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HomeMy WebLinkAbout01-20-12COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: KIMMEL CAROL A 49 LEE ANN COURT ENOLA, PA 17025 /old REMARKS: CHECK# 409 REV-1162 EX111-961 PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT N0. CD 015491 ACN ASSESSMENT AMOUNT CONTROL NUMBER TOTAL AMOUNT PAID: INITIALS: CJ 537.76 SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS _ r _ ~ -._ . ~,. MEMBERS 1 ST FCU 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 point 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:relatlonshlp 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. Please call 717-787-8327 with questions. CO!lPLETE PART 1 BELOW * SEE, REVERSE SIDE FOR FIL3NB AND PAYMENT INSTRUCTIONS ~ PENNSYLVANIA INHERITANCE TAX BUREAU OF INDIVIDUAL TAXES ~ ~~['~ORMATION NOTICE FILE No. 21...`a-DOg~ PO BOX 280601 penn ~", }Ll~/~~ AND ACN 11185176 FUIRRISBURG PA nlza-o6o1 oevnaTMew ; ~'= '~~AXPAYER RESPONSE ~'~ ' DATE 12-30-2011 REV-1543 EX 11FP (A5-11) ~~~~ ~~~ ~~ `~ ~~, ~~ TYPE OF ACCOUNT EST. OF MARIAN M LEE ® SAVINGS C~>,Jt $$N 198-22-9920 ~ CHECKING L +~ Vt~Rj DATE OF DEATH 12 -16 - 2011 ~ TRUST fli Ith1~?~ ~'+~ ~ COUNTY CUMBERLAND ~ CERTIF. I'1#J~~ REMIT PAYMENT AND FORMS T0: CAROL A KIMMEL REGISTER OF WILLS 1910 LULA LN 1 COURTHOUSE SQUARE ENOLA PA 17025-1415 CARLISLE PA 17013 Account No. 1062-00 Date 06-13-1951 Ta ensure proaer credit to the account, two Established copies of this notice ^ust aecoepany payeent to the Register of Wills. Make check Account Balance $ 3, 709.98 payable to "Register of Wills, Agent". Percent Taxable X 16.667 NOTE: If tax payeents are Bade within three Amount Subject to Tax $ 618.34 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Aro inheritance tax due will becoee delinquent Potential Tax Due ~ 27.83 nine eonths after tho date of death. PART TAXPAYER RESPONSE 1^ A. ~ The above inforeation and tax due is correct. Resit payeent 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 an official assesseent will be issued by the PA Departeent of Revenue. C ONE BLOCK B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return 0 N L Y filed by the estate representative. C. ~ The above inforea ion is incorrect and/or debts and deductions were paid. Coeplete PART 2~ and/or PART ~ below. 99~ PART If indicating a different tax rate, please state ~ ~ ' ~i'''`~~M i P~~~~ relationship to decedent: ~„`~ 8 TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS , LINE 1. Date Established 1 ~~'` ~~' 2. Account Balance 2 ~ ~;:.,~ i, 3. Percent Taxable 3 X .,mss. 4. Amount Subject to Tax 4 5. Debts and Deductions 5 - 6. Amount Taxable 6 ~ ~~ ° 5~ ~~~ ~ I}' '~ ~~i~~~~~ 7. Tax Rate 7 X ~~^ k 'I`II ili~+'i sz, ~i 8. Tax Due 8 $ ~xi PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I reported above are true, correct and com et• to he best of my knoxledge and belief. HOME C `?17 ) "~3~-~ '~..3 ~~-.. WORK ( ) -~~ TA AYER SIGNATURE TELEPHONE NUMBER DATE ~ PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE FILE N0. 21--~a-~g~j BUREAU OF INDIVIDUAL TAXES Po Box 2BOSOl pen - ~~-~ ~ AND ACN 11185178 HARRISBURG PA nlza-osol oEPARTM ~,, ka; ~ TAXPAYER RESPONSE DATE 12-30-2011 REV454~~~ ~F s ,«.7-. ~~~ ~~~ ~~ ~ ~~• ~~ TYPE OF ACCOUNT EST. OF MARIAN M LEE ~ SAVINGS SSN 198-22-9920 ® CHECKING DATE OF DEATH 12-16-2011 ~ TRUST QRPF{A~I~~+~AAS~~~~WV~~ COUNTY CUMBERLAND ~ CERTIF. ~~4lVYiJ ~„ ~ REMIT PAYMENT AND FORMS T0: CAROL A KIMMEL REGISTER OF WILLS 1910 LULA LN 1 COURTHOUSE SgUARE ENOLA PA 17025-1415 CARLISLE PA 17013 MEMBERS 1ST F CU 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 1n PART 1 below and wrlting "spouse" 1n 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. Please call 717-787-8327 with questions. COMPLETE PART 1 BELOW * SEE itEVERSE 's-iDE FOit FItiN6 /kMe=PA1(MfftT INSTRUCTIONS Account No. 1062-11 Date 10-19-1993 To ensure proper credit to the account, two Established copies of this notice ^ust accoapany payaent to the Register of Wills. Make check Account Balance ~ 588.88 payable to "Register of Wills, Agent". Percent Taxable X 16.667 NOTE: If tax payaents are aade within three Amount Subject to Tax $` 98 • 15 months of the decedent's date of death, Tax Rate X . 