Loading...
HomeMy WebLinkAbout08-29-11~~ fie" PENNSYLVANIA INHERITANCE TAX BUREAU OF INDIVIDUAL TAXES INFORMATION NOTICE PO BOX 280601 ' ' HARRISBURG PA 1,128_0601 Penn V'a~'1l ~ AND DEPARTMENT R~VL7VUE °~:. 3 , ~AXPAYER RESPONSE REV-1543 EX AFP (OS-11) - ~~,. rJ ~~ ~~ ~ ~ .. ~ ~~x 9 ~.. ~~ ~~~ ~~ ~.. , o BLAKE H WERT 700 JULIE CT MECHANICSBURG PA 17055 FILE N0. 21"' ~ ~~/~ 1 ACN 11154471 DATE 08-18-2011 TYPE OF ACCOUNT EST. OF FLORINE M WERT ^ SAVINGS SSN 167-24-11b3 ® CHECKING DATE OF DEATH 01-03-2011 ^ TRUST COUNTY CUMBERLAND ^ CERTIF REMIT PAYM ENT AND FORMS T0: . REGISTER OF WILLS 1 COURTH OUSE SQUARE CARLISLE PA ;17013 SOVEREIGN BANK ecords indicate that at the death of the above-named decedent, provided the department with the information below, which wa:; used in calculating the inheritance tax due. deceased and any amount other than zero is reflected below on the Potential Tax Due line, note n notify the department of your relationship to the deceased byechecking Box/Cni n1 PART of this account. If you are the spouse of the If you believe he information is incorrect, lease obtain written correction from the financial institution, atta has may be due, but you must it to th° above address Please call 717-787p832? w;th , o~ ~ I below and writing "spouse" in PART 2. COMPLETE PART 1 BELOW * G~_ t o~_ copy to this form and return SEE REVERSE SIDE FOR FILING AND PAYMENT TNCTOnrrrn.... Account No. OS7117n~Qfl Account Balance Percent Taxable Amount Subject to Tax Tax Rate Potential Tax Due PART DEBTS AND DEDUCTIONS CL Laze 09-13-1983 Established $ 4,b43.27 X 50.000 $ 2,321.b4 X .15 $ 348.25 TAXPAYER RESPON: E 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 return this notice to the Register of Wills and 0 N E an official assessment will be issued by the PA Department of Revenue. 0 N Y B. ^ The above asset has been or will be reported and tax filed by the estate representative. paid with the Pennsylvania inheritance tax return G• ~ The above informs ion is incorrect and/or debts and deductio "`------~~~ Complete PART 2~ and/or PART 3^ ns were paid. below. PART If ind' icating a different relationshi t tax rate, lease~tate p o decedent: Q TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST LINE 1. Date Established ACCOU N TS 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 T X PAR 8. Tax Due 8 T DATE PAID Iln.l.. TOTAL CEnter on Line 5 of Tax Comnutat;.,.., AMOUNT PAID --• ~~,~a~ «es or perjury, I declare that the facts I reported above are true, correct and complete to the best of my knowledge and belief. /Y' Wiwi HOME C '7 l~ ~ ('~, g ~ >~ (o ~o~ TAXPAYER SIGNATURE WORK ( ~ TELEPHONE NUMBER ~_ ZZ~ If - DATE ---- ........ ivnJ To ensure proper credit to the account, two copies of this notice must accompany payment to the Register of Wills. Make check Payable to "Register of Wills, Agent". NOTE: If tax payments are made within three months of the decedent's date of death, deduct a 5 percent discount on the tax due. Any inheritance tax due will become delinquent nine months after the date of death. PA DE \ .