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Home My WebLink About07-14-10BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 REV-1543 IX 11FP (BB-OB) OF TAX ON JOINT/TRUST ACCOUNTS 1 Z~~~ J~~.. { Ei P~ ~5~~ OF JUNE D SMITH SSN 201-18-7266 C~~F~K ~~ DATE OF DEATH 02-02-2010 Q~~~~k~'~ ~~~t~OUNTY CUMBERLAND CI 1~~!!?~ ~ ,~.~ p~~ J('~ R~T PAYMENT AND FORMS T0: GEORGE A SMITH U REGISTER OF WILLS 28 NORTH 23 ST 1 COURTHOUSE SQUARE CAMP HILL PA 17011-3816 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 duo. Records indicate that at the death of the above-named decedent, You were a ioint owner/beneficiary of this account. If you feel the infonation 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 Account No. 1010125413176 Date 11-02-2005 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 3, 390.97 payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to Tax ~ 1,695.49 NOTE: If tax payments are made within three months of the decedent's date of death, TaX Rate X , 1 5 deduct a 5 percent discount on the tax due. Potential Tax Due g 254.32 Any Inheritance Tax due will become delinquent nine months after the date of death. PART TAXPAYER RESPONSE 1 .. A. ~ The above information and tax due is correct. Resit 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 return this notice to the Register of 0 N E 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 Penn 0 N L Y to be filed by the estate representative. Sylvania Inheritance Tax return 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:- W /~ ~ 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. lax Rate 8. Tax Due PART 0 DATE PAID PAYEE 2 3 X 4 5 6 7 X 8 $ PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE AND FILE N0. 21-~o-/aa9 ~'`:!'~~~~~,~~`~~"RESPONSE ACN 10134100 -••-~ ~ °s r r} }~ DATE 06-17-2010 K ! i (i _i DEBTS AND DEDUCTIONS CLAIMED DESCRIPTION AMOUNT PAID TOTAL (Enter on Line 5 of Tax Computation) 4 Under penalties of perjury, I declare that the facts I have reported above are true, correct and comp a to the best of m knowledge and belief. ,7 ~ ~~ HOME C7[~ ) 7 AXPAYER S NATIIRF WORK ( ) ~`l~~U ADI2 A101521 TF8P2276 Account Detail Inquiry CZ120201 07/08/10 13:52 Org: 075 Serv: DDA Acct: 1010125413176 Tax Id: Memo: H. Legal Title GEORGE A SMITH Tax Id: 5193128542 JUNE SMITH Primary Address: 28 NORTH 23 ST CAMP HILL PA 170113816 Jr/ S Affil Pre Last First M Sr Address PRIMARY SMITH JUNE 23RD PRIMARY SMITH GEORGE A 23RD INQUIRY COMPLETED Command: F1=Help F2=Erase F3=Exit F4=Next F7=Bkwd F8=Fwd Mrgr St: Addr Type N Addr V-Code: City ST Tax Id CAMP HI PA S201187266 CAMP HI PA 5193128542 g;~, ~3'aNti, 1d.h'. JU'~ 0 0 2010 tiAIG'HOVrA - C~ Nunlar IMe.... 1 e.. tin.. ... _ . _ _ To hey agN ills ~~ d ~ and ~~ laundering adivitiee, Federal lave requires al oPe b obtain, verify and record InNorrretion that identHies each Person who amid ,~a,~ ~ ~ ~~ b ~^~ nnet subaequern signature cards Yve ~ ~~ d operr4rg fuh+rv ecoaaMS. Your signaWne on this Agreertterrt will give Thta Agreement, boMt ~~ ~YrMrers and artynnre ovr+r Mrs phone. appiceble b any deposit aooauy Mret you ~amandsd tram time b tirr by WedtOVia, is aDreerrerR does not Jay vuilf arraUref De-aort sigr~ierk eilher~ldatatand this autiarized siprter. ifoWavar, K a~oultts an ntrich ny name may appear end I am not the M you open an aooolalt an behalf d araMner person (tor ~'~We. you open an aooalrM ore areiodlen, guardian. trusts), you veil need b oortlpbts a separate ~~n10~'1 "t>~aboount. Kyou frees any qusMlprs. pease cs3n a wad,o~;a Swaanst ta- ItiesrnrbrwM; ~` ~D ~ APasrrrent, I augorize any yYadtovta Bryn Cyy~,~.) v~ y~ i open an aooourrt now ar b the finttae b accept and ad upon Inahud'are from me b do the fdbwMg: • b open deposit amoursa with Waetaaia; • b transfer M or any Portion d the balance al my accarrNa (including aadil aoc0rsrls); • ~Y~n y oMa a~~ °t account infarrnatlon or otherwise • b at:laln relabel senAOes ofkred by WacFavfe. Aa used in. this ApteeneM, the lame 'tx0duets', "services" end •aooourrt!