045 deduct a 5 percent discount on the tax due. Any inheritance tax due will become delinquent Potential Tax Due ~ 4 • 42 nine aonths after the date of death. PART ': TAXPAYER RESPONSE a A. ~ The above infonation and tax due is correct. Reait payaent 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 C 0 N E ~ an official assessaent will be issued by the PA Departwent of Revenue. BLOCK B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return 0 N L Y filed by the estate representative. C. ~ The above inforaa ion is incorrect and/or debts and deductions were paid. Coaplete PART 2~ and/or PART 3^ below. PART If indicating a different tax~rate~l~ase_,gtate a relationship to decedent: '"1~~ii~~--- TAX RETURN - CALCULATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 __ ___ 2 ~ 3 X 4 5 6 $ 7 X 8 ~ PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the Pacts I reported above aro true, correct end com etc to th be of my owledge and belief. HOME C "~!"'t. ) ''3 Z" ~ WORK C ) f!Q --/.i TAXPAY~GNATURE TELEPHONE NUMBER DATE .~, PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE FILE N0. 21 -~2'06~3 BUREAU OF INDIVIDlU1L TAXES AN D PO BOX 280601 p ~ ACN 12101456 HARRISBURG PA Ines-o6ol oe ~"~i ~ TAXPAYER RESPONSE DATE 01-10-2012 REV ' t ~. -~1 w. :t.w \" ~~~~ JA~V 20 PAS 12M 5~ QRP~ C(~.1Rr GRANT L LEE ~~~' 49 LEE ANN CT ENOLA PA 17025-1937 EST. OF MARIAN M LEE SSN 198-22-9920 DATE OF DEATH 12-16-2011 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS ® CHECKING TRUST CERTIF. F ULT ON BANK NA 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 y0U are the 5pou5e 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.relatlonshlp 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. Please call 717-787-8327 with questions. COMPLETE PART 1 BELOW '* "SEE RE'i1ER'Sf SIDE FOR FILING AHD PAYMENT-'INSTRUCTIDNS Account No., 3624-337 15 Date 09-15-2010 To ensure proper credit to the account, two Established copies of this notice wst accowany paytaent to the Register of Wills. Make check Account Balance $ 999.34 payable to "Register of Wills. Agent". Percent Taxable X 16.667 NOTE: If tax pageants are aade within three Amount Subject to Tax $ 166.56 eonths of the decedent's date of death, Tax Rate X , 00 deduct a 5 Dercent discount on the tax due. Any inheritance tax due will becoee delinquent Potential Tax Due ~ • 00 nine eonths after the date of death. PART TAXPAYER RESPONSE A. ~ The above inforeation and tax due is correct. Resit pageant 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 assesseent will be issued by the PA Departeent of Revenue. C ONE B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return 0 N L Y filed by the estate representative. C. ® The above inforea ion is incorrect and/or debts and deductions were paid. Coeplete PART 2~ and/or PART ~ below. PART If indicating a different tax r~e, Please state relationship to decedent: ~ ~ ~S ~ TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Established 1 2. Account Balance 2 $ 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 5. Debts and Deductions 5 - 6. Amount Taxable 6 7. Tax Rate 7 X 8. Tax Due 8 ~ PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of per3ury,'I declare that the facts I reported above are true, correct and complete to the best of my knowledge and belief. HOME C ~'~~ ) ~3~~ '~71z-- ~ WORK C ) ' AXPAYER SIG TURE TELEPHONE NUMBER DATE BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 ~n DEPART REV •1543 EX 11FP (RS-11) - ~.-.~ FILE ACN DATE N0. 21'1 121 1457 01-10-2012 ~~~~ ~~~ ~yo ~~ j2~ ~ TYPE OF ACCOUNT EST. OF MARIAN M LEE ^ SAVINGS SSN 198-22-9920 ® CHECKING .