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HomeMy WebLinkAbout03-0328CO~ONHEALTH OF PENNSYLVANIA DEPARTNENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 171Z8-0601 REV-16,1S EX ~FP C09-00) ZNFORNATZON NOTZCE AND TAXPAYER RESPONSE F'rLE NO. 21' dO ~'0~'~ ~ ACN 05105670 DATE 05-0~-Z005 JAY E GAINOR 1008 HAVENHOOD CT MECHANICSBURG PA 17050 TYPE OF ACCOUNT EST. OF HELEN J GAINOR [] SAVINGS S.S. NO. 201-16-q985 [] CHECKING DATE OF DEATH 01-16-2005 [] TRUST COUNTY CUHBERLAND [] CERTTF. REHIT PAYHENT AND FORHS TO: REGISTER OF HILLS CUHBERLAND CO COURT HOUSE CARLISLE, PA 17015 PNC BANK has provided the Deportment with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you mere a joint oNner/bafleficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to th~c fe.~.. ~nd r~turn it t~ th; ~bo~ ~ddr~s;. Th~ ~co,~nt ~s t~b!= ~ accordance ~?i~h the Inher~tencc T~ L~ of the Coe~oneo~Ith of Pennsylvania. Questions may be answered by calling (717) 787-8527. COMPLETE PART ! BELOH # x # SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 51~0022191 Data 01-01-1978 Establ i shed Account Balance 2,5~. 07 Percent Taxable X 16.6 67 Amount Subject to Tax 590.69 Tax Rate X . OEi5 Potent/al Tax Due 17.58 To insure proper credit to your account, tho (Z) copies of this notice must accompany your payment to the Register of Nills. Hake check payable to: "Register of Nills, Agent". NOTE: If tax payments are made within three (3) months of the decedent's date of death, you may deduct a SZ discount of the rex due. Any inheritance tax due oill become delinquent nine (9) months after the date of death. PART TAXPAYER RESPONSE CHECK ONE BLOCK ONLY PART TAY. LTNE A. [--~ The above information and tax due is correct. 1. You may choose to remit payment to the Register of Nills with two copies of this notice to obtaln a discount or avoid interest, or you may check box "A" and return this notice to the Register of Hills and an official assessment will be issued by the PA Department of Revenue. B. D The above asset has been or w111 bo reported and tax paid with the Pennsylvania Inheritance Tax return to be filed by the decedent's representative. C. J-]The above information is incorrect end/or debts and deductions were paid by you. You must complete PART []and/or PART []below. Zf you indicate a different tax rate, please state your relationship to decedent: RETURN - COMPUT^TZON OF TAX OH JOZNT/TRUST ACCOUNTS 1. Date Established I 2. Account Balance 2 3. Percent Taxable 3 X ~. Amount Subject to Tax ~ 5. Debts and Deductions ~ 6. Amount Taxable 6 7. Tax Rate 7 X 8. Tax Due 8 PART DATE PAID DEBTS AND DEDUCTIONS CLAZHE]] PAYEE DESCRIPTION AHOUNT PAID r~, TOTAL (Enter on Line .; of Tax _c-_~m~utation) $ Under pen~P]~ias of porju I declare that tho facts T have reported above are true, correct and nd belief complet, t o/t~e/best/~ . WORK ( 7/'7 ) [~ 2'~ '7~ TAXPAYER S[6RAT~RE TELEPHONE NUMBER DATE GENERAL INFORHATION 1. FA/LURE TO RESPOND NILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. Z. Inheritance tax becomes delinquent nine months after the decedant's date of death. 5. A joint account is taxable even though the decedent's name ams added as a matter of convenience. 4. Accounts (including those held between husband and wife) which the decedent put in joint names within one year prior to death ara fully taxable as transfers. 5. Accounts established jointly betaeen husband and wife aero than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust far" another or others are taxable fully. REPORTING INSTRUCTIONS - PART I - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions ere not being claimed, place an in block "A" of Part I of the "Taxpayer Response" section. Sign two copies and submit them with your check for the amount of tax to the Register of Nills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-154B EX) upon receipt of the return from the Register of Hills. Z. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decadent's representative, place an "X" in block "B" of Part I of the "Taxpayer Response" section. Sign one copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept /BO601, Harrisburg, PA 171Z8-0601 in the envelope provided. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check block "C" and complete Parts Z and according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of #ills of the county indicated. The PA Department of Revenue will issue an official assessment (Fora REV-1548 EX) upon receipt of the return free the Register of Hills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE.' For a decedent dying after II/II/BI: Accounts which the decedent put in joint names within one (I} year of death are taxable fully as transfers. However, there is an exclusion not to exceed $3,000 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk (wx) appears before your first name in tho address portion of this notice, the $3,000 exclusion already has been deducted from the account balance as reported by the financial institution. Z. Enter the total balance of the account including interest accrued to the date of death. 3. The percent of the account that is taxable for each survivor is determined as A. The percent taxable for joint assets established aero than one year prior to the decedent's death: I DIVIDED BY TOTAL NUMBER DF DIVIDED BY TOTAL NUNBER OF X 100 = PERCENT TAXABLE JOINT ONNERS SURVIVING JOINT ONNERS Example: A joint asset registered in the name of the decedent and two other persons. I DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY Z (SURVIVORS) = .167 X 100 = 16.77. (TAXABLE FOR EACH SURVIVOR) B. The percent taxable for assets created within one year of the decedent's death or accounts owned by the decadent but held in trust for another individual(s) (trust beneficiaries): I DIVIDED BY TOTAL NUHBER OF SURVIVING JOINT X 100 = PERCENT TAXABLE OHNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY Z (SURVIVORS} ' .50 X 100 = 507. (TAXABLE FOR EACH SURVIVOR} The amount subject to tax (line 43 is determined by multiplying the account balance (line Z) by the percent taxable (line 5. Enter the total of the debts and deductions listed in Part $. 6. The amount taxable (line 63 is determined by subtracting the debts and deductions (line 5) from the amount subject to tax (line 7. Enter the appropriate tax rate (line 7) as determined baloa. Date of Death Spouse Llneal Sibling 07/01/9~ to 12/$1/9~ 3Z 6Z 01/01/95 to 06/30/00 OX 6Z lSZ 07/01/00 to present OX NThe tax rate imposed on thl ne younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the chitd is 07.. The lineal class of heirs includes grandparents, parentst children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, ahether by blood or adoption. The "ColLateral" class of heirs includes al1 other beneficiaries. CLAINEI) DEDUCTIONS - PART $ - DEBTS AND DEDUCTIONS CLAIHED ALlowable debts and deductions ara determined as follows: A. You legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paper 8 1/2" x 11". Proof of payment may be requested by the PA Department of Revenue. RUSSELL E. GAINOR 8204 JAY E. GAINOR 230 PENNSYLVANIA AVE. d ~ t ~ 00'..~ 60-1273/313 ENOLA, PA 17025-3030 Date /~,_- 1~6 Order of L i~/4"/,.'/~/g'/4/~ LT~ O~:~ J _. Dollars O. PNCBA PNC B~ N.~ ~al PA For BUREAU OF /ND'rVZDUAL TAXES 'rNHERITANCE TAX DIVISTON DEPT. ZSD601 HARRISBURG,, PA 17128-0601 JAY E GAINOR 1008 HAVENWOOD CT MECHANICSBURG PA 17050 COHMONWEALTH OF PENNSYLVANIA DEPARTHENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEHENT, ALLONANCE OR DISALLOHANCE OF DEDUCTIONS, AND ASSESSNENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE OZ-O2-ZOOq ESTATE OF 6AINOR DATE OF DEATH 01-16-Z003 FILE NUNBER Z1 03-0328 COUNTY CUMBERLAND SSN/DC 201-16-q983 ACN 03105670 Amount: REV-I;q8 EX AFP COl-OS) HELEN J HAKE CHECK PAYABLE AND REHZT PAYHENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS REV-1548 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSENENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSHENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE OZ-OZ-ZOOR ESTATE OF GAINOR HELEN J DATE OF DEATH 01-16-2003 COUNTY CUMBERLAND FILE NO. Z1 03-0328 S.S/D.C. NO. ZOl-16-q983 ACN TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED JOINT