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HomeMy WebLinkAbout03-07-11COMMONWEALTH OF PENNSYLVANIA REV-1162 EX111-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 014083 STOUFFER RICHARD 158 SPRUCE HOLLOW ROAD CONNELLSVILLE, PA 15425 ACN ASSESSMENT AMOUNT CONTROL NUMBER ---- fold ---------- ESTATE INFORMATION: SSN: 204-02-1478 FILE NUMBER: 211 1-0300 DECEDENT NAME: STOUFFER AMY E DATE OF PAYMENT: 03/07/201 1 POSTMARK DATE: 03/07/201 1 COUNTY: CUMBERLAND DATE OF DEATH: 1 1 /21 /2010 REMARKS: SEAL CHECK# 3642 11114198 ~ $22.60 11114129 ~ $22.57 11114128 ~ $22.65 1 1 1 14204 ~ $15.01 11114197 ~ $45.67 11114200 ~ 522.77 11114202 ~ 575.51 TOTAL AMOUNT PAID: 5226.78 INITIALS: HMW RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE r~ BUREAU OF INDIVIDUAL TAXES AND F I LE NO. 21°l !~ D~ ~~~ Po Box z8o6o1 TAXPAYER RESPONSE ACN 111/14198 HARRISBURG PA 17128-0601 DATE 03-02-2011 REV-1543 EX AFP (08-08) RICHARD E STOUFFER 158 SPRUCE HOLLOW RD CONNELLSVILLE PA 15425 EST. OF AMY E STOUFFER SSN 204-03-1478 DATE OF DEATH 11-21-2010 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. ACN B 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 (717) 787-83?7 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 4990041 Date 02-21 -1998 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance ~` 1 ~ 004.26 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject t0 Tax $` 502.13 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due ~` 22.60 nine months after the date of death. PART TAXPAYER RESPONSE 0 ~. ~~; A. The above information and tax due is correct. Remit 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 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 estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART ~2 and/or PART 3~ below. {`:+~ 3 PART If indicating a different tax rate, please state ~ a relationship to decedent: \\~ TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS ' LINE 1. Date Established 1 \ \\ \\~ 2. Account Balance 2 $ \~ \~\\\ 3. Percent Taxable 3 X ~ O \ 4. Amount Subject to Tax 4 5. Debts and Deductions 5 \~ \ \ 6. Amount Taxable 6 $ ~~'~ \ \ \ ~ ~ \ y 7. Tax Rate 7 X ~.:~~~~ ~~ \ \ ~~~ ~\ 8 . Tax Due 8 $ ~\~~~~~~~.~\~~~ ~~\ \ ~\ ~~ \ ~~~ PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and plete to the best of my knowledge and belief. HOME ~7oZy ~ (r~ ~ 'l~~r~`' ~„1 z ~~ ~ WORK ( ~ ~ - 7' `~ TAXPAYER SIGNATURE TELEPHONE NUMBER DATE TOTAL CEnter on Line 5 of Tax Computation) S PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D Po eox z8o6o1 TAXPAYER RESPONSE HARRISBURG PA 17128-0601 REV-1543 EX AFP <08-OB> RICHARD E STOUFFER 158 SPRUCE HOLLOW RD CONNELLSVILLE PA 15425 FILE NO. 21' ~ ~`~(~,~-0~' ACN 11114129 DATE 03-02-2011 EST. OF AMY E STOUFFER SSN 204-03-1478 DATE OF DEATH 11-21-2010 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. ACNB 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 questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 4990157 Date 05-05-1998 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance ~` 1 ~ 003.10 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $` 501 .55 months of the decedent's date of death, Tax Rate )( .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential TaX Due ~` 22.57 nine months after the date of death. PART TAXPAYER RESPONSE ,, ,, , _ .,, A. The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or check box "A" and return this notice to the Register of C H E C K 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 O N L Y to be filed by the estate representative. 