~ DATE OF DEATH 12-16-2011 ^ rRUST ~,~ ~~ COUNTY CUMBERLAND ^ CERTIF. REMIT PAYMENT AND FORMS T0: CAROL A KI MMEL REGISTER OF WILLS 49 LEE ANN CT 1 COURTHOUSE SQUARE ENOLA PA 17025-1937 CARLISLE PA 17013 F ULT ON BANK NA 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 Point 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. Please call 717-767-8327 with questions. COMPLETE PART I BELOW * SEE REVERSE SIDE .FOR FILING AND PAYME~fT INSTRUCTIONS Account No. 3624-33715 Date 09-15-2010 To ensure proper credit to the account, two Established... copies of this notice ^ust accowparry paywent to the Register of Wills. Make check Account Balance ~` 999.34 payable to "Register of Wills, Agent". Percent Taxable X 16.667 NOTE: If tax paywents are wade within three Amount Subject to Tax $` 166.56 months of the decedent's date of death, Tax Rate ~( , 0 4 5 deduct a 5 percent discount on the tax due. Aryl inheritance tax due will becowe delinquent Potential Tax Due $ 7 • 50 nine wonths after the date of death. PART TAXPAYER RESPONSE 1^ A. ^ The above inforwation and tax due is correct. Rewit paywent 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 assesswent will be issued by the PA Departwent of Revenue. ONE C BLOCK B. ^ The above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return 0 N L Y filed by the estate representative. C. ^ The above inforwa ion is incorrect and/or debts and deductions were Daid. Cowplete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state 2 relationship to decedent: TAX RETURN - CALCULATION LINE 1. Date Established 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 ~ PENNSYLVANIA INHERITANCE TAX I,~.FORMATION NOTICE n ~ ~~, AND MENT ~ ~ ~s~ ~~~~# -. AXPAYER RESPONSE OF TAX ON JOINT/TRUST ACCOUNTS 1 2 $ 3 X 4 $ 5 6 ~ 7 X g ~ DEBTS AND DEDUCTIONS CLAIMED Under penalties of perjury, I rFeclare that the facts I reported above ars true, correct and cowplete to t best of my know 9e and belief. HOME C ??'~ ) 232-- ~? 1 'Z-- /` WORK C ) /~3-- TAXPAYER SIGNATURE TELEPHONE NUMBER DATE DATE PAID PAYEE DESCRIPTION AMOUNT PAID .~ ,.'. i..:~ ~i~~`~PENNSYLVANIA INHERITANCE TAX ' „_ ORMATION NOTICE FILE N0. 21 ~j BUREAU OF INDIVIDUAL TAXES ~ ~{~~ a~~p Po Box zao6ol Penn t ~~ ~,~!~~ ~ AND ACN 11185177 HARRISBURG PA lnzs-o6ol oEPnRrMEmT '~~ ~~':-A~CPAYER RESPONSE DATE 12-30-2011 REV-1543 E% 4FP <R5 -11) Z ~ Pty IZ~ ~~ TYPE OF ACCOUNT EST. OF MARIAN M LEE ® SAVINGS ~ SSN 198-22-9920 ~ CHECKING -~'~ T DATE OF DEATH 12-16 - 2011 ~ TRUST tJt~~n ,~}„ ~ COUNTY CUMBERLAND ~ CERTIF. REMIT PAYMENT AND FORMS T0: GRANT L LEE REGISTER OF WILLS 49 LEE ANN CT 1 COURTHOUSE SQUARE ENOLA PA 17025-1937 CARLISLE PA 17013 MEMBERS 1ST F CU 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 Point 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. Please call 717-787-8327 with questions: COMPLETE PART 1- B~AW * ~C€i1= dtE1FERSE SI#3E FOR FII..I~iC•- ~Il R+AYMEb4T INSF~iJtCTIONS Account No. 1062-00 Date 06=13-1951 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 $ 3 ~ 709.98 payable to "Resister of wills, Agent". Percent Taxable X 16.667 NOTE: If tax payments are made within three Amount Subject to Tax ~` 618.34 wonths of the decedent's date of death. Tax Rate ~( , 00 deduct a 5 percent discount on the tax due. Arb inheritance tax due will bacome delinquent Potential Tax Due ~ .00 nine months after the date of death. PART TAXPAYER RESPONSE 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due 3 X 4 5 6 _~_- 7 X 8 ~ PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIPTION AMOUNT PAID TOTAL CEnter on Line 5 of Tax Computation) i Under penalties of perjury, I declare that the facts I reported above are true, corraet and comp`! a be f my knowledge and 'belief. HOME t "ti'? ) 73~-^ ~7f~- WORK C ) ~_''/~"/~ TAXPAYER SIGNATURE TELEPHONE NUMBER DATE n ~ ....