HomeMy WebLinkAbout02-09-11COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 171'<'.8-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
REV-1162 EX(11-96)
NO. CD 013995
CHIODI DIANE H
24 ANDES DRIVE
MECHANICSBURG, PA 17055
---- fold
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
---------- --------
ESTATE INFORMATION: ssly: 204-~ 2-7757
FILE NUMBER: 21 1 1 -01 70
DECEDENT NAME: DALBON HELEN C
DATE OF PAYMENT: 02/09/201 1
POSTMARK DATE: 02/07/201 1
COUNTY: CUMBERLAND
DATE OF DEATH: 08/09/2010
REMARKS:
10173317 ~ $8.00
TOTAL AMOUNT PAID:
$8.00
CHECK#1299
INITIALS: HMW
SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
PENNSYLVANIA INHERITANCE
INFORMATION NOTICE
BUREAU OF INDIVIDUAL TAXES ,A N D
PO BOX 280601
HARRISBURG PA 17128-0601 TAXPAYER RESPONSE
TAXI
REV-1543 EX AFP (08 08) I
** DIANE H CHIODI
24 ANDES DR
MECHANICSBURG PA 17055
FILE N0. 21
ACN 10173317
DATE 12-21-2010
E:iT. OF HELEN C: DALBON
SSN 204-12-7757
DATE OF DEATH 08-09-2010
COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
TYPE OF ACCOUNT
SAVINGS
XI~ CHECKING
TRUST
CERTIF.
WACHOVIA BK NA
potential tax due. Records indicate that pat the de th of the aboveltnamed de edent,lyou were~a joint owner/benefi~iaralculating the
If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to
and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealthlofaccount.
Pennsylvania. Please call C717) 787-8327 with questions, this form
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTI
Account N~. 101024737b942''" Date •NS
02-05-2010
E5 tablishe d To ensure proper credit to the account, two
copies of this notice must accompany
Account Balance $ payment to the Register of Wills. Make check
Percent Taxable ~~~ 00 payable to "Register of Wills, Agent".
Amount Subject to Tax X 100.00
$ ~ ~ 0 NOTE: If tax payments are made within three
Tax Rate X months of the decedent's date of death,
Potential Tax Due 15 deduct a 5 percent discount on the tax due.
$ (~ . 0 0 Any Inheritance Tax due will become delinquent
PART nine months after the date of death.
10 TAXPAYER RESPONSE
FAILURE TO RESPOND WILL RESULT IN AN'OFFICIAL TAX ASSESSMENT
A• ~ The above information and tax due is correct.
Remit payment to the Register of Wills with two copies of this notice to obtain
C H E C K 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.
B L 0 C K B. ~ The above asset has been or will be reported and tax
0 N L Y to be filed by the estate representative. paid with the Pennsylvania Inheritance Tax return
C• ~ The above inforrma~ion is incorrect and/or debts and deductions were paid.
Complete PART 2~ I and/or PART 3~ below.
PART 7f i.. .I: ....ar__ ._ _ _ u
^
2 - - --• ~ ~~ ~~~<
relationship to decedent: <ax rate, please state
CIFFICI
USE
ONL:~ ~ AAF
TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST PA DEPART ~ OF RC-uENU~
dive i. Late C~tafJll~i~et]
i ACCOUNTS PAl) r- 4, , Y'i
+ + ~
~
2. A c c o u n t B a l a n c e 2 $ •,$`8 ~ f "i 1 r
'-~'*,",~;,?~~` - :
_ ~' ~.,~,~:
3. Percent Taxable
3 )( 2 -~ ~-~ ~ ~ •'y -
4. Amount Subject to Tax q $ ' ~' - ~-
5. Debts and Deductions 5 - 4 '`~~~~`Y
7
'
6•
Amount Taxable
6
$
5
~~ ~.~. r
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7. Tax Rate
7
X
.00 6 ~ • • -~ •
8. Tax Due 8 $ Qp 7 - .1
PART $
PAYEE
DESCRIPTION
AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation)
Under penalties of $
perjury, I declare that the facts I have reported above are true, correct and
complete to the best of my knowledge and belief.
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TAXPAYER SIGNATURE WORK ( )
TELEPHONE NUMBER ~ ~_'~
DATE
DEBTS AND DEDUCTIONS CLAIMED
DATE PAID
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