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: ~~ ~. ~~ TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS ~ P ~ \\\~~ _ _ LINE 1. Date Established 1 ~ ~~ 2. Account Balance 2 \ ~~~ X ~ \ \\ 3. Percent Taxable 3 \ 4. Amount Subject to Tax 4 $ ~ ~ ~ \\ 5. Debts and Deductions 5 $ ~ 6. Amount Taxable 6 ~ ~ X `~`~\`\~~~ ~ \\ ~\ 7. Tax Rate 7 $ 7 ~~~ 8. T a x D u e 8 ~~~ ~~~r,_ .~ .:~ ~~ PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and mplete to the best o my knowledge and belief . HOME C7~ cf ) ~~ to ~'~ y-5 TAXPAYER SIGNATURE TELEPHONE NUMBER DATE TOTAL CEnter on Line 5 of Tax Computation) S PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE AND FILE NO. 21`'' ~~-a~ ~~ BUREAU OF INDIVIDUAL TAXES Po Box 280601 TAXPAYER RESPONSE ACN 11114128 HARRISBURG PA 17128-0601 DATE 03-02-2011 REV-)543 EX AFP (08-OB) RICHARD E STOUFFER 158 SPRUCE HOLLOW RD CONNELLSVILLE PA 15425 EST. OF AMY E STOUFFER SSN 204-03-1478 DATE OF DEATH 11-21-2010 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST a CERTIF. ACNB 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 (717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 4990360 Date 10 - 02-1998 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 1 , 006.69 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 503.35 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Anv Inheritance Tax due will become delinquent Potential TaX Due $ 22.65 nine months after the date of death. PART TAXPAYER RESPONSE ..... ... NT, 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 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 estate representative. C. ~ The above informs ion is incorrect andlor 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: \ ~ ~ ~ ~~ `"~ ~, , 2 ~ ~ ?~ TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS ~ ~ \~~ ~~~~ ~~ '~ LINE 1. Date Established 1 2. Account Balance 2 ~ ~~ 3. Percent Taxable 3 X ~~ 4. Amount Subject to Tax 4 $ `~ 5. Debts and Deductions 5 $ \\~ \ 6. Amount Taxable 6 7. Tax Rate 7 X `~ '~ \ \\~\ \ ~ \~ 8. Tax Due 8 $ ~ ` \ ~ ~\ \"~~ \~~ \ ~ ~ ~~ PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are/true, correct and co~plete t~oJthe bes of my knowledge and belief . HOME C 7oZ ~j ~ (~~le ~ l ~.~~~ tC/ ~ ~ WORK C TAXPAYER SIGNATURE TELEPHONE NUMBER DATE TOTAL CEnter on Line 5 of Tax Computation) S PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE AND FILE N0. 21° f ~"-v''~a~ BUREAU OF INDIVIDUAL TAXES Po Box 280601 TAXPAYER RESPONSE ACN 11114204 HARRISBURG PA 17128-0601 DATE 03-02-2011 REV-1543 EX AFP (OB-08) RICHARD E STOUFFER 158 SPRUCE HOLLOW RD CONNELLSVILLE PA 15425 EST. OF AMY E STOUFFER SSN 204-03-1478 DATE OF DEATH 11-21-2010 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. ACNB 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) 787-837.7 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 5990409 Date 11 -15-1998 To ensure proper credit to the account, two Established copies of this notice must accompany Payment to the Register of Wills. Make check Account Balance $ 2 000. $3 s payable to "Register of Wills, Agent". Percent Taxable X 16.667 NOTE: If tax payments are made within three Amount Subject to Tax $ 333.48 months of the decedent's date of death, Tax Rat e X .045 deduct a 5 percent discount on the tax due. Anv Inheritance Tax due will become delinquent Potenti al Tax Due ~` 15.01 nine months after the date of death. PART TAXPAYER RESPONSE The above information