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Home My WebLink About06-11-10COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1 7 1 28-0601 RECEIVED FROM: CLAYCOMB LARRY R 141 MIDDLESEX ROAD CARLISLE, PA 17013 -------- fold PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT ESTATE INFORMATION: SSN: 210-38-4407 FILE NUMBER: 2110-0601 DECEDENT NAME: CLAYCOMB HELEN DATE OF PAYMENT: 06/ 1 1 / 2010 POSTMARK DATE: 06/1 1 /2010 COUNTY: CUMBERLAND DATE OF DEATH: 03/24/2010 REV-1162 EX(11-96) NO. CD 012895 ACN ASSESSMENT AMOUNT CONTROL NUMBER 10500759 ~ $10,002.35 TOTAL AMOUNT PAID: REMARKS: FROM LARRY R CLAYCOMB CHECK# 108 $10,002.35 INITIALS: SAP SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES FILE N0. 21' /"Q'°~Or PO BOX 280601 aC.,_`''~~~1' ~ ~,;f TAXPAYERNRESPONSE ACN 10500759 HARRISBURG PA 17128-0601 ''~..'~. •--! ' ~' .. .~ ~ ~r`'i' ~f~?ri I t? DATE 04-27-2010 TYPE OF ACCOUNT ~~~~ ~~~ ~ ~ ~~ `~` ~ g EST. OF HELEN CLAYCOMB ^ SECURITY S.S. N0. 210-38-4407 Q sEC ACCT ~~~~~ ~F DATE OF DEATH 03 - 24 - 2010 ^ srocK Q~~!"}~i~~'~ ~a~R~ COUNTY CUMBERLAND ^ soNDs ~d~,.r~, tLd ~_ ~:~r• ,_,~1„ 1'"~, REMIT PAYMENT AND FORMS T0: LARRY R CLAYCOMB REGISTER OF WILLS 141 MIDDLESEX ROAD 1 COURTHOUSE SQUARE CARLISLE PA 17013 CARLISLE PA 17013 MERRILL LYNCH has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a beneficiary of this asset. If you feel this information is incorrect, please obtain written correction from the transfer agent, 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. Questions may be answered by calling C717) 787-8327. COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 87257395 To insure proper credit to your account, two C2) copies of this notice must accompany your DOD Valuation 701 , 926.15 payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". Percent Taxable X 33.333 NOTE: If tax payments are made within three Amount Subject to Tax 233, 973.04 (3) months of the decedent's date of death, Tax Rate X .045 You may deduct a 59: discount of the tax due. Any inheritance tax due will become delinquent Potential Tax Due 10 , 528.79 nine C9) months after the date of death. PART TAXPAYER RESPONSE ,~, ::.•c 1 rf:x/f: • orrf~• } r ::f•;, ~, ~ r.'Fn`? o-;'/~::: f/` G rr:.r '.'•'!f'; `r.F`s::/~'.:'.•a~r`k%.' <r{"~ "':7'r} :;"r ` r. :. : ^ <'f.y:" • • " r.:,G 'r`~" 9 f z~,r~' : ,ff: , }:' > r"•ff~ ' ' •;,'k>,'.f,~'a....;~•',• Sy} ;ys''rr~ ~`r ,a,.'~~(F/.y/,.' :''s~~~ : ~ f;~ '} F `F• : :..:. f +r3•f :<r ,'if~~'<~., f,'•: ~~~'9~~~'f~f'':.•:'•`:r~i':`k. r:: %•% ..::z' ,'fa. ¢.F'• :`l:` rh r•`I.%~ff ':`:// '/:r ` ,• 3 ~ ~.`5./.:.: ::5f•p: Y.../'.: F•:::afi r!/` :r .. :: r.nu. ` : :.,S..,G:.:.F•~:.:7.• ::.:.:.