HomeMy WebLinkAbout02-23-12BUREAU OF INDIVIDUAL TAXES
PD BOX 280601 fi[~.
HARRISBURG PA 17128-06
;~.~_ PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE FILE N0. 21 - ~ ~, -~'1~14
AND ACN 12110832
~ ik~n~ DATE 02-15-2012
,«.,~;,~.'b~„l~hF TAXPAYER RESPONSE
v i ; RE8 -I.54~ E1(;
~~~? ~~~ ~~ P~ ~~ G~
QRPH~~'S ~;0~.)PiT
TERRY A GLASS
2 HILLTOP DR
MT HOLLY SPGS PA 17065-1800
EST. OF MARY J TREGO
SSN 177-16-0188
DATE OF DEATH o2-O1-2012
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 FCU provided the department with the information below. which was used in calculating the inheritance tax due.
Records indandtanhaamounte ther thanezeroeisareflectedtbelowwoo theoP tentialb Tax~Dueylineh~note~no tax mayo be due,h but you must he
checking Box C in PART 1 below and writing "Locthe11fo°m eAdTreturn
deceased Y
notify the department of your relationship to the deceased by
If you believe the information is incorrect, please obtain written correction from the financial institution, attach a copy
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. 233525-40 Date 07-31-2003 To ensure proper credit to the account, two
copies of this notice must accompany
EStablished payment to the Register of Wills. Make check
16 ~ O 16 , 87 payable to "Register of Wills, Agent".
Account Balance 50.000
Percent Taxable X NOTE: If tax payments are made within three
Amount Subject to TaX $ 8 ~ ~~$ • 44 months of the decedent's date of death,
. 0 4 5 deduct a 5 percent discount on the tax due.
Tax Rate X Any inheritance tax due will become delinquent
$ 360.38 nine months after the date of death.
Potential Tax Due
TAXPAYER RESPONSE
PART
FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMEN
A, ^ The above information and tax due is correct.
f Wills with two copies of this notice to obtain
Remit payment to the Register o
this notice to the Register of Wills and
a discount or avoid interest, or return PA Department of Revenue.
C H E C K an official assessment will be issued by the
ONE
orted and
tax paid with
the Pennsylvania inheritance tax return
C
BLOC K B. ICI The above asset has been or will be rep
r-v filed by the estate representative.
0 N L Y
r debts
~ The above informs ion is incorre~t and deductions were paid.
C,
below
PART 2~ and/or PART
t
l
e
e
Comp ~-1 w w C
PART If indicating a different tax rate, please state
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
e T~v nua
PART
DESCRIPTION
AMOUNT PAID
s
TOTAL (Enter on Line 5 of Tax Computation)
Under penalties of perjury, I declare that the facts I reported above are true, correct and
/ 81g
complete to the best of my knowledge and belief. HOME ~ ~ 7 ~ y~~ Zz~S z~Z3--1~-
_ ~ WORK ( .J
TELEPHONE NUMBER DATE
_....~.vr crGUATIIRF
OF TAX ON JOINT/TRUST ACCOUNTS
1
2 $
3 X
4
5
6 `~
X
8
PAD
1
2
3
4
5
6
7
8
urr 11.1RL U~~ ~~.~ , L^a ,,. ..
PA DEPARTMENT OF REVENUE
DEBTS AND DEDUCTIONS CLAIMED
.~ PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE FILE N0. 21-I~"Cbl~-f 4`
BUREAU OF INDIVIDUAL TAXES ~r~ r`; ". lr'~,~",~ ~c AND ACN 12110833
Po Box 26o6oI pennsy~il~ ,' " yAXPAYER RESPONSE DATE 02-15-2012
HARRISBURG PA 17128-0601 pEPARrr+eNTO~'~p{~...1/' [t9Ue ~~~
REV-1543 EX AFP-(~'ii> ~" ~ ~~ ~~., ~ ~
~` ~j ~g } TYPE OF ACCOUNT
'-ljz 4 '.i.3 L~ ~1~~ ~' ~~) ~ SAVINGS
EST. OF MARY J TREGO CHECKING
SSN 177-16-0188
C~~R~ C1~ DATE OF DEATH 02 - o l - 2012 ~ TRUST
CUMBERLAND X~ CERTIF.
