HomeMy WebLinkAbout11-07-11BUREAU OF INDIVIDUAL TAXES
PO BOX 280601
HARRISBURG PA 17128-0601
pennsylv~i{i~
DEPARTMENT OF REV~E
REV-1543 EX e a ,.~.•
a e
Established
EST. OF DENISE BREKOSKY
~~~RK(~ SSN 168-52-4402
ORPH,~;N'S (;Q~)~~ DATE OF DEATH 03 -10 - 2011
Cl)M~~~'L~i~{', ~~~ PA COUNTY CUMBERLAND
LAWRENCE J BREKOSKY REMIT PAYMENT AND FORMS T0:
147 FAIRWAY DR REGISTER OF WILLS
DILLSBURG PA 17019-1542 1 COURTHOUSE Sf~UARE
CARLISLE PA ].7013
N 0. 21 -'' "' // /~
11171762
10-31-2011
TYPE OF ACCOUNT
^ SAVINGS
® CHECKING
^ TRUST
^ CERTIF.
CITIZENS BANK OF PENNSYLVANIA
Records indicate that at the death of the above-named decedent,
provided the department with the information below,
notify the department you were a which was used in calculating the inheritance tax due.
deceased and any amount other than zero is reflected below on the Potential Tax Due line, note
t ,)oint owner/beneficiary of this; account. If
If you believe he informatfon ~lsrincolrarectn ph ease obtain written correction from the financial institution a
p to the deceased b checkin Box C in PART 1 below and writin you are the spouse of the
it to the above address. Please call 717-7g7-8327 with y 9 no tax ma
Y be due, but you must
COMPLETE PART 1 questions. 9 "spouse" in PART 2.
BELOW * SEE REVERSE SIDE FOR FILING ttach a copy to this form and return
account No. 6202489506 AND PAYMENT
D t
Account Balance
Percent Taxable
Amount Subject to Tax
Tax Rate
Potential Tax Due
PART
AILURE+'. i'0
To ensure proper credit to the account,
copies of this notice must accompany two
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 inheritemca tax due will become delinquent
nine months after the date of death.
PENNSYLVANIA INHERITANCE TAX
.- .I ~ QRMATION NOTICE
' : ~ , ~ U{-
'~' AND FILE
~?~~AYER RESPONSE; ACN
~_ DATE
09-11-2003 INSTRUCTIONS
$ 2,179.15
X 50.000
$ 1,089.58
X
$ .15
163.44
A _,._t,-,s ;seaa..L ~lCE$ITI.T :_~~; ~ O~~ ~~A~
~
., .
..
r'
~`AX
• ^ The above information .'Au
S SS1dl_!~'('
C H E C K and tax due is correct.
Remit payment to the Register
f
C
0 N E o
Wills with
a discount or avoid interest,
an official a
this
o
r two copies of this notice to obtai
BLOCK
~
B'
ssessment will be
issued
b
v the
^ Th
notice to the
PA Department
Register of
of Re n
Wills and
0 N L Y
e above asset has been venue.
or will be re orted and
filed by the estate representative. p tax
paid with
the Pennsylva
i
C'
~ The above i n
a inheritance tax return
nforms
Complete PART ~2 ion is incorrect and/or debts a
and/or PART 3^ b
l nd deductions wer
PART If
indicatin„
e
ow. e
paid.
..~rrerent tax rate, please state
2 relationship to decedent:~_ _ 1~ D
TAX RETURN - CALCULATION OF T'
LINE 1. AX ON JOINT/TRUST ACCOUNTS
Date Established
2. Account Balance 1
2 $
3• Percent Taxable
s X
4. Amount Subject to Tax y $
5. Debts and Deductions 5
6• Amount Taxable
6 $
7. Tax Rate
7 X
B. Tax Due
8 $
PART
DATE
PAID PAYEE
DEBTS AND DEDUCTIONS CLAIMED
DESCRIPTION
Under penalties of perjury,
complete to the best of~y k
a~ ~ ~
AMOUNT PAID
TOTAL CEnter on Line 5 of Tax Computation)
I declare that the facts S
9owledge and belief. I reported above are true, correct and
// HOME ( 7/7 ) S/3~_~-~y
TELEPHONE NUMBER
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