•F:'1:.. :.4.... /•..fr ` .y~ p:f : /. .:.',?;.: :r .::' 'fb<.:.::.:r. .: f:~.'f.:.,. :.:<.: ~~lf,:~ r.'3fp..v:.G:. i•.r~ :.f.. ;p r8.r ...d/.l. f:h :`:'.4~:.:: r '~~ A. The above information and tax due is correct. LjJ~ You may choose to remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or you may check box "A" and return this notice to the Register of ONE Wills and an official assessment will be issued by the PA Department of Revenue. BLOCK B. ^The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return ONLY to be filed by the decedent's representative. C. ^ The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART ~ below. ~~y;.'r,",f:`•3'' i'•'Li'•r.`f~F:~:., r:' :y t'f:;y 'f 'ra4'. r3;r :'.•/•,••:: PART If you indicate a different tax rate, please state your :fs~1,hfi's~~~~r,,~, £` "` ry: ;':~' ;.>. relationship to decedent: '~r ~~~ ~ ~:f' ~. rf•r~f r5 TAX RETURN - COMPUTATION OF TAX ON ABOVE ASSETCS) `~ ~%~~~f%~• `~ `~f• ` f ~~`%`~`• °'~' ' I ~9~::: r ~ ' ~~r3~fy`.:.: JX.,,'n'•l: p.:Jo: %•'':%M1 'r:r ',fig' y ../u ~ ~ f 5"~'.° LINE 1 . DOD Valuation 1 ~}".:~~~~~%' ~~%~~~ • ~ ' `~~ '~• f .%.; 2. Percent Taxable 2 X >~~-~;~~x•>cFr`f~~`~'yy r '`;.} ,4~ ff:: ;;~~ 3. Amount Subject to Tax 3 ~H, l~f<. `~;~ 4 '• ~ ~ `;yr: '` 4 . Debts and Deductions 4 - `' `~'}r s%•'~• rr< . ~i ..~ ~ :~'!'%' °•<::: ~~~'`y'Y° ..s~:: ~•£~h,•. rj'y:., •. !: Ifi4rf` .' `Yip`' /:.:r'..i.:r ;6, p %'.c /`6':4:/";'' ry~5:%r'.'~r'` }~'!n':.,~.`y,:,ffy/~/,r'`/frfJ.: . ,+ .FS~~,. `,~~' f :l• 5%s' .r:~f,•Y'' fF,:ti"ffi%'. 5. Amount Taxable 5 ;...,,;~.: ~~% ?~~`'`~~%,rl f 1:~::sl • ~3 :'%` r`,`r1g ~~ ' ' ` • } o n f, 6 . Tax Rate 6 X `~,r °f„ ~'"' ~~"f ~ },.,!i~` :. ~'a".,~,`r'%;%~' %'i::; ;'.;F/.::;Y``f.~`,:'~,'/~t''`.,`'f`.6fFi~t{i`9'` ::::::•:' • '` i`~r,`¢ ''~',~~rf~ ` fi 'r. r j . . I. ~':.'I: Y~~ . ~,f:~r/,}!.~' ~' 3`~•+r~~~:'k:::.//U.~F 5 . ,~.r .~r~r•.: r . f{'`,klG~:G nF.r. 7 . Tax Due 7 "~~"~fr>''~':: :. <,¢:~~ ti-,'f,; .o-r:. ` :x• PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE 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 plete to the best of my knowledge and belief. HOME C ! WORK C ) j ~ TAXP SIGNAT RE TELEPHONE NUMBER T COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: CLAYCOMB PAUL E 351 BIRCH LANE BEDFORD, PA 15522 fold PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT ESTATE INFORMATION: SSN: 210-38-4407 FILE NUMBER: 2110-0601 DECEDENT NAME: CLAYCOMB HELEN DATE OF PAYMENT: 06/ 1 1 /2010 POSTMARK DATE: 06/ 1 1 /2010 COUNTY: CUMBERLAND DATE OF DEATH: 03/ 24/ 2010 REV-1162 EX(11-96) NO. CD 012893 ACN ASSESSMENT AMOUNT CONTROL NUMBER 10500760 f $10,002.35 TOTAL AMOUNT PAID: REMARKS: CHECK#106 SEAL INITIALS: SAP $10,002.35 RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES 3; '^'F~~('? }~""~t'~ ±'~~~" AND FILE NO. 21- ()' (,~~p('~ PO BOX 280601 ~~r iJ1~~~'' j `„'~' ~ ~~ - TAXPAYER RESPONSE ACN 10500760 HARRISBURG PA 17128-0601 ;,~> 1' ',_~, ; ~_, ~~'~~~•~ t `~ ~ ~~~L:.=.~ DATE 04-27-2010 REY-1543A AFP <7-00) ~Q I Q Jt#H I I AI'# i~~ ! ~ ~OR~~~'~ ~C~JRT ` ~ -__, i~ PAUL E CLAYCOMB 351 BIRCH LANE BEDFORD PA 15522 TYPE OF ACCOUNT EST. OF HELEN CLAYCOMB ^ SECURITY S . S . NO . 