C~?~{-!Q~}'~ ^()~,;~~T COUNTY
~'`llftJ~f-~-~;y ~~~~, ~ r1 , R~ REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
TERRY A GLASS 1 COURTHOUSE SQUARE
2 HILLTOP DR CARLISLE PA 17013
MT HOLLY SPGS PA 17065-1800
MEMBERS 1ST FCU provided the department with the information below, which was used in calculating the inheritance tax due.
deceased dandtanyaamounteother thanezeroeisareflectedtbelowwonetheoP tentialbeTax, Dueylineh~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.
it touthelabove addresermaPleasescallo717c787p8327ewobhaquestionsn correction from the financial institution, attach a copy to this form and return
COMPLETE PART I BELOW ~ SEE REVERSE SIDE FOR FILING AND PAYMENT TNSTRUCTiONS
Account No. 233525-41 Date 07-31-2003 To ensure proper credit to the account> two
copies of this notice must accompany
Established payment to the Register of Wills. Make check
$ 14,560.80 payable to "Register of Wills, Agent".
Account Balance 50.000
Percent Taxable X NOTE: If tax payments are made within three
Amount Subject to Tax $ 7 ~ 280 • 40 months of the decedent's date of death,
. 0 4 5 deduct a 5 percent discount on the tax due.
Tax Rate X Any inheritance tax due will become delinquent
Potential Tax Due $` 327 • 62 nine months after the date of death.
TAXPAYER RESPONSE
PART
FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT
The above information and tax due is correct.
A
ies of t
o
his notice to obtain
, ^
Remit payment to the Register of Wills with p
two c
the
t Register of Wills and
a discount or avoid interest, or return this o
notice
PA Department of Revenue.
C H E C K an official assessment will be issued by the
ONE
orted and
tax paid with
the Pennsylvania inheritance tax return
C
B L 0 C K B. ~ The above asset has been or will be rep
filed by the estate representative.
0 N L Y
r debts
t
formation is incorre
i and deductions were paid.
c
n
C, ~ The above
below
PART 2~ and/or PART
t
l
e
e
Comp t 1, r~ A A C
PART If indicating a different tax rate, please state
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
n~~e
OF TAX ON JOINT/TRUST ACCOUNTS
1
2
s X
4 '~
5
6 '~
7 X
8 `~
PAD
urr 11.1NL IJJL ~~,~ , ~~ •••••
PA DEPARTMENT DF REVENUE
1
2
3
4
5
6
7
H
DEBTS AND DEDUCTIONS CLAIMEu
PART
PAYEE DESCRIPTION
DATE PAID
AMOUNT PAID
s
TOTAL CEnter on Line 5 of Tax Computation)
Under penalties of perjury, I declare that the facts I reported above a~ tru ~ G irec~` d~ ;~~
HOME C 7 ~ ~ GJ!/ dn/ `~`.
complete to the best of my knowledge and belief. WORK C 7~7 ~ .Ti/-3~~Z~S Z~2,~-'{ Z
T TELEPHONE NUMBER DATE
BUREAU OF INDIVIDUAL TAXES
PD BDX 266601 pennsylvar~d
HARRISBURG PA 17128-0661 DEPARTMENT OF REVENUE
REV-1543 EX AFP (OS-11
PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE FILE
-' '~"~'"'~ ~}F AND ACN
=Tq;~~~RAtYER RESPONSE DATE
~~~~ ~ ~ ~.B ~3 ~~ 3' ST. OF MARY J TREGO
SSN 177-16-0188
,r,LF~~ {~i {(^; DATE OF DEATH 0 2 - O 1- 2 012
IJiT~~.~~e"!~ ~~~~r}T COUNTY CUMBERLAND
CI'fv.~...r~ ~~~\~~ ~~ RAREMIT PAYMENT AND FORMS T0:
TERRY A GLASS 1 REGISTER OF WILLS
1 COURTHOUSE SQUARE
2 HILLTOP DR CARLISLE PA 17013
MT HOLLY SPGS PA 17065-1800
No. 21-i~.-Ci`I (,n
12110834
02-15-2012
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 d dandtanyaamounteother thanezeroelsareflectedtbelowwonethe~PotentialbeTaxl Dueyl~nehlnoteono 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 P R
decease
lease obtain written correction from the financial institution, attach a copy to this form and return
If you believe the information is incorrect, p
;t to the above address. Please call 717-787-8327 with questions.