• inldude various wit Products. services and amounts made sealable b you by W+7chovia. II nara than one Ix+rson k named in Mrs tills for any secant, surh a0oounl vein ba oonsldered a Jolrt aoaorat hretructlons whicfi aRect any d rtry joint aocat~pte may b3plv~r by any ;,,:,r ~+M ovvrrer. References b me in this Yetrugiona eecMon shell a rear)+~' account h0kter(s). T~ b the M I ~Y g~ ketrrrctlona aaly or In writing, in person. by man, mesaerrger, talepAorre. facsimile, . whs service, autome0ed taller madrka, or by any other raasonabie tigrebse with the sa s e~a8 KK ~ °~ trrstructlons which do not contain my Irtseuctlons were signed by me. However, I doarrrenbador~llafona n18)'• at rm aplbn, require my origirrel signahre or any other /'Qeenent auCratzes ignahnre an This Wadavia borer verbal ~ Your a To ederrd sbD Pay-nent ordere up b sbr (6) money. haters the eo~atiorr dMIIs sbr~moMh rtaat ~~ a verbal order for such extension lalepfrone cols Nor various Parbd. t authorize WachOVia b record end rnanlor any purposes, Iratuding b encore scenery, b pr0vids a nxpd d such oonverseMOns and b hrprove the gasify p f > b me. 1 spree b folow such eecuriy Prooedues ore Wadable may require. The aecrsity procedure ~ ~ ~ ~ the alAtrantialy d yNhudiona wlydi are not delivered in person by aotxaar6) b one or more ~ but not lirt~ihed b. the wlro inatsfer d nwney from arty of my lderNMlCetiorr Code try me ar a parso~ ~ the aptlon d Wachovla: (1) delivery of a personal or a person ~~ b ~ ~• (Z) a celbedr, {3) a redfatl0n by me Wadlovta Mae fn i8b ba me d one or more iperns of mY Peraprat ifamatlon which about rhe, or (4) vDi08 recoyritlon Of me combned wlh tl1e use d carte Probing questicre. Tlw telephone rasrrbar(a) b aArdr callbadta abet be made anon ba ~' ~~ rsanber(s) Wadavla may flees for rta- in Its records or aadgrrsd tome by a telephone servin provider. i agree that ihb severity pnoocdure YaetaMore. ) ~rea~ ~ n • ibd.ry ~ ~sryreincaUon code and will P~errt ~ ~ dseemir+ation d such code. I d N1ietaver~kidnd b Wednvla flamrless from any bases, dertngea, suit and _ indud7g any naesarable aaortxys• fees, ttrat Wadavia Mret WadaNa has ~Ying ~ ~ from me, or anyone purporting b be me, )rpv~ aornplked with the appicabb sacudty poeeduroe. I ~rav+~tga receipt d the Wadable fu198 and nepriations governin . requests and agree b ba bouxi by Its tame as may be amended from time ~ tirr~y trertsfer Aalepfanos wTemr and Carditlons; i ages b be board by Mrs farms end oordibore Induding, but not lmPoed b Wachavin's Oepoett Agreanwnl and Oisdoauras, ~ a~the future a service whkh I ot><ain from -Nadavia met i 8170 agree b Pay a1 fop asaodated MMh 6Ud1 pnpdudat0 aocourts and ServiOBe in OpCardBnCa VhM1 the fee er:hedU106 wtrirh will be Provided b me try Wadavia. 11000 692279 (50lpky Rev 01) 0150134231 COMPLETE THE APPROPRIATE W-e FOREIGN CERTIFICATION FIXtM IF YOU ARE CLAJAMNG FOREIGN E)(EMPTION STATUS. RIGHT OF SURVIVORSHIP (ONLY NC ACCOUNTS): t undenfand that by eatabfehirg a Joint fleoount under the provisions oh. North Carolina Genanl Slatuts 53-146.1 that 1. Wachovia may pay the money !n the account b, ar on the order d, airy person named in the account unless we have agreed with the bank that withdrawals require moro than one syreture: and 2. Upon lire dasth of one faint owner the ngrley rerrralnirg M Mle seeount wM belong to tM surviving )clot owners and will not pass ty tnirsrifanoa b Nts halre of ttre da Joint owner or be controlled by tM deceased JdM owney wHL I ~ el to'treats thlRi~_ht of 8urvivorshlp for any JoirK aceourrt SignaWre FORM ilYg StkIAL SECURfTY NUMBER OR EMPLOYER iOtcNT1FICATION NUMBER CERTIFICATION (Not applipble for Non-Resident Aliens): Cms Soda) Severity Number or Enpbysr Identifaatian tr,enber shoWd nekh the first name listed on the account and wi be used for tax reporting purApea,) I. Sestet SaeuMy Number or 6npoyer Idenhflcatlon Nrartber: II. Itreran ~~~n~IdMrg checlt this box: III. Certifiwti0n .Under penalties d DAY. I certify Thal: ~ F~MPT ~• The raariber set bntir above >s my conreq asset secnxly number or anpoyer ~dentllkadon norther (or I have appled for and I am waiting for a rantber b be Issued b 2. I am not subject b bedcup wlMrAold6g because: (a) 1 am euaenrpt tnxn )>a~p xilNaldrg, or (b) I have not been refitted by the IntBrrurl Reventp greyba CII~Sj that I em anbjact b tx7rJwp wilhhotdkq as a nrsrlt d falrre b report d irrOereK 0- dMderrde, a (c) the IRS hays ratified me that i am rb longer subject b badnq wlMoltlrg. 