~~ OF ~ ~ N PAD ~ `\.\\ 2 , ~\ 3 \~ ~ \\~~~~ 5 b .. 7 8 AIMED PAYEE DESCRIPTION OCAL REGISTRAR'S CERTIF'ICAT WARNING: It is Illegal to dl.lplicate this co IOIV OF DEATH pY by photostat or photograph. Fee fl,r thi~~ (certificate. `~(i.O(- F---17.0 2 9 6_~. 2_- _ <`erli~~ic~atif,n '~un~l-tie)~ ttt''rrr~TH ~OF P ,,'t'~~a-~----, Fti~ ~, off/ ~- ~~. i ~,~ _. :o~~~ ~~, ,, ~EM~ OF/~~~~ This is to certitw ttlat the intormaCion here given c~)r'"ectl_y ~('P)~ ~ f~)~(~m an original Certificate of Dea dul.~ filed wii'_h me as Local Registrar. The origin certificate w~ilE he f~~,rwarded to the State Vit Records Uffice for per)nanent filing. -- ~ ~ ~/ Local Rc~~istr.(r Date Issued H,05.1a3 REV 1,2°06 TvPE / ~~ ~ COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS PERMA ~r CERTIFICATE OF DEATH ,_,a,,,y d o.ceasd (~ ~, ~.~) (See instruct)ons and examples on reverse) Florins M. 111-ert STATE FILE NUMBER 2 Sax 3. Soda) Sscurty Number - ~ Age (~ &rpb•Y- under, Female 167 - 24 - 1163 a. Date d Deatlr (Monet, day, yeah uro•r, da 6. D.b d adh January 3, 2011 " Dm Faora Mkaaet ~ 7• and state a ea Place d Dean Cf>adc • 80 January 4, 1930 Paxinos, Pa. a» Yom' Hospital: 6b. Cary d Death Other 6c. City. Boro, Twp. d Death ad FadWy Name (" rat kaibrpon, 7Ne abeel and amber) ~ lnpatiera ^ ER f Oulpa"art ^ DOA ^ Nursing Home ^ Residence ^ Otlrer - SPap~': Cumberland East Pennsboro 9. wee t d Hispanic origin? Select Speciality at Holy Spirit Hospital (" ~• ao•dh~ ~, ~ "° ~ Yea 10 R~e~ A^1BA~^ ~~+ east, wNb eb • 1,. Decadert'a UsuY don Kind d work done moat d ib. Do not state ro' 12. Wet Mexican, Ptbrlo Rican. etc.) (~i01MM wind d work l(ind d eutkrss / I Decedent ever:, me 13. Detedenra Eduadion (specpy arty Npheu grade White Elementary /~e~or~ °0rtp~ u. Marital Status: Homemaker ~ S' Ar"1ed ~? Menied, Neva, Married, ,5 Own Home ^ Yas ~ No 7Z ry (a12) Cdkge (1'4 or 5+) w'dDN'~, Dnoroed (SpeciyJ S`"v"'r'g SPOt'3B (" wp•, 9Na maiden name) - ,6. a g Add1B~ (~``°~'• dy' `°""'• ~~~ _~ ~) Married Blake H. Wert 700 Julie Court ~ rRa t7a sea PA DktDecede,x Mechanicsburg, Pq 17055 I-rye^a ,7t.~Yea,DecedsntLived;n Fairview ,m. cataty York ray 18. Fltplefs Name (Post, rttiddle, Iasi, stdPot) 17d. I~ No, Decedent lived within Twp. ,g. Mdhs/s Name Acaral Lkrya °f William Davis (FxaRmiddle,maidenaumarrb) Gy/eoro ~~ era "'°~ R'Pe / P'°") Violet Trego Blake H. Wert 20b. lnfamam's Maiinp Address (Street, dy / bwn, sea, zip cads) 2'a M,e~~y"~'°°dD~p°8"°n 700 Julie Court Mechanicsburg, PA 17055 ,° • IO~earw , ~ Cremetgn ~ Donaaon 27b. Dated ~ ©Otlter . Renaval from Slate ~ Was C+amatlon a• Dorrstbn Autllorjzsd ~POSiion (Mmtn, deY, Peru) 2,c. Place d DispoeNion (Name d cemetery, ar other place) •' 22a d F,,;,,a, '"d1e1 EaamN'er/' C7 ~Yes^ No January 7, 2011 Norhtumberland Memorial Park ltd. La~bon (~/'~~"• sea, zpcode) ~~h- 22b.Litena•N~ro•r Sunbury, PA 17801 22c. Nmne and Address d FadWy only when certllykg . 