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Home My WebLink About11-07-11BUREAU OF INDIVIDUAL TAXES PD BOX 280601 HARRISBURG PA 17128-0601 Pennsylvania DEPARTMENT OF REVENUE REV-1543 EX AFP (05.11) PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE FILE NO. 21 11-0779 AND ACN 11139217 * * ~A~~~~~ ~~~~c~s~ * ~ DATE 11-02-2011 .~ ~~ i jL~~ ~~ ~j~~:'~= ~ ~~ S~~-~~~ ~~ f`~~~j~ ~ ~ ~ ~/ ~ / GAIL GREEN 119 CALAMAN RD CRANSTON `~ RI 02910-4230 Ce; . c f~/~~~1/ ~~~~ CCU ~~~/~ ~~ ~-y ES OF JEFFREY D POLLAK SSN 087-36-4142 DATE OF DEATH 01-03-2011 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: ~~TYPE OF ACCOUNT SAVINGS ® CHECKING TRUST CERTIF. REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 ,,/ l `S~~ ~ TT~~~~ WELLS F ARGO provided the department with the information below, which was used in calculating the inheritance tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If yoU art 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, but you must notify the department of your relationship to the deceased by checking Box C in PART 1 below and writing "spouse" in PART 2. If you believe the information )s incorrect, please obtain written correction from the financial institution, attach a copy to this form and return ;t to th? ahnve address. Please call 717-787-8327 with questions. COMPLETE PART 1 BELOW ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 1010199086555 Date 03-03-2008 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 $ 15,773.00 payable to "Register of Wills, Agent". Percent Taxable X 16.667 NOTE: If tax payments are made within three Amount Subject to Tax $ 2 ~ 628 • 89 months of the decedent's date of death, Tax Rate ~( , 12 deduct a 5 percent discount on the tax due. Any inheritance tax due will become delinquent Potential Tax Due $ 315.47 nine months after the date of death. PART TAXPAYER RESPONSE =_r~~ _, , FAILURE TO RESRQND WILL RESULT IN AN OFFICIAL TAX ASSESS:I'~E1V~ - A. ~ The above information and tax due is correct. ~~-te SJ Remit payment to the Register of Wills with two copies of this notice to obtr}?n -,, _ a discount or avoid interest, or return this notice to the Register of Wills--and. _ C H E C K an official assessment will be issued by the PA Department of Revenue. -- '~; ONE - C ~ B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania .in~heritanc~ .tax return T' O N L Y filed by the estate representative. r~ r. j L i -r, C. ~ The above infarma ion is incorrect and/or debts and deductions were paid. ~`' Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state OFFICIAL USE ONLY ~ AAF relationship to decedent: PA DEPARTMENT OF REVENUE TAX RE TURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Date Established 1 i 2. Account Balance 2 +fi 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 S 6. Amount Taxable 6 $ 6 7. Tax Rate 7 X 7 8. Tax Due 8 $ 8 PART DEBTS AND DEDUCTIONS CLAIMED neTR= porn PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I reported above are true, correct and complete to the best of my knowledge and belief. HOME ~ WORK ( ~ TeYpevFa SIGNATURE TELEPHONE NUMBER DATE IUIXL \CnlCf- ull Li~~o u. .. .. - -"- REV-1162 EX111-96) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1 7 1 28-0601 RECEIVED FROM: GREEN GAIL 119 CALAMAN RD CRANSTON, RI 02910 PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT ACN ASSESSMENT CONTROL NUMBER folA ESTATE INFORMATION: SSN: 087-36-4142 FILE NUMBER: 2111-0779 DECEDENT NAME: POLLAK JEFFREY D DATE OF PAYMENT: 07/13/2011 POSTMARK DATE: 07/12/2011 COUNTY: CUMBERLAND DATE OF DEATH: 01 /03/201 1 AMOUNT 11139217 ~ $394.33 11139216 ~ 5394.33 TOTAL AMOUNT PAID: REMARKS: SEAL CHECK# 6258 INITIALS: DB RECEIVED BY: 5788.66 GLENDA EARNER STRASBAUGH REGISTER OF WILLS NO. CD 014705 TAXPAYER i?~ +t s` z: h.~ i~~' t` i ti fit' ~• fy. 3. ~c~ ' ~ _.;_V t." _.. ~ -. r r OR~;~' ',1; ~ ;~~J~T CUPL"~ I_ , , ~ ^i ~ PA '^Q` ^~ L ` V / V ~i c~,> ~ v , ~v/~ v \ .~ -- -= 1 ~~ '~ •'+~ v E~j i~ :;'~ { _} ."..} [ ,I •:~7