and tax due is correct. A. ~ Remit payment to the Register of Wills with two c opies of this notice to obtain a discount or avoid interest, or check box "A" and return this notice to the Register of C H E C K Wills and an official assessment will be issued by the PA Department of Revenue. ONE BLOC 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 estate representative. C. ~ The above informs zon is incorrect and/or debts and deductions were paid. ~.,y , Complete PART 2~ and/or PART 3~ below. ~ ~ r- -~ p T If indicating a different tax rate, please state ~ \\ ~ 2 relationship to decedent: \ \ ^ ~ TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS ~ ~. ~ D ~ ~\ ~\ LINE 1. Date Established 1 \~ 2. Account Balance 2 $ X ~~\ 3. Percent Taxable 3 4. Amount Subject to Tax 4 $ ~~~, 5. Debts and Deductions 5 ~~ ~ \ $ \\ ~ ~ ` ~\~ \ \~~ 6. Amount Taxable 6 7. Tax Rate 7 $ \\ \~~ ...~~ ~~ ~~.\\~ ~~\ 8. Tax Due g ~~ ~ . ~ PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true!, corcr~ect and omplete to the best f my knowledge and belief. HOME C7~ 7 ~ ~~~ ~~~/s.S e _ - C 1C~-~. ~ ~ ~ ~ WORK ( ) ~ -, ~ - ~/ TAXPAYER SIGNATURE TELEPHONE NUMBER DATE TOTAL CEnter on Line 5 of Tax Computation) S PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE j BUREAU OF INDIVIDUAL TAXES AND F I LE NO. 21 "' / j - ~~ ~ ©~ Po Box 2BO6o1 TAXPAYER RESPONSE ACN 11114197 HARRISBURG PA 17128-0601 DATE 03-02-2011 REV-1543 E% AFP (88-88) RICHARD E STOUFFER 158 SPRUCE HOLLOW RD CONNELLSVILLE PA 15425 EST. OF AMY E STOUFFER SSN 204-03-1478 DATE OF DEATH 11-21-2010 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. ACNB 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 ]oint 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 (717) 787-8327 wi#h questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 4990107 Date 03-20-1998 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 2 ~ 029.60 payable to "Register of wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 1 ~ 014 .80 months of the decedent's date of death, Tax Rate )( .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential TaX Due $ 45.67 nine months after the date of death. PART TAXPAYER RESPONSE A. The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or check box "A" and return this notice to the Register of C H E C K 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 O N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. ~"~ t~~~ r -.,..a PART If indicating a different tax rate, please state ~\ relationship to decedent: ~~\ TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS ~;\ LINE 1. Date Established 1 ~ \ `~~ ~~ ~ \ $ \ \ \ 2. Account Balance 2 ~ \ ~ ~ X 3. Percent Taxable 3 \~ 4. Amount Subject to Tax 4 ~. 5. Debts and Deductions 5 - ~~. \ ~ \\ ~~\ ~\\\ \ \ 6. Amount Taxable 6 $ ~ ` ,. ~~ \\ \\\~\\\~ \ 7. Tax Rate 7 X $ ~ ~~. ~ .~~ \~~o~~O..~o ~~ ` 8. Tax Due 8 ~ ~ ~~ ~ ~ ~ ~ PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties e to the c mplet of perjury, I declare that the facts I best of my knowledge and belief . have reported above are true, correct and HOME C ~~ ~ } (~ ~ ~ '~ 1 ~~ S' / ~ TAXPAYER SIGNATURE TELEPHONE NUMBER DATE TOTAL CEnter on Line 5 of Tax Computation) S PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D PD Box z8o6o1 TAXPAYER RESPONSE HARRISBURG PA 17128-0601 REV-1543 EX AFP (08-08) FILE N0. 21 -- ~ ~ ~~G~ ACN 11114200 DATE 03-02-2011 RICHARD E STOUFFER 158 SPRUCE HOLLOW RD CONNELLSVILLE PA 15425 EST. OF AMY E STOUFFER SSN 204-03-1478 DATE OF DEATH 11-21-2010 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. ACNB 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 Pen r.rylvania. Please call C717) 787-83?7 with questions. -COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 4990616 Date 07-25-1999 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 3, 036.51 payment to the Register of Wills. Make check payable to Register of Wills, Agent Percent Taxable X 16.667 Amount Subject to Tax $ 506.10 NOTE: If tax payments are made within three months of the decedent's date of death, Tax Rate X . 045 deduct a 5 percent discount on the tax due. Potential Tax Due $ 22.77 Any Inheritance Tax due will become delinquent nine months after the date of death. PART TAXPAYER RESPONSE A.n~/I 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 paid with the Pennsylvania Inheritance Tax 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3~ below. r«., ~~-.~a eturn PART If indicating a different relationship to decedent: tax rate, please state `~~~ ~ .....~ \\\ ~ ~\ TAX RETURN COMPUTAT ION OF TAX ON JOINT/TRUST ACCOUNT S ~ \ LINE 1. Date Established 1 , \ \ ~~` 2. Account Balance 2 \ 3. Percent Taxable 3 X \~\ 4. Amount Subject to Tax 4 $ ~ 5. Debts and Deductions 5 - ~~\\ ~ 6. Amount Taxable 6 $ ~\~ ~ ~~~ 7. Tax Rate 7 X ~ \•~~ ~~~ \~ ~ ~ 8. Tax Due $ ~~ PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIP TION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best f my knowledge and belief . HOME C ~~ y ) ~ ~- -l YS ti cCr2 C~ .,~ WO R K C ? ~ ., ~._ r~ TAXPAYER SIGNATURE TELEPHONE NUMBER DATE iviia~ itnier on a ne 5 of Tax Computation) ~ PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D Po Box 2BO6o1 TAXPAYER RESPONSE HARRISBURG PA 17128-0601 RFV-1543 EX AFP (OB-08) FILE N0. 21'J~ I ~(1~V~ ACN 11114202 DATE 03-02-2011 RICHARD E STOUFFER 158 SPRUCE HOLLOW RD CONNELLSVILLE PA 15425 EST. OF AMY E STOUFFER SSN 204-03-1478 DATE OF DEATH 11-21-2010 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. ACNB 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 wi±h questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 4990887 Date 07-01-2000 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance ~` 10 ~ 067.50 payable to "Register of Wills, Agent". Percent Taxable X 16.667 NOTE: If tax payments are made within three Amount Subject to Tax ~` 1 ~ 677.45 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due $ 75.51 nine months after the date of death. PART TAXPAYER RESPONSE 0 A.~The above information and tax due is correct. Remit 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 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 estate representative. C. ~ The above informs zon 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 ~ ~ \ ~ ~ ~ ~ 2 relationship to decedent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS P ~~ ~ \ ~ LINE 1. Date Established 1 ~~~~ ~ \ O\ ~~ \ 2. Account Balance 2 $ \ X 3. Percent Taxable 3 "'. ~~~ 4 $ ' ~ 4. Amount Subject to Tax \\ ,~ ~ ~ ,.~ ~ ~ 5. Debts and Deductions 5 ~ ~ ~ ~~~ \ 6. Amount Taxable 6 $ ~ ~ " `\\~\\\ e~\\ \ 7. Tax Rate 7 X $ 7 ` e ~`~ ~ ~ ~ ~\ ~ ~~ ~ o 8. Tax Due 8 , ~ s~~ ~ PART DEBTS AND DEDUCTIONS CLAIMED a DATE PAID PAYEE DESCRIPTION AMOUNT PAI D Under penalties of perjury, I declare that the facts I have reported above are true, correct and the best of my knowledge and belief . ete to c m pl HOME ( 7~~ J) ~,~ ~ ~ y~ 4f / ~ ~ TAXPAYER SIGNATURE TELEPHONE NUMBER DATE TOTAL CEnter on Line 5 of Tax Computation) S