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~ s PENNSYLVANIA INHERITANCE TAX
BUREAU OF INDIVIDUAL raxES INFORMATION NOTICE
PO BOX 280601 D FILE N0. 21~ _ ~ r /j~~l
HARRISBURG PA 17128-0601 r ~~ t '~~i'" r AND U
en - t.
DEPARTMEN~I)~~tEVtE1Gl1E_ ~ ~-F_. ~''AXPAYER RESPONSE ACN 1114 256
REV-1543 EX~AfP.:(•g5;-~lY~', ~f~ ~ ~ DATE 06-30-2011
_ i
' ~ j ,~~;~ b: r• ~, TYPE OF ACCOUNT
'`~`~ '~ ~' ~~~' ,`.:f J EST. OF ANN L MILLER
SSN ~ SAVINGS
171-24-0781 ~ CHECKING
C~.~RK (~~' DATE OF DEATH 0 6 - 0 7 - 2010 ~ TRUST
~RPF~,~~~'4 ~;(~~?~~ COUNTY CUMBERLAND
riill .r"~` ~ ak>M ~ ~ ~ CERTIF.
~[J y ~f`'"f' ,r`~;`~ rt p~ REMIT PAYMENT AND FORMS T0:
DONALD C MILLER
214 N 33RD ST REGISTER OF WILLS
CAMP HILL PA 17011 1 COURTHOUSE SQUARE
CARLISLE PA 17013
METRO BANK
Records indicate that at the death of the above-named decedent,
provided the department with the information below, which was used in calculating the inheritance tax due.
you were a joint owner/beneficiary of this account. If you are the spouse of the
deceased and any amount other than zero is reflected below on the Potential Tax Due line, note no tax may be due b
notify the department of your relationship to the deceased by checking Box C in PART 1 below and writing "spouse" in P
If Y^!~ believe .he infprm~tl4!1 is ;, Ut yoU mUSt
it to the above address. Please call e717c787~8327ew~thaquestionsr correcti~r from the f'. 1 +,+; ART 2.
1'1ZnC18 ~nSt'LU~~pn. attach a copy to this f0iiii and return
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 536894744 Date
03-16-2005
To ensure proper credit to the account, two
Established copies of this notice must accompany
Account Balance $ 2, 083.99 payment to the Re
Sister of Wills. Make check
Percent Taxable X Payable to "Register of Wills, Agent".
Amount Subject to Tax 100.00
2, 083.99 NOTE: If tax payments are made within three
Tax Rate X months of the decedent's date of death,
Potential Tax Due 15 deduct a 5 percent discount on the tax due.
+fi 3 1 2 . ( 0 Any inheritance tax due will become delinquent
PART nine months after the date of death.
\\\ TAXPAYER RESPONSE
. ....~ ~~~ o ~~ ~~
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.
B L 0 C K B. ~ Th above asset has been or will be reported and tax
O N L Y led by the estate representative. Paid with the Pennsylvania inheritance tax return
C• The above informs ion is incorrect and/or debts and deductions were paid.
Complete PART 2~ and/or PART ~ below.
PART If indicating a different tax te, please state
relationship to decedent:
TAX RETURN - CALCULATION OF TAX O JOINT/TRUST ACCOUNTS
LINE 1. Date Established 1 \
2. Account Balance
3. Percent Taxable
4. Amount Subject to Tax
5. Debts and Deductions
6. Amount Taxable
7. Tax Rate
8. Tax Due
PART
2 $
3 X
4
5
6
7 X
8 +~`
DEBTS AND DEDUCTIONS CLAIMED
DESCRIPTION
TOTAL CEnter on Line 5 of Tax Computation)
Under ~
penalties of perjury, I declare that the facts I reported above are true correc a d
complete- tto the best of my knowledge and belief.
~a~, _ (J~ ~r ~ HOME C ~ ..
TAXPAYE~~R`"'~~~S---IGNATURE WORK ( ~
TELEPHONE NUMBER - r
DATE
DATE PAID PAYEE
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