OR TRUST ASSET INFORMATION 03105670 FINANCIAL INSTITUTION: PHC BANK ACCOUNT NO. 51~0022191 TYPE OF ACCOUNT: ( ) SAVINGS (~ CHECKING ( ) TRUST ( ) TIME CERTIFICATE DATE ESTABLISHED 01-01-1978 Account Balance Percent Taxable X 0.166 Amount Subject to Tax 390.69 Debts and Deductions - .00 Taxable Amount 390.69 Tax Rate X .q5 Tax Due 17.58 TAX CREDTTS: 2,5qq.07 NOTE: TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE ABOVE ADDRESS. MAKE CHECK OR MONEY ORDER PAYABLE TO: "REGISTER OF WILLS, AGENT." PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 0q-11-2003 CDOOZ~q2 .88 17.58 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE IF PATD AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDZTIONAL INTEREST. ~ ( IF TOTAL DUE ZS LESS THAN $1, NO PAYMENT IS REQUIRED. ZF TOTAL DUE ZS REFLECTED AS A 'CREDIT' (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) 18.q6 .88CR .00 .88CR PURPOSE OF NOTICE: To fulfill the requirements of Section Zl~O of the Inheritance and Estate Tax Act, Act Z5 of ZOO0. (TZ P.S. Section 91~0). PAYMENT: REFUND (CR): OBJECTIONS: ADMIN- iSTRATIVE CORRECTIONS: DZSCDUNT: PENALTY: INTEREST: Detach the top portion of this Notice and submit with your payment to the Register of Hills printed on the reverse side. -- Make check or money order payable to: REGISTER OF HILLS, AGENT. A refund of a tax credit, which was not requested on the tax return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (RE¥-13I$). Applications are available at the Office of the Register of Hills, any of the g$ Revenue District Offices or by calling tho special Z~-hour answering service for forms ordering: 1-800-36Z-ZOSO; services for taxpayers eith special hearing and or speaking needs: 1-800-4q7-30ZO (TT only). Any party in interest not satisfied with the appraisement, a11oaance, or diselloaance of deductions or assessment of tax (including discount or interest) as shown on this Notice may object aithin sixty (60) days of receipt of this Notice by: --eritten protest to the PA Department of Revenue, Board of Appeals, Dept. ZBIOZ1, Harrisburg, PA 171lB-lOll, OR --electing to have the matter determined at the audit of the account of the personal representative, OR --appeal to the Orphans' Court Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, DEPT. lB0601, Harrisburg, PA 171ZB-0601 Phone (717) 787-6505. See page S of the booklet "[nstructions for Inheritance Tax Return for a Resident Decedent" (REV-1501) for an explanation of administratively correctable errors. If any tax due is paid within three ($) calendar months after the decedent's death, a five percent (SI) discount of the tax paid is allowed. The 15Z tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January lB, 1996, the first day after the and of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning with first day of delinquency, or nine (9) months and one (l) day from the date oF death, to the date of payment. Taxes which became delinquent before January l, I98Z bear interest at the rate of six (6g) percent per annum calculated at a daily rate of .00016~. A11 taxes which became delinquent on or after January 1) 198Z mill bear interest at a rate which mill vary fram calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 198Z through 2003 are: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor 198Z ZOZ .O005fi& 1987 9g .OOOZfi7 1999 7Z .00019Z 1985 16Z .000¢38 1988-1991 llZ .000301 ZOO0 8Z .O00Z19 xgaq 11X .000501 1992 92 .0002q7 ZOO1 92 .000247 1985 132 .000356 1993-199~ 72 .000192 ZOOZ 6Z .O0016q 1986 102 .O0027~ 1995-1998 9Z .O00Zfi7 2003 52 .000137 --Interest is calculated as follows: /NTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DALLY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days · beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. COttHONWEALTH OF PENNSYLVANIA DEPARTNENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. ZB0601 HARRISBURG, PA 171ZB-0601 RE¥-IS,:iS EX AFP (og-DD) ZNFORMATZON NOTZCE AND TAXPAYER RESPONSE FZLE NO. Zl~'~-i~'~ ACN 03105670 DATE 03-04-2003 JAY E GAINOR 1008 HAVENNOOD CT NECHANICSBURG PA 17050 , TYPE OF ACCOUNT EST. OF HELEN J GAINOR [] SAVINGS S.S. NO. 201-16-1983 [] CHECKINg DATE OF DEATH 01-16-2005 [] TRUST COUNTY CUNBERLAND [] CERTIF. REHIT PAYNENT AND FORES TO: RESISTER OF NILLS CUNBERLAND CO COURT HOUSE CARLISLE, PA 17013 PNC BANK has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correct[on fram the financial institution, attach a copy cf Pennsylvania. Questions amy be answered by calling (717) 787-8527. CONPLETE PART 1 BELOW x x # SEE REVERSE SIDE FOR FILING AND PAYNENT INSTRUCTIONS Account No. 5140022191 Date 01-01-1978 Established Account Balance Z, 31q. 07 Percent Taxable X 16. 