210 - 38 - 4407 X^ sEC ACCT DATE OF DEATH 03-24-2010 ^ s-rocK COUNTY CUMBERLAND ^ BONDS REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 MERRILL LYNCH has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, You were a beneficiary of this asset. If you feel this information is incorrect, please obtain written correction from the transfer agent, 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. Questions may bw answered by calling 1717) 787-8327. COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 87257395 To insure proper credit to your account, two (2) copies of this notice must accompany Your DOD Valuation 701, 926.15 payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". Percent Taxable X 33.333 NOTE: If tax payments are made within three Amount Subject to Tax 233, 973. U4 (3) months of the decedent's date of death, TaX Rate X . QC~rj You may deduct a 5% discount of the tax due. Anv inheritance tax due will become delinquent Potential Tax Due 1 0 , 528 • 79 nine C9) months after the date of death. PART TAXPAYER RESPONSE £l ~'~'r; or:,..,, 'Fr'F % ./ 9'~ `f:'y`' •w%.: >>Y:. ;~. y~ r.~~,;r:> . r„ •:r.`1 r:; :'•,,,u.; , rr y:r .~ .G ,fr".?,. ^ 'i:.~ . 3,: ~. ~~~~~; r•o r'`rf.. ` r~ u~ :,;,/fir ' ~~:: fb~. ~. : Z:. .:, : . i.. , r 'rlyd :, ! •.`~. rrd,"r+,o: ., :i4 ~ f F". ~, •~• :i`~:.:. .CM:" rhr .9.: %'~r:' r !.: ::~': :,`•.~~/~..r...yr rn,, r r,:i: :t•:` 'r-'/ c,n,..'.~~' % /~ r.'rg' r<.% : /.•.: ~:r , f~ 1:. .:rF.. ,.Ir.`'; ~ rint< :..:•.y,.o..~,u..r ffl,ry..ri•,. ~~:r "r ~~•,'. r u "f.~ °,•'b' .yrr:.fl r <,la. !i..,fr.'. r::„F, r/i..'. 15.;::.:r^, /.'•` •%,<t9`r: :r'.%.:>:..,I.,!fzl... :. ... ../,.:..r. r:A"~ ruk.;y:`n•,::, r..r..~ . r.1 %.n•. 1r%',!•ll :r:&,.... or9.'r...: :....:.:....,:...:.::. ... :..:... rr , ,.. .. .:.. : A. ~7he above information and tax due is correct. 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or you may check box "A" and return this notice to the Register of ONE Wills and an official assessment will be issued by the PA Department of Revenue. BLOCK B. ^The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return ONLY to be filed by the decedent's representative. C. ^ The above information is incorrect and/or debts and deductions were paid by You. You must complete PART ~ and/or PART ^3 below. PART If you indicate a different tax rate, please state your •~~<h jy%.;:'',~' fr+~.~• ,, ~ ~F: ,, .~'~ i relationship to decedent: ~%~' ,~"~Y''"~{'"` "~' '~•' 'ir ':~ ^ `~ h~:i~~`' ~ f+ ~ tip `f`+~,~~y ::, .,:.: . r ~r / r . r .~f ~~; :. .. r / .: ': TAX RETURN - COMPUTATION OF TAX ON ABOVE ASSET CS) •"`"~ :.»::... r r .: .:.. r:.. .. ~y' ~.:.:l9fr,'r l r..rr; r' . ',~:5:>',f; LINE 1. DOD Valuation 1 ~`•r~~~• '`'~~ "'~ 1. ~`' r ''~' '~``~'" ~'F;}7:, '~ f ' ~: .:• ,~: '~ , r~/.,6. frr' lr:: ~ °: ~V f`f r /,rv ^~ ` / y'`r;: f ii `f • 4 r`sF'`! r~'•ya°r•`r ,fi.' C' /,~ i': 2 . Percent T a x a b 1 e 2 X F .