3. t am a U.S. person Cirrdudirg a U.S. rosident alien). Cary}iptipr Nrstrra:Mons - Yw rtsrat was out item 2 abrnre M you have been ratiflad by the drvldBr~lds awn ere ~~~ subjoq b backup withholdug because of under roporflnp 4rteraet or your tax return. Ll BY clleclting this box I errr requesting iesuanoe d an ATM Card or ChedrCerd. The Inbmal Revenue Service does not regWre your consent to any Ixovisbn of fhb doeumant offer than lira CArMtICatIOM nputred b avoid baCbrD WNhhOldinn GEORGE A SMITH '""` "811° 28 NUF2TH 23 ST CAMP HIU... PA 17011 3816 Addroe. DOCUMENT STORAGE COPY SEND TO: NC8538 Customer Access Agreement 1-800-275.3862 W~cxovrA Customer Access Agreement 0152038163 To help tight Ole funding of terrorism and money laundering activities, Federal law requires all financial ine6hrtiona b obtain, verify and record infomtatlon that Identifies each person who opens an amount. This Agroement {S'rgneture Card) Is tlestgned to eliminate most subsequent signature cards and aultxxizalions when opening future accounts. Your aignature on this Agreement will give you ttp convenience of banking anywhere and anytime over the pique. This Agreement, txNh raw and as it may be amended from Ilme to time Dy Wactavia, Is appOcable to any deposit socount that you open with any Wachovia Bank either now or In the future for yourself or jointly with another person or autttodzed signer. I understand this agreement does not apply to amounts on which my name may appear and I am not the authorized signer. However, H you open an account an behalf of another pennon (for example, tl you open an account as custodian, guardian, trustee), you will need to complete a separate Agreement for that account If you have any questions, please call a Wachovia Specialist toll- free at 1-800.WACHOVIA (600-822~ti84). fnstructfons: By signing this Agreement, I authorize any Wachovia Bank {"INachovia') with which I open an axount now or In the future W accept and act upon instructions tram me to do the following: • to open deposN accounts with Wachovia; • to transfer all or any portion of the balance of my accounts (including credit • to dose deposU amounts, process changes of account information Or otherwise servke any of my wacfavla accounts: • to obtain related eervicea offered by WadaNa. AS used in this Agreement the terms "products'. 'services" and 'accounts" include various deposit products, services and amour>ta made avaflable to yt~, by Wachovia. If more than orw parson Is named in the title for arty account, such account will be considered a joint amount. Instructions wltich affect arty of my joint amounts may be given by any joint account owner. References to me In this Instructions section shall also rater to the joint account holder(s). I may give instructions orally or in writing, in person, by mall, messenger, telephone, facsimile, computer tenrlinel, wire service, au6omated teller machine, ar by any other reasonable method. Wechovia may amept and ad upon ouch instructions which do not contain my signature with Ole same effect as If such Instnrctions vrere signed by me. However, I acknowledge ttwt Wactavia rnay, at its option, require rc~Y original signature or any other documentation before ameptinngg and acting upon any mstruk:tians. Your signature on this Agreement autlrorfzes Wachovia to honor verbal s~P payment ortlers up to six (6) months. To extend slop payment orders, WBChovia mull receive a verbal order for such extension before tli0 expiretlan of this six rrtonth period. I authorize Wedavla to record and monitor ar~y telephone pUs for various pwposes, including to ensure amuroq, to provWe a record of such oonversetiens and to improve the quality of service to me. I agree to fallow such security procedures as Wachovia may require. The security procedure agreed upon for verifying the authenticity of inatructions which are not delivered in person by me for any purpose (including, txd not limited to, ilre wire transfer of money tran any of my amounts) Is one or more of the folowing al the option of Wachovia: {f) deivery of a personal identification code by me ore;person purporting to be me, (2) a cal~ack, (3) a reciletion by me or a person purporting to be me