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Date 07-31-2003 To ensure proper credit to the account, two
Account No. 233525-48 copies of this notice must accompany
Established payment to the Register of Wills. Make check
Account Balance $` 90,460.01 payable to "Register of Wills, Agent".
X 1 6 . 6 6 7 NOTE: If tax payments are made within three
Percent Taxable
Amount SUbjeCt t0 TaX $ 15 ~ 076 • 97 months of the decedent's date of death,
. 0 4 5 deduct a 5 percent discount on the tax due.
Tax Rate X -Any inheritance tax due will become delinquent
$ 678.46 nine months after the date of death.
Potential Tax Due
TAXPAYER RESPONSE
PART
FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMEN
A, ^ The above information and tax 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
C H E C K an official assessment will be issued by the PA Department 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
D N L Y filed by the estate representative.
C, ~ The above informs ion is incorrect below, debts and deductions were Paid.
Complete PART ~ and/or PART
OFFICIAL USE ONLY ~ AAF
PART If indicating a different tax rate, please state PA DEPARTMENT OF REVENUE
relationship to decedent:
TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS PAD1
LINE 1. Date Established 1
2 $ 2
2. Account Balance X 3 -
3. Percent Taxable 3
$ 4
4. Amount Subject to Tax 4 5
5. Debts and Deductions 5 $ 6
6. Amount Taxable 6
~ X 7
7. Tax Rate $ $
r..., n,~e B
PART
DATE PAID PAYEE
DEBTS AND DEDUCTIONS CLAIMED
DESCRIPTION
AMOUNT PAID
s
TOTAL CEnter on Line 5 of Tax Computation)
Under penalties of perjury, I declare that the facts I reported above are true, Goer/rect~n~! 8 ~ `\
complete to the best of my knowledge and belief. HOME ~ 7~7 ~ ~~d ~ ~ 2^~3~/~
woRK c 7i ~ .,~ 3-
TELEPHONE NUMBER / DATE
_ .-~... r,mr
~~~ PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE FILE No. 21-~i-(,i~r~~~.
BUREAU OF INDIVIDUAL TAXES _~~~ AND ACN 12110835
PD Box zao6ol pennsylvani ; lam(}~'; ~~; T~X~R~4G~ER RESPONSE DATE o2-15-2012
HARRISBURG PA 17128-0601 DEPARTMENT OF REVENUE ~~ - ~ _ ~ ~.
',, ~ '; (~
eEV-:saa ex AFP cos-a> ~ "-~ ~- ~ --~ -•~~ ~ ~ TYPE OF ACCOUNT
~~~k~ i C.U ~~ ~~ ,~j: T. OF MARY J TREGO ~ SAVINGS
$$N 177-16-0188 ~ CHECKING
1 DATE OF DEATH 02-01-2012 ~ TRUST
CLERIC (~~ ~ CERTIF.
r~ ~~ ;-~ , ~ T COUNTY CUMBERLAND
ORPh.:i~ S ~.,G~F ,
C~~~PRI-~%3 ,~r,`A~ ~,~ PA REMIT PAYMENT AND FORMS T0:
KELLY REGISTER OF WILLS
JOANN 1 COURTHOUSE SQUARE
16 MOUNTAINVIEW DPA 17013-1097 CARLISLE PA 17013
CARLISLE
MEMBERS 1ST FCU provided the department with the information below. which was used in calculating the inheritance tax due.
Recorased dandt any aamounteother than ezero ei sa refl ectedtbel owwone theoPotenti albeTax1 Dueyl i ne h~ note ono tax m y be due.h b t youe must he
dece checking Box C in PART 1 below and writing "toothie"fonm PAdTreturn
notify the department of your relationship to the deceased by
it toutbelabove addresormaPleasesca11o717c787p8327ewobhaQUestionsn correction from the financial institution. attach a copy
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Date 07-31-2003 To ensure proper credit to the account, two
Account No. 233525-48 copies of this notice must accompany
Established payment to the Register of Wills. Make check
90 , 460 . O1 payable to "Register of Wills, Agent".
Account Balance 16.667
Percent Taxable X NOTE: If tax payments are made within three
AmOUnt Subject to Tax $ 15, 076 • 97 months of the decedent's date of death,
. 0 4 5 deduct a 5 percent discount on the tax due.
TaX Rate X Anv inheritance tax due will become delinquent
678 , 46 nine months after the date of death.
