HomeMy WebLinkAbout01-17-12COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17126-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
REV-1162EXI11-96)
NO. CD 015463
OROURKE JACK R
3710 CONWICK DR
SOUTHPORT, FL 32409-1669
fold
ESTATE INFORMATION: ssN: 2os-22-osoe
FILE NUMBER: 211 1-0944
DECEDENT NAME: O'ROURKE ROBERT
DATE OF PAYMENT: 01 / 1 7/201 2
POSTMARK DATE: 01 / 1 3/201 2
COUNTY: CUMBERLAND
DATE OF DEATH: 08/21 /201 1
REMARKS:
CHECK# 6608701551
SEAL
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
1 1 184780 ~ S 1,016.02
TOTAL AMOUNT PAID:
INITIALS: DMB
RECEIVED BY:
S 1,016.02
GLENDA EARNER STRASBAUGH
REGISTER OF WILLS
ISTER OF WILLS
t
+ PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE FILE N0. 21 11-0944
BUREAU OF INDIVIDUAL TAXES
Po Box zsocol r~ r ~~ {r,~n~rlvania AND ACN 11184780
HARRISBURG PA I~zs-g6ol pEPAgTM~T oFRE~EN~E TAX PAYE R R E S P O N S E
~~;._ ~ _ DATE 12-29-2011
. ~;.._.., :.. _„ _., C5Y-15A3JEX AFP (05 -11)
r. ~ - - -
l; _...
JACK R OROURKE
3710 CONWICK DR
SOUTHPORT FL 32409-1b69
EST. OF ROBERT OROURKE
SSN 209-22-0308
DATE OF DEATH 08-21-2011
COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
TYPE OF ACCOUNT
SAVINGS
CHECKING
TRUST
CERTIF.
WELLS FARGO 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 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, 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 is incorrect, please obtain',written correction from the financial institution, attach a copy to this form and return
it to the above address. Plea_e call 717-7A7-A?2? with qu(kst.ions.
COMPLETE PART 1 BELOW * SEE REVE~tSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 1010264503769 Date ' 04-09-2010
Account Balance
Percent Taxable
Amount Subject to Tax
Tax Rate
Potential Tax Due
PART
CHECK
ONE
BLOCK ]
ONLY
Established
$ ' 13,546.89
X 50.000
$ ' 6,773.45
X .15
$ 1,016.02
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.
IFAIL~t~~,,: , , ~OHI~~LL ° 1T IN AN OFF~~L ~'AX ASSESSMENT
A. The above information a d tax due is correct.
Remit payment to th 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
an official assessm nt will be issued by the PA Department of Revenue.
B. ~ The above asset has beeh or will be reported and tax paid with the Pennsylvania inheritance tax return
filed by the estate representative.
C. ~ The above informs ion i5 incorrect and/or debts and deductions were paid.
Complete PART ~2 and/br PART 3~ below.
PART
2^ If indicating a different
relationship to decedent: tax rate, please state ,~~ OFFICIAL USE oONLY ~ AAF
PA DEPAKTMEN7 OF REVENUE
TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS PAD
LINE 1. Date Established 1 1
2. Account Balance 2 $ 2
3. Percent Taxable 3 X ~ 3 '
4. Amount Subject to Tax 4 $ (}
5. Debts and Deductions 5 - rj
6. Amount Taxable 6 $ b
7. Tax Rate
8. Tax Due 7
8 X
$ ~ 7
~~g
PART DE BTS AND DEDUCTIONS CLAIMED
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
TOT L CEnter on Line 5 of Tax Computation) 8
U nder penalties of perjury, I declare th t the facts I reported above arp truce. nnrraet nnA
complete to the best of my knowledge and belief. L
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