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PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE N0. 21 ~/°~`~G"~
ACN 11117755
DATE 03-17-2011
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FRANCIS I EWING
201 E MAIN STREET
LANDISBURG PA 17040
EST. OF AMBER M LEIBIG
SSN 187-44-9172
DATE OF DEATH 02-25-2011
COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
1 COURTHOUSE SgUARE
CARLISLE PA 17013
TYPE OF ACCOUNT
SAVINGS
CHECKING
TRUST
CERTIF.
FIRST NB OF MIFFLINT OWN 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 C717) 787-8327 with questions.
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 4113997 Date 09-06-2007
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 9, 373.42
payable to Register of Wills, Agent .
Percent Taxable X 16.667
NOTE: If tax payments are made within three
Amount Subject to Tax $ 1 , 562.27 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 ~` 70.30 nine months after the date of death.
PART TAXPAYER RESPONSE
a
~~
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 disc ount 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.
0 N E
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 file d by the estate representative.
C. ~ The above informs ion is incorrect and/or debts and deductions were paid.
Complete PART L=J 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
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
^3
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
Under penalties of perjury, I
complete to the best of my IS,c~
SIGNATURE
a a the facts I have reported above are true, correct and
ge d elief . HOME C ~
WORK c 717 ~ 774-7435
St 2, ESq, TELEPHONE NUMBER DATE
TOTAL (Enter on Line 5 of Tax Computation) S