7o dre best IurowMdpa, death attuned at the time. dab and FD-012662-L Myers Funeral Home, Inc. 37 East Main Street Mechanicsburg, PA 17055 pltyaidsrt's not avaieble a inr d dean b Nate stated. (Signature and title) ~ catae d death. 23b. License Number • 23c. Dare Signed (Month, day. year) wno 2p~ by pa,pr 2a. tans a Death (Meth, ~ , • 25. Dab Prorwrsrced pip Y Y•~) M. 26. Was Cate Referred b Medal Examiner /Coroner for a Reason Other scan CAUSE OF DEATH ^ Yes ~ Crenvdion or Dorxationl hem 27. Pan 1: Fnbr the (See Mesfructlons and examples) ~$IDfffi,4 -diseases, injures, a compficaytes . pet yam, ~~ ~ deatlt. DO N0T order r APProxkrtale interval: Part ": Eller other ' rssprabry arraeL a ventriwar fibdpappr widqut terminal events such u Cardiac Ornet b Death 28. Did Tobatxo Ilse stawvrrg the eaobgy. List any one cause on each Cwe. r CAUSE (Frral) daeasa a ~ ~ but ^d reaul6ng n the urxlMying cause given n Pan I. C~ rou0s b DeaM7 in death ~ r ~~~ ~ Robaby i ~. ; eNy fa cortdi6orta p ant Due as a txxxsequenee d): , 2s. ~emale: Mob the taup YYM~an ire a b. r --'---- -}~'Ffot (tiaaew a kriYi Md ~ Duero (a as a corraequarxe d): ~ W9rrerM witlan Past Year everkc rastlirq n deaM) LAST. c. ~ ^ Pregnant at irna d death Due b (a as a r ^ ~ pfe9nanL but pregnant witlrin 42 days • ~ °f)' r d death d. r ----~---~_ 30a Was an r ~ ~ were ' F ~ 31. Mamsr d Death ryury (Month, de , r ~ W9rent. but pregnant 43 days b 1 year r ----.~_ _~_~- Defore death Avalable Prior b 32a. Date d I ' Y Y•erl 32b. Deaaibe Flow ~, o~Ra, ~ Urtlugwn d pregnant wkhin the pest Y•er d Cause d Death? •L"Y NaWral ^ Hprddde 32c. Place of kYurY Hone, Farm, ^ Ves ~No ^ Yes ^ No ^ Acddent ^ Pendkg lmroadgapan 32d. Tuns or Injury 32e. kyury at Work? 32t. d T Otlux &a~g, etc. (Speciy)~'' Fes' 33a Ceriiar c,urrdt ~ sacrde ^ Coukl Nd be Detemwred ,, ^ Yes ^ fao ^ Drver// opereta~0(passe,~, ^ Pedestrian ~ Location d injury (Street. dy /town, state) _ ( °Ay °^B) t7tlbr Spealy ro aecumd ardio~tM~ r ~raan nsa pronaarced death and cortplatsd lbm 23) 33b. signature and rdlsd Md PhYMcisrt (Phyarcran both causya) and msrroer a. stated _ _ _ _ _ , ~ / l/. c romeaaamykawltdm.tie.m«tunaaxn»net ~dt~amaNyk,gbtauaeordeaBq ------------------------- l/. - CL.~ . • leaoe, and due to the ~ License r ., ~+ Mtdlal Examirw/ Cororw c•u•Na) and manner as stated_ _ ~ 33d. Date Signed ~ (Madh aac u, OntMbnkdaxaminatbnsnd/orimead ---------------- •~YY ) o gatbn, in my oleinion, death accurrod at the Clete, dent, and place, end dw to the ca ~ ~ ~~ ..~.i ~ '- ` % ' 3 -" I ~ uaa(y end ~~ ~ Address of Person Who w ; a Signature and Daakd ~~ ~ ~~ New a^d Campasui Cause d Death (Item 27) Type / Prnt ~ - ~ I ~ I ~ I 1 I .~ I 3s. Date ~ (Month, day, Year) I-( N C• tf~~c:. ~ ~e ~?> ~ /i ~u/ p ~ j Cif ~. D(sposition Perm" No. ~! "7 / ~ ~ 7 jt(litf{~i(fitt~/tiitiifi~i(~tit~~fitt~t{~itili!!(~Sli{~(~-tii .~ ~ ~. l -~ ~' ~ l ,,, ,~ ~,,. n ~S „~~ S ", ~ ~~ ~d S :. ~ ~ W~ ~ ~ ,~~~ tiv ~,.. G '~ ~ ~~rttt~~ . ~ _, __ - - -- -