~".. •~..~..~..r • ;~'% s' . ,f;%,`r~.~%' >~ ~~•~':.~ .~,~; i' : . ~~.c~~%`?. H F./r~"6 'F%ff .; ~r r~ r~,r%/~''. ~ ?: r.:y%•~. ~~: `%F,.! r..: r,.•,fr, ~ f r C:~rk. Cl. F' •; fj yy.': `'r;ril fr , r/ Nk //"'~!''' /' 6' "` /,~ rir"•. 3 . Amount Subject t o Tax 3 '%%;y %%~ ~~%f`~x¢`t %`%`r'%~ii~s~'u , ,: `r'r~~`;rr' `••;!~' / ~; ;~`.'~~. 4. Debts and Deductions 4 - ~%`'`~~F ~` ~ ~ ~ rfr ~, ,.; ,~r.,;:w •'l r'..;hr %'`s9• ~`'~ ` r` ,l9'3`'• ~ if"k•~` r"' ylrls 5. Amount Taxable 5 '~"~~~. `"~'~'~' ~~ ''~~% !'" ~ f ~"~`'~ :Y: :::i!.G~ liFr.'.fj,•.~ifl,:': ` :l.:, y..~r+ ~~ ~ , y: Ff'f r7• } rrry r,. ,,N~aJ//r'~~~' ~{~~ i {;: f ~ r,/ 'F•G~9: 6. Tax Rate 6 X ~%,:l~~~~.~,~`.,~~~.."~.. r ;~f.r-:• ~`r.,;°' ;5,.yflCp~:rn„„%`G ~~/•..%e ` •'i •'fi.` . '.~:.r ri 7 . Tax Due 7 _ ~~~F.:;:.,,< : f prr`: rC::..r„~.:.,:,~.<> ;:~^/~:,4, :.r ;;s'. ,~rr.~, x.~< PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID TOTAL CEnter on Line 5 of Tax Computation) S Under penalties of perjury, I declare that the facts I have reported above are true, correct and c plete to the best of my knowledge and belief. HOME C S~~ ~ ~ ~ 7~ ~ ~,y~ ~~ ~ WORK C ) d TAXPAYER SIGN URE TELEPHONE NUMBER D`AT COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: MITTONG BETTY L 330 ENOLA RD CARLISLE, PA 17013 - fold PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT ACN ASSESSMENT CONTROL NUMBER ESTATE INFORMATION: SsN: 210-38-4407 FILE NUMBER: 2110-0601 DECEDENT NAME: CLAYCOMB HELEN DATE OF PAYMENT: 06/ 1 1 /2010 POSTMARK DATE: 06/1 1 /2010 COUNTY: CUMBERLAND DATE OF DEATH: 03/24/2010 REV-1162 EX111-96) NO. CD 012894 AMOUNT 10500761 ~ ~ 10,002.35 TOTAL AMOUNT PAID: REMARKS: SEAL CHECK#107 INITIALS: SAP RECEIVED BY: $10,002.35 GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 r t r•. gar -a #"±''~ ~ r ,. ~~4.S.~iti,. 4. V ~.5P3A~~~ ,QO) ~. •. J ~~ ~ ~ ~~~ ~ ~ Ht~ ~~~ ~~~~ ~~ 0~'~'~ UC~U~T BETTY L MITTONG 330 ENOLA RD CARLISLE PA 17013 INFORMATION NOTICE AND TAXPAYER RESPONSE FILE N0. 21'/j~"DCpO~ ACN 10500761 DATE 04-27-2010 TYPE OF ACCOUNT EST. OF HELEN CLAYCOMB ^ SECURITY $,$, N0. 210-38-4407 X^ SEC ACCT DATE OF DEATH 03-24-2010 ^ s-rocK COUNTY CUMBERLAND ^ BONDS REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 MERRILL LYNCH has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a beneficiary of this asset. If you feel this information is incorrect, please obtain written correction from the transfer agent, 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. 4uestions may be answered by calling f717) 787-8327. COMPLETE PART 1 BELOW ~ * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 87257395 DOD Valuation 701 , 926 • 15 Percent Taxable X 33.333 Amount Subject to Tax 233, 973.04 Tax Rate X .045 Potential Tax Due 10 , 528 • 79 To insure proper credit to your account, two C2) copies of this notice must accompany your payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". NOTE: If tax payments are made within three (3) months of the decedent"s date of death, You may deduct a 5% discount of the tax due. Any inheritance tax due will become delinquent nine C9) months after the date of death. PART TAXPAYER RESPONSE l ~ .;F,.:. ::k , ,~ fl ~ . .. }.,. :: :. n~ +. ... ^ is f~i': ~`Y" fJ .' Vii: , :: y: ., : ~~~ f' f; .. ~,.