HomeMy WebLinkAbout01-10-11 (5)COMMONWEALTH OF PENNSYLVANIA REV-1162 EX111-96)
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 1 7 1 28-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO.
CD 013871
SAKSA CHARLOTTE M
969 CHARTERHOUSE CT
WESTERVILLE, OH 43081
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
-------- fold ---------- --------
10173684 ~ $213.84
ESTATE INFORMATION: sSN: 163-44-4552
FILE NUMBER: 211 1-0042 ~
DECEDENT NAME: POZSGAY MADELINE M ~
DATE OF PAYMENT: 01 / 10/201 1 ~
POSTMARK DATE: 01 /07/201 1
COUNTY: CUMBERLAND ~
DATE OF DEATH: 10/29/2010
TOTAL AMOUNT PAID: $213.84
REMARKS:
CHECK# 9087
INITIALS: DB
SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH
REGISTER OF WIL LS
REGISTER OF WILLS
BUREAU OF INDIVIDUAL TAXES '
PO BOX 280601
HARRISBURG PA 17128-0601
REV-1543 EX AFP (OB-OB)
PENNSYLVANIA INHERITANCE TAX'
INFORMATION NOTICE
AND
'~'~'AYER RESPONSE
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CHARLOTTE M SAKSA
969 CHARTERHOUSE CT
WESTERVILLE OH 43081
FILE N0. 21 -- ~ I - ~~
ACN 10173684
DATE 12-23-2010
EST. OF MADELINE M POZSGAY
SSN 1b3-44-4552
DATE OF DEATH 10-29-2010
COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
TYPE OF ACCOUNT
SAVINGS
CHECKING
TRUST
CERTIF.
DOLLAR 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, 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 qu25tions.
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Under penalties of perjury, I declare that the facts I have reported above are true, correct and
complete to the best of mpy knowledge and belief . HOME C Ej ~ 1 ) p 1) ~ app S
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TAXPAYER SIGNATURE TELEPHONE NUMBER DATE
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