Potential Tax Due
TAXPAYER RESPONSE
PAR T
~ FAILURE TO RESPDND WILL RESULT IN AN OFFICIAL TAX ASSESSMEN
A
CHECK
ONE
[ BLOCK
ONLY
C.
^ The above information and tax 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
an official assessment will be issued by the PA Department of Revenue.
® The above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return
filed by the estate representative.
The above informs ion is incorrect belowr debts and deductions were paid.
Complete PART 2~ and/or PART
ONLY ~ AAF
PART If indicating a different tax rate, please state
relationship to decedent:
TAX RETURN - CALCULATION
LINE 1. Date Established
p. Account Balance
3. Percent Taxable
4. Amount Subject to Tax
5. Debts and Deductions
6. Amount Taxable
7. Tax Rate
o Tom,, n:,e
PART
DATE PAID PAYEE
PAD
1
2
3
4
5
6
7
~, 8
OFFTCIAL USE
PA DEPARTMENT OF REVENUE
DEBTS AND DEDUCTIONS CLAIMED
DESCRIPTION
AMOUNT PAID
TOTAL CEnter on Line 5 of Tax Computation)
s
of perjury, I declare that the facts I repor
oV 't
eC
e
Under penalties
cpmglete to th;
(/ /~/,J~
best
/f/j
o~ ~ ;,dge and belief.
--
HOME
WORK ( ~~,
-^ ^„r
C ,
L0
~T'7
)
uuunCO ~7 / 7
7
_a~ -~/F+
DATE
OF TAX ON JOINT/TRUST ACCOUNTS II
1
2 $
3 X
4 '~
5
6 '~
7 X
8 $
\.~ PENNSYLVANIA INHERITANCE TAX
{~'~, INFORMATION NOTICE FILE No. 21_ ~•~--Cj~1~~~
BUREAU OF INDIVIDUAL TAXES ~",~~ tF r ~~V~' ~ AND ACN 12110944
Po Box 2eo6B1 pens ~ ! ` DATE 02 -16 - 2012
HARRISBURG PA 17128-0601 DEPARTMENTSE~ENLJB '`_ k~ _,^'~AXPAYER RESPONSE
RFV-1543 E% AFP (05-11)
Q CLERK ~Jtr' +~{ ~{
~~~f',~~,rr~- ,~~;r C:^.> FAA.
EST. OF MARY J TREGO
SSN 177-16-0188
DATE OF DEATH o2-O1-2012
COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
~* TERRY A GLASS 1 COURTHOUSE SQUARE
2 HILLTOP DR CARLISLE PA 17013
MT HOLLY SPGS PA 17065-1800
TYPE OF ACCOUNT
SAVINGS
CHECKING
TRUST
CERTIF.
MEMBERS 1ST FCU provided the department with the information below, which was used in calculating the inheritance tax due.
deceaseddandtanyaamounte ther thanezeroeisareflectedtbelowwonetheDPotentialbeTaxlDueylinehlnoteDno tax mayobe due hbut 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 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 REYERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 233525-49 Date 11-12-2011 To ensure proper credit to the account, two
copies of this notice must accompany
EStablished payment to the Register of Wills. Make check
ACCOUnt Balance $ 7 , 842 22 payable to "Register of Wills, Agent".
X 5 ~ • ~ ~ ~ NOTE: If tax payments are made within three
Percent Taxable
$ 3, 921.11 months of the decedent's date of death,
Amount Subject to Tax 045 deduct a 5 percent discount on the tax due.
TaX Rate X Any inheritance tax due will become delinquent
Potential TaX Due $ 176 • 45 nine months after the date of death.
TAXPAYER RESPONSE
PART
FAILURE TO RESPDND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT
The above information and tax due is correct.
A
s of t
i
his notice to obtain
, ^
e
Remit payment to the Resister of Wills with two cop
the Register of Wills and
t
a discount or avoid interest, or return this o
notice
PA Department of Revenue.
C H E C K an official assessment will be issued by the
ONE
orted and
e
b
tax paid with
the Pennsylvania inheritance tax return
BLOC K
C p
e r
B. ~ The above asset has been or will
filed by the estate representative.
0 N L Y
r debts
t
information is incorre and deductions were paid.
3
C, ~ The above
below
PART ~ and/or PART
t
l
e
e
Comp ~~ w wC
PART If indicating a different tax rate, please state
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
a Tnv rlue
PART
DATE PAID PAYEE