667 Amount SubSect to Tax 390.69 Tax Rate X . 045 Potential Tax Due 17.58 To insure proper credit to your account, tee (Z) cop[es of this notice must accompany your payment to the Register of Hills. Hake check payable to: "Register of Wills, Agent". NOTE: If tax payments are made within three (3} months of the decedent's date of death, you amy deduct a 5Z discount of the tax due. Any inheritance tax due w[[l become delinquent nine (9) months after the date of death. PART TAXPAYER RESPONSE A. r~'The above JnformetJon and tax due is correct. 1. You may choose to remit payment to the Register of Hills with two copies of this notice to obtain CHECK a discount or avoid interest, or you may check box  ONE 3 Wills and an official assass~eent will be issued by the PA Department of Revenue. BLOCK J B. [] The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return ONLY to be filed by the decedent's representative. [] The above information is incorrect and/or debts and deductions were paid by you. C. You must camp[ate PART [] and/or PART [] be[ow. PART If you indicate a different tax rate, please stats your [] relationship to decedent: TAX RETURN - CONPIJT?.T!ON OF TAX _nH .JO!NT/TRIJST ACCOUNTS LINE 1. Date Established 2. Account Balance ~ $. Percent Taxable $ X q. Amount SubSect to Tax q $. Debts and Deductions ~ - 6. Amount Taxable 6 7. Tax Rate 7 X 8. Tax Due 8 PART DATE PAID DEBTS AND DEDUCTIONS CLAZNED PAYEE DESCRIPTION ANOUNT PAID / TOTAL (Enter on Line S of Tax Computation) $ Un_der,~alties of perjury, Z declare that the facts I have reported above are true, correct and comple//+,a~to//~he)]~st o~m~k~_nowledge and belief. HONE C 7' 7 TAXPAY TELEPHONE NUHSER D~TE GENERAL INFORHATZON 1. FAILURE TO RESPOND NZLL RESULT ZN AN OFFICIAL TAX ASSESSHENT aith applicable interest based on information submitted by the financial institution. 2. Inhar[tance tax becomes delinquent nine months after tho decadant's data of death, $. A joint account is taxable avon though the decedant's name was added as a matter of convenience. 4. Accounts [including those held bataaan husband and wife) ahich the decedent put in joint names within one year prior to death ara fully taxable as transfers. 5. Accounts estabLished jointly between husband and aifa aero than one year prior to death ara not taxable. 6. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING iNSTRUCTIONS - PART I - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part I of the "Taxpayer Response" section. Sign tam copies and submit them with your check for the amount of tax to the Register of Wills of the county indicated. The PA Bapartaant of Revenue mill issue an official assessment [Form REV-1548 EX) upon receipt of the return from the Register of Nills. Z. BLOCK B - If the asset specified on this notice has been or will ba reported and tax paid with the Pennsylvania Inheritance Tax Return fiIad by the dacadant's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Bapt zanB01, Harrisburg, PA 171Z8-0601 in the envelope provided. $. BLOCK C - If the not[ca information is incorrect and/or deductions ara being claimed, check block "C" and complete Parts 2 and according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Nills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-IS~8 EX) upon receipt of the return from the Register of Hills. TAX RETURN - PART Z - TAX COMPUTATTON LINE 1. Enter the date tho account originally ams established or titted in the manner existing at data of death. NOTE: For a decedent dying after 1Z/1z/az: Accounts which the decedent put in joint names within one (13 year of death ara taxable fully as transfers. However, there is an exclusion not to exceed $3,000 par transferee regardless of the value of the account or the number of accounts held. If a doubZa asterisk (ex) appears before your first name Jn the address portion of this notice, the S3,000 excLusion aIready has bean deducted from the account balance as reported by the financial institution. Z. Enter the total balance of the account including interest accrued to the date of death. 