~:. ....~, . .f:p 'f•~7 r'f'r~F• f'i ` ;~?'i o.f :::.i:,: k rf.:,S„v c: •i a• •.i :: J : ~. ,.O : r •'." 9::i. •%•. ,f':' f+..r:..t i '•d'F!:{i,;y:... .:il ::.:.. a;. i..:.,4. ru..,:. .: ., b'.:•:,•:h:::. :,/.. /f:. J..., 1M% :.F: f../•'v (a /'.A`:•:••'.. r-,:.: .. f::: /'r:: n9 o.J: .f 4na fi. l : ,:./ :5 Y 6 Jw%:.` .r::': ' r ioY`F..; :., r': .. d..:.R.;:f:.: .. R.f•.: •.f `'.;::f:'.:; n.f:af ...l.'.,, A. The above information and tax due is correct. 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or you may check box "A" and return this notice to the Register of CHECK Wills and an official assessment will be issued by the PA Department of Revenue. ONE 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 decedent's representative. C. ^ The above information is incorrect and/or debts and deductions were paid by You. You must complete PART ^ and/or PART ^ below. , please state our P RT If you indicate a different tax rate y d nt: t d hi ti l `>'fl:%`~1 ~%•,~' f. +~~ ••;F~• .e'•s"` ,f, .'fn`~;.,• ~'•~r<1.,~ ~r ^~% ' ~~`r"'`f'~ ~~ '~`~• ~~J ece e o ons p a 2 re y TAX RETURN - COMPUTATION OF TAX ON ABOVE ASSETCS) %~~.~ rr:~y , :.` ' LINE 1. DOD Valuation 1 •'Fr•)r~•: fi.t`.4 ` .[`1 %,fy l~L, .`L: ;; d,% J ' :: ~~., .: .. } ':r'i:Y,.;: %Fy,':''~% ~~«`"'%'''y'`',{'"` •~;~~ ~`~lf '~~r' , ~ f: ,~ . "rv~~`,~F~;,~~~~ K' ,'.`~,~: f 2. Percent Taxable 2 X ~ Amount Subject to Tax 3 3 ,~~;,ry,~ ~'` ~~~~ ' ~ . Debts and Deductions 4 - 4 q.:.l sr,`,sii';fo, fr""`.'~ i %/, i/~ sir o r, . ri/': n :h, v %;~f'7 4hx,~ ~: '~%' {~,`^ytf.' :~ F: / , ~ yj~ •':~'/r~~'~`j:`d/. '~f5:'%f:~ n ` a' ~!% . I nss; : G' ..:~`%` ~ ~':: :. lF5 i' Fri ~~~~ ~ ' •••~. ~ . .: .. ,,.,., , /.,~ f „f: r ,/~,,.`. ~' %f~yN` •a£/;. ' ,gr',.:.fs !`•,~rrf;,% • ,•`.`'''' ! f~. ,,,, ;~„,' 'y~ ••~' ':~,. ~ ~ nom, rf~,>,r/'~ r.~ '~ ., : ~ ~'~'~„%~ 5 . Amount T a x a b 1 e 5 f ,,``l~ .r . ' r 7/ l •` / / ! ~ + v Y `ib• f ::N ~ ~ `'` ~~y 6 X t 6 T R r r isf . . ~ :~ 1 .:• .: . $ %:~f ~ b%h % " ~ ~ff~ % ~.~' `f ~' , Sri ~;>•~:~'/~`: ,%.~ ..r '~ J . a e ax 7 . Tax Due ~~ yy `,, f dy~f .: rgd:~:' Jt' r.! . ,:/: y9fF5f~iy+ k r ~ ~J ` "'rr <;//in%+^h;Y''9!f,!,.% fr%' G 'r~;>< ~ ~.~ . .<. ,, . t., :,~ . ,~ „ . ,.,.. ~:: PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID TOTAL CEnter on Lfne 5 of Tax Computation) ~ Under penalties of perjury, I declare that the facts I have reporit-e~d/~aJbove'']are true,,e^~co7rrect and / c mplete to the best of my knowledge and belief. HOME C /l / ) c~~~ (~' / ~ < WORK C ) TAXPA SIGNATUR TELEPHONE NUMBER DATE