HomeMy WebLinkAbout09-22-10BUREAU OF INDIVIDUAL TAXES
PO BOX 280601
HARRISBURG PA 17128-0601
REV-1543 E% AFP (08-08)
PENNSYLVANIA INHERITANCE
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
TAX
FILE N0. 21 ' ~v - G,(.Q U
ACN 10152341
DATE 09-17-2010
TYPE OF ACCOUNT
EST. OF KENNETH L CLOUSER rya ® SAVINGS
SSN 300-32-23 ~, - ;NECKING
DATE OF DEATH 04 -11- t/~ ~~ `.T~JST
COUNTY CUMBERLAND ~ ~ m... ,tTIF.
REMIT PAYMENT AND FORMS T0: ~ 1'~I N ~~`. "s
MARY A CLOUSER REGISTER OF WILLS ~v~~ t`J ~~~ Ft::.
230 E WATER ST 1 COURTHOUSE SQUARE ~ ~ ~t "D -'
MIDDLETOWN PA 17057-2256 CARLISLE PA 17013 ~b ~ _-`'~i
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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 point 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 account is taxable in accordance with the Inheritance Tax 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
Under penalties of per3ury, I declare that the facts I have reported above are true, correct and
c~o,,m~p"lete to then best of my knowledge and belief . HOME C '~/ '~) C} ~ ~- _ ~ ,S /J ..--
yr1.Q~ur ~. 1 .r WORK C ) -.ZO -~r.~/ G
TAXPAYER SIGNATURE TELEPHONE NUMBER DATE
TOTAL (Enter on Line 5 of Tax Computation) $