3. The percent of the account that is taxable for each survivor is determined as folloes: A. The percent taxable for joint assets established more than cna year prior to the decedant's death: I DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X lO0 = PERCENT TAXABLE JOTNT ONNERS SURVIVING JOINT ONNERS Example: A joint asset registered in the name of the decedent and two other parsons. I DIVIDED BY 3 [JOINT OWNERS) DTVIDED BY Z [SURVIVORS) = .167 X 100 16.7Z [TAXABLE FOR EACH SURVIVOR) B.The percent taxable far assets created eJthin one year of the dacadent's death or accounts owned by the decedent but held in trust for another indivlduaI(s) (trust beneficiaries): I DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT X 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decadent and two other persons and established within one year of death by the decedent. I DzVIDEO BY Z (SURVTVORS) = .50 X IO0 = 50Z (TAXABLE FOR EACH SURVTVOR) 4. The amount subject to tax (line 4) is determined by multiplying the account balance (line Z) by the percent taxable (line 5. Enter tho total of the debts and deductions listed in Part 3. 6. The amount taxable (line 6) is determined by subtracting the debts and deductions (line 5) from tho amount subject to tax (line 7. Enter the appropriate tax rate (1ina 7) as determined below. De~e of Death Spouse Lineal Sibling Collateral 07/01/94 ~o 12/51/94 01/01/95 ~o 06/50/00 OX 6Z 1EX 15X 07/01/00 ~o presen~ OX 4.EX~ NTha tax rate imposed on the nat vaIue of transfers from a dec :y-one yaa,S age younger at death to or for the usa of a natural parent, an adopt[va parent, or a stepparent of the child is OX. The lineal class of hairs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes alL children of the naturaI parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" ara defined as individuaLs who have at Least one parent in common with the decedent, whether by blood or adoption. The "Collateral" class of hairs includes all other beneficiaries. CLATMED DEDUCTTONS PART $ - DE]ITS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You legally ara responsible for payment, ar the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can ~urnish proof of payment. C. Debts being claimed must ba itemized fully in Part 3. If additional space is needed, usa plain paper B l/Z" x 11". Proof of payment may bo requested by the PA Department of Revenue. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 002442 GAINOR JAY E 1008 HAVENWOOD COURT MECHANICSBURG, PA 17050 ........ fold ESTATE INFORMATION: SSN: 201-16-4983 FILE NUMBER: 2103-0328 DECEDENT NAME: GAINOR HELEN J DATE OF PAYMENT: 04/14/2003 POSTMARK DATE: 04/11/2003 COUNTY: CUMBERLAND DATE OF DEATH: 01 / 16/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 03105670 $17.58 TOTAL AMOUNT PAID: $17.58 REMARKS: JAY EGAINOR SEAL CHECK//8204 INITIALS: CW RECEIVED BY: DONNA M. OTTO DEPUTY REGISTER OF WILLS REGISTER OF WILLS · Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. · Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: JAY E. GAINOR 1008 HAVENWOOD COURT MECHANICSBURG, PA 17050 If YES, enter de~v6~ry address belQ~,: ,4PI~ 2 1 2003 ~;L,~ro 3. Service Type [~ Certified Mail [] Express Mail [] Registered [] Return Receipt for Merchandise [] Insured Mail [] C.O.D. 4. Restricted Delivery? (Extra Fee) [] Yes 2. Article Number (Transfer from service label) 7001 2510 0006 5862 0838 PS Form 3811, August 2001 Domestic Return Receipt 102595-02-M-0835 PA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 28O6O1 HARRISBURG PA 17128-0601 h.llh.h,~lh,hlh,hlh.,Ih~lh..,Ihh~ll