~~ PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE FILE N0. 21~~a..~j~j BUREAU OF INDIYIDUAL TAXES- r~ Po BDX 280661 ~1Cinn ~~~~ ~ AND ACN 11185177 HARRISBURG PA 17128-0601 1''DE~PARTMENT o~. ,~ 4sr AXPAYER RESPONSE i,~ ; ~.~!~ DATE 12-30-2011 REV-1543 E~~~~~ f~OS-11~S• ~~fZ .SAN Z~ ~~ t2~ :?~ L ~~. GRANT L LEE 49 LEE ANN CT ENOLA PA 17025-1937 EST. OF MARIAN M LEE SSN 198-22-9920 DATE OF DEATH 12-16-2011 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT ® SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST F CU 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 3oint owner/beneficiary of this account. If y0U ere the SpDUSe Of the deceased and any amount other than zero 1s 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. Please call 717-787-8327 with questions. COMPLETE PART 1 BELOW * SEE.RE1/fRSf SIDE FOR FILiN6 AN@ PAYMENT ~lISTRUCTIONS Account No. 1062-00 Date 06-13-1951 To ensure proper credit to the account, two Established copies of this notice aust accoapany 7 0 9.9 8 payaent to the Register of Wills. Make check Account Balance ~ 3, payable to "Register of Wills, Agent". TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due 1 2 ~ 3 X 4 5 6 7 X 8 PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIPTION AMOUNT PAID ~ c ~ TOTAL CEnter on line 5 of Tax Cowputation) 6 Under penalties of perjury, I declare th8t,the facts I,reported above are true, correct and complete to the best of knowledge snd belief. HOME C ~f'7 ) ~3~---^ ~~~2 i w ~^ WORK C ) ~;'~ Y-'LZ TAXPAYER SIGNATURE TELEPHONE NUMBER DATE ~ "PENNSYLVANIA INHERITANCE TAX BUREAU OF INDIVIDUAL TAXES ~° INFORMATION NOTICE FILE AN D NO. 21 ~~'~6~3 Po Box zao6ol ~ ACN 11185179 WIRRISBURG PA 17128-0601 ~ ~T.,,a~v~+>~: it~ TAXPAYER RESPONSE DATE 12-30-2011 R wt?xkr fa~~1~ ~,~ ~~~ ~Q ~~ ~~~ Sg TYPE OF ACCOUNT ~ EST. OF MARIAN M LEE ^ snvlNGs SSN 198-22-9920 ® CHECKING ~~~ DATE OF DEATH 12-16-2011 ^ reusr ~~~iS ~,t1ur~~ COUNTY CUMBERLAND ^ CERTIF. pj -.I`~ REMIT PAYMENT AND FORMS T0: GRANT L LEE REGISTER OF WILLS 49 LEE ANN CT 1 COURTHOUSE SQUARE ENOLA PA 17025-1937 CARLISLE PA 17013 MEMBERS 1ST F CU 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 point owner/beneficiary of this account. If y0U 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" 1n 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. Please call 717-781-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 1062-11 Date 10-19-1993 To ensure proper credit to the account, two Estatr135hed copies of this notice wust accomparFy payment to the Register of Wills. Make check Account Balance $ 588.88 payable to "Register of Wills, Agent^. Percent Taxable X 16.667 NOTE: If tax payments are wade within three Amount Subject to Tax $ 98.15 wonths of the decedent's date of death, TeX Rate X , QQ deduct a 5 percent discount on the tax due. Arty inheritance tax due will becowe delinquent Potential Tax Due $ • 00 nine months after the date of death. PART 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 an official assesswent will be issued by the PA Department of Revenue. C 0 N E ~ BLOCK B. ^ The above asset has been or will be reported and tax paid with the Pennrilvania inheritance tax return 0 N L Y filed by the estate representative. C. ® The above informs ion is incorrect and/or debts and deductions were paid. Complete PART ~ and/or PART 3^ below. PART If indicating a different tax rate, please state Z^ relationship to decedent:. -~ ~'kS~~ TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS LINE I. Date Established 1 . ~ ;~ `~'~ 2. Account Balance 2 ~ Y 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 w { ~ s 5. Debts and Deductions 5 - „ ~N , ~ 6. Amount Taxable 6 $ "`>?~ 'Ijf 7. Tax Rate 7 X psi°, ~ .~ `- 8. Tax Due 8 PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID 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 C `7i'? ) `?3 ~- I7 f .Z'- WORK ( ) TAXPAYER SIGNATUR TELEPHONE NUMBER DATE .~ .