold
ESTATE INFORMATION: 55rv: i~2-24-also
FILE NUMBER: 2110-0455
DECEDENT NAME: CIREIBELBIS MARY L
DATE OF PAYMENT: 014/30/2010
POSTMARK DATE: 04/15/2010
COUNTY: CUMBERLAND
DATE OF DEATH: 12/ 1 9/2009
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
101 ~ 58.20
REV-1162 EX(11-96)
TOTAL AMOUNT PAID:
REMARKS: PATRICIA JANTE-CLAPPSY
CHECK#1901
INITIALS: WZ
SEAL RECEIVED BY:
58.20
GLENDA EARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
PENNSYLVANIA INHERITANCE TAX
MID PENN BANK provl dad the Dapartaent with the inf oraation below, which has been used in calculating the
potential tax due. Records indicate that et the death of the above-naaed decedent, you were a joint owner/beneficiary of this account.
If you foal the Snforastion is incorrect, please obtain written correction froa the financial institution, attach a copy to this fora
and return it to the above addrpss. This account is taxable is accordance with the Inheritance Tax lws of tha ~naeonw•allh of
Pennsylvania. Please call (717)j 787-8327 with questions.
COMPLETE PART 1 BLOW ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
INFORMATION NOTICE l,
r .~
BUREA~OF INDIVIDUAL TAXES ~ '~ ;. i't n,- ~~y~ FILE N0. 21 /U' UYsS
Po BDx zaosal *%~',-~'~ N.LrSPONSE ACN 10118688
HARRISBURG PA 17128-0601 1
tit"""`'~~~4 `~- `;r"~,.`-~ DATE 03-31-2010
R5Y-1563 EX KP toe-00)
ZQ~Q ~PR 30 Q TYPE OF ACCOUNT
EST.30F MARY L DREIBELBIS ^ snvlNCs
CLERK QF pSpSTE OF DEATH721241912D09 ^ TRUSTING
Of3PHAIU,, ~DJNTY CUMBERLAND CERTIF.
RE PAYMENT AND FORMS T0:
P14iA8i2lA A PPS REGISTER OF WILLS
5500 F GLOUCEStER ST 1 COURTHOUSE SQUARE
MECHANICSBURG PA 17D55 CARLISLE PA 17013
Account No. 104067 Date 03-06-2006 To ensure proper credit to the account, two
Established copies of this notice aunt accoaparo
Account Balance $ 3 6 4 . 5 6 paysent to the Register of Wills. Make check
payable to "Register pf Wills, Agent".
Percent Taxable X 50 .000
Amount Subject to TiX ~ 182 .28 NOTE: If tax paysents era aade within three
aonths of the decedent's date of death
Tax Reto
X
.045 ,
deduct a 5 percent discount on the tax due.
Potential Tax Due ~ 8 . 2 0 Any Inheritance Tax due will bacoae delinquent
nine nonths offer the date of death.
P~T
1 TAXPAYER RESPONSE
CHECK
ONE
BLOCK
ONLY
A. ~ The above inf oraation and tax due is correct.
C. ^ The above inf oraa Son is incorrect and/or debts and deductions were paid.
Cpaplete PART 2~ and/or PART 3^ below.
', Reait payunt to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest, or check box "A" end return this notice to the Register of
Wills and an official assessaent will ba issued by the PA Dapartaent of Revenue.
B. ~ The above asset has been or will be reported and taz paid with the Pennsylvania Inheritance Tax return
tp 6e filed by the estate rap resentative.
PART 3r 3na3CiL3ng a d3tferent tax rate, please state
relationship to deleedent:
TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS
LINE 1. Date Established 1
2. Account Balance 2 ~`
3. Percont Taxable 3 X
4. Amount Subject to Tax 4 ~
5. Debts and Deduetioms 5 -
6. Amount Taxablo 6 S
7. Tax Rate 7 X
8. Tax Duo B
PART DEBTS AND DEDUCTIONS CLAIMED
DATE PAID P~4YEE DESCRIPTION AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation) ;
Under penalties of perj!u ry, I declare that tho facts I have reportod above era true, correct and
complete to the host of my knowledge and belief. HOME C )
WORK C )
TAXPAYER SIGNATURE TELEPHONE NUMBER DATE
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