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BUREAU OF INDIVIDUAL TAXES
PO BDX 288601 ~ ;- pennsylVami~;
HARRISBURG PA 17128-0601 ri..' DEPARTMENT OF REVEBUE.L
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ELIZABETH K STONER
651 CANDLEWYCK RD
LANCASTER PA 17601-2853
TYPE OF ACCOUNT
OF RUSSELL F ELLENBERGER
EST ~ SAVINGS
.
SSN 207-07-6629 a CHECKING
DATE OF DEATH 08-13-2011 ~ TRUST
COUNTY CUMBERLAND ~ CERTIF.
REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
M & T BANK provided the department with the information below, which was used in calculating the inheritance tax due.
deceased dandtany aamounteother than ezero ei sa refl ectedtbel owwone theoP tenti alb Taxi Dueyl i ne h~ noteono tax mayo be due h but you must he
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 is incorrect, please obtain written correctTOn firom the financial institution, attach a copy to this form and return
it to the above address. Please call 717-787-8327 with questions- -
-" "-- COMPLETE-PART 1 BEL041 * SEE REVERSE-SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 10625682 Date 05-26-1994 7o ensure proper credit to the account, two
copies of th15 notice oust accOmp any
Established payment to the Register of Wills. Make check
Account Balance ~` 67 ~ 020 • 87 payable to "Register of Wills, Agent".
X 1 6.6 6 7 NOTE: If tax payments are made within three
Percent Taxable
Amount Subject to TaX $ 11 ~ 170 • 37 wonths of the decedent's date of death,
. 1 5 deduct a 5 percent discount on the tax due.
Tax Rate X Any inheritance tax due will become delinquent
Potential Tax Due ~` 1 , 675.56 nine wonths after the date of death.
PART TAXPAYER RESPONSE
FAILURE TO RESPOND YIiLL RESULT IN AN OFFICIAL T,4X ASSESSMENT
A. ^ The above information and tau due is correct.
Remit payment to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest, or return this notice to the Register of Wills and
CHECK an official assessment will be issued by the PA Department of Revenue.
B L 0 C K B. The above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return
C ONE
O N L Y filed by the estate representative.
C. ~ The above informs ion is incorrect and/or debts and deductions were Daid.
Complete PART ~ 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 RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS -PAD1
LINE 1. Date Established 1 $ 2
2. Account Balance 2 X 3
3. Percent Taxable 3 _
4. A®ount Subject to Tax 4 $ 5
5. Debts and Deductions 5 $ 6
6. Amount Taxable 6
7 X 7
7. Tax Rate $ 8
8. Tax Due B
DEBTS AND DEDUCTIONS CLAIMED
PART
AMOUNT PAID
PAYEE DESCRIPTION
DATE PAID
s
TOTAL CEnter on Line 5 of Tax Coraputation]
Under penalties of perjury, I declare that the facts I repot HOME oy( are t~ e, correct and (~
`~ _ complet 'rtoo~th~e ~b~est o\f~m}y,~knowledge and belie1,f'.` WORK C `~ ~ a~~ ~ ~ ~ ~ `-' ~ O
~.7} ~"" ~ ,~~~`~~J~SJ'U_ ~,T~`~-~~ ~'~ ~f ~ "'S~~ TGI FPHDNE NUMBER DA E '
PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE FILE NO. 21 11-0971
AND ACN 11183200
TAXPAYER RESPONSE DATE 12-21-2011
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