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Home My WebLink About02-22-12BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 !~4 REV IT.C1F REV EN UE'~,.. ~P lRb-:~7 . PENNSYLVANIA INHERITANCE TAX e INFORMATION NOTICE -,.~ -~,~t. ~~ AND FILE N0. 21u I~~ ~ '~l ! C TAXPAYER RESPONSE ACN 11185103 :"' ..~~ DATE 12-30-2011 ~'~ ~ i~ ~€~ 22 P~~ It ~ u ~t EST. OF JANET M HEELER SSN 183-07-8398 vLER~ ~~ DATE OF DEATH 11-28-2011 l ~1 ~i T QRIP^i-t>~~S ~'~"R~rn~nn COUNTY CUMBERLAND ~~~~rin' tl_r- ,~.~ ~` - REMIT PAYMENT AND FORMS T0: SUSAN H COOK REGISTER OF WILLS 290 STROHM RD 1 COURTHOUSE SQUARE SHIPPENSBURG PA 17257-9653 CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS © CHECKING TRUST CERTIF. ORRST OWN BANK 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. Please call 717-787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 103005084 Date 09-20-2004 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 2, 316.62 payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to Tax ~` 1,158.31 NOTE: If tax payments are made within three months of the decedent's date of death, TaX Rate X ~ 15 deduct a 5 percent discount on the tax due. Potential Tax Due $ 173.75 Any inheritance tax due will become delinquent nine months after the date of death. PART TAXPAYER RESPONSE 0 FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or return this notice to the Register of Wills and 0 N E 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 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 ~ below. PART ^2 TAX LINE it inalcaiing a different tax rate, please state relationship to decedent: RETURN - CALCULATION 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 3^ PAD 1 2 3 4 5 6 7 B OFFICIAL USE ONLY ~ AAF PA DEPARTMENT OF REVENUE DEBTS AND DEDUCTIONS CLAIMED ~inr ~ or iax computation) $ Under enalties of perjury, I declare that the facts I reported above are true, correct and compl a to the best of my knowledge and belief. HOME C , 71 ;~ ~ Q ` G `~ ~ Lam/ -- ~ "7/ ~ ~ S 3 ~-~ ~i TAXPAYER SIGNATURE TELEPHONE NUMBER ATE DATE PAID PAYEE DESCRIPTION AMr111 A1T owrn