O1 one or more items Of my personal Infomuflon which Wachovla has in ks records about me, or {4) voice recognltlon of me combined with the uas of certain probing queslbns. The telephone number(s) to which gllbacka shall be made shafl be any telephone numbers} Wadgvia may have for me in its records or arty telephone number assigned to me by a telephone service provider. i agree Ihal Otis security procedure constitutes a commerdaly reasonable melted of providing security against unauthorized instructions. I agree to maintain the confidentiafiry of arty personal identification ode and will prevent the unauthorized dissemination of stuff code. t agree to indemnity end hold Wadavia harmless from any losses, damages, suite and expenses, of whatever kind, including any reasarabl8 ettomeys' ik:es, Thal Waefavia may Inver as a result of raying upon inslnrcUons from me. or anya~e purporting to be me. provided that Wachovla has complied with the appltcabls security procedures. 1 acknowledge receipt of the Wachovia ndes ~d regulations goveming money transfer requests and agree b Oe bound by its terms as may be amended from t(me b time. Aueptanee of Terms and Conditions: I agree to be bound by Ole terms end conditions including, but not Gmlled to WadaNa's DeposU Agraemerd and Disclosures, applkable to each product of service whkh 1 obtain from Wachovia now Or in the future, which temts and corditlons will be provided to me. I also agree to pay all fees aasoeiated with such products, accounts and services in accordance with the fee adtedules wttich win be provided to coo by Wachovia, If you are claiming Foreign Exemption Status, the appropriate W"8 Foreign Certification Form must be completed for each account owner. OF SURVIVORSHIP (NC and TN ACCOUNTS ONLY: I understand that by signng below end establishing a Joint account under the provisions oL North Carolina General Statute 53.146.1 and Tennessee Cade 42-2.703 that: t. Wachovla may pay the money in ttte account to, or On the order ol, any garcon named in the account unless we have agreed with the hank that withdrawals require more than one aignature: and 2. Upon the death of one Joint owner the money remaining in the account wlq belong to the survtving joint ownere and w61 not pass by Inheritance to the heirs of the dewased joint owner or be coMrolNd by the deceased John owner's wlq. 1 DO elect to create the Right of Survivonhlp for any Joint account By checking this box t am requestlng issuance of an ATM Gard or CheckCard. The Internal Revenue Service does not require your consent to any prow this document other than the certifleatlons reeulred to avetd ha~4„~,.,trtir...r, ~~~~ ~ ~ Slenatun (above IIneI 562279 (Rev 02} PrintName JUNE SMITH Only arre signature per agreement Address 28 N 23RD STREET CAMP HILL PA 17011 DOCUMENT STORAGE COPY SEND TO: NC8538 FORM W6 SOCIAL SECURITY NUMBER OR EMPLOYER IDENTIFICATION NUMBER CERTIFICATION (Not appilcaWe for Non•Resident Alfern): (The Social Security Number or Employer IdentlUcefion Number stautd match the first name listed on the account and will be used for tax reporting purposes.) I. Social Security Numtter or Employer Identlflcation Kumber: 201187266 11. If exempt from backup wNhholding check Chia tax: ~ EXEMPT III. Certification - Under penaltles of perjury, I certly that: f. The number set forth above is my correct social security number or employer idenu7uation numt»r (or I have applied tpr and I am waiting for a number to be issued to me), arxt 2, I am not wbjed to badtup wNhholdlrrpp because; (a) i am exempt from backup withholding, or (b) I have nW been noted by the Intemal Revenue Servke (IRS) that I am wbjecl to backup withholding as a rewH of failure to report all inleroat or dividends, or {e} the IRS has notified me that I am no bnger subject to backup withholding. 3. I am a U.S. person (including a U.S. resident alien). CeRtfleaOon tnstructbna • You must cross out item 2. atxrve it you have treen notified by the IRS that you arc currently subject to hackup withholding because of under reporting interest or dividends on your tax return. 12/01 /2005 r~ ~ I ~® ~' W `~, ~~ ~. o a. ,~~ Z ~ e o ~~~ -" ~ ~ a J Q 0 ~, - `` O qi' ~. Q a a 0 .. ~ ~ ~Q N ~~ W m ~ ~ N I ,~ ~ °°°iii ~ ~~ 0 3