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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
POZSGAY JUDITH M
681 ST JOHNS DR
CAMP HILL, PA 17011
role
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
ESTATE INFORMATION: SsN: ~s3-as-a552
FILE NUMBER: 211 1-0042
DECEDENT NAME: POZSGAY MADELINE M
DATE OF PAYMENT: 03/25/201 1
POSTMARK DATE: 03/24/201 1
COUNTY: CUMBERLAND
DATE OF DEATH: 10/29/2010
REV-1182 EXI11-961
NO. CD 014186
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
11116863 ~ 5225.05
TOTAL AMOUNT PAID:
REMARKS: JUDITH POZSGAY
CHECK# 2527
SEAL
INITIALS: WZ
5225.05
RECEIVED BY: GLENDA EARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE
BUREAU OF INDIVIDUAL TAXES AND FILE N0. 21 11-0042
PO BOX 280601 (} ,;~,T~,'.~'F^~~(B~-YER RESPONSE ACN 11116863
HARRISBURG PA 17126-6601 ~~ ! ''~~~
((rr~~~{{~~~((`` "-`~' ~ c DATE 03-14-2011
REV-1563 EY •Fr (EE•YE)~i )I 1,_ 1! ~~~~_.. i.'J
p TYPE OF ACCOUNT
~~~ i ~~R 2~ ~~~~ `~' ~`~ EST. OF MADELINE M POZSGAY ^ SAVINGS
SSN 163-44-4552 ~ CHECKING
CLERK QF DATE OF DEATH 10-29-2010 ~ TRUST
ORPHANS COURT COUNTY CUMBERLAND Q CERTIF.
C1xulBERtAND CCU. PA REMIT PAYMENT AND FORMS T0:
JUDITH M POZSGAY REGISTER OF WILLS
681 SAINT JOHNS DR 1 COURTHOUSE SQUARE
CAMP HILL PA 17011-1326 CARLISLE PA 17013
PNC BANK NA vrovidad the Department with the information below, which has been used in calculating the
potential tax due. Records intlieata that at the death of the above-named decedent, you ware 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 fora
and return it to th• above address. This account is taxable in accordance with the Inheritance Tax laws of the Commorn+ealth of
Pennsylvania. Please call C717) 787-6327 with euestions. --
COMPLETE PART 1 BELOW ^ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 21000194185 Data 11-23-1992 To ensure proper credit to the account. two
Established copies of this notice must accompany
Account Balance
Percent Taxable
Amount Subject to Tax
Tax Rate
Potential Tax Due
PART
CHECK
ONE
[ BLOCK
ONLY
g 10,002.35
X 50.000
$ 5,001.18
X .045
g 225.D5
oar^ent to the Register of Wills. Mske cheek
payable to "Register of Wills, Agent".
NOTE: If tax payments are wade within three
months of the decedent's dat• of death,
deduct a 5 portent discount on the tax due.
Am Inheritance Tax due will become delineuent
nine months after the data pf death.
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 into rest, 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.
B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
to be filed by the estate representative.
C. ~ The above inf orma Yon is incorrect and/or debts and tleductions were paid.
Complete PART ~ and/or PART 3^ below.
PART If Sndicatin9 a dlfferant tax rata, please state
relationship to decedent:
TAX RE TURN - 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. Taz Due 8
PART DEBTS AND DEDUCTIONS CLAIMED
DATE P AID PAYEE DESCRIPTION AMOUNT PAID
Under penalties of perjury, I declare that the facts I have reported above
complete to the best of my knowletlge and belief. un ur i "1/^l
rue, correct and
7r ~_~9u9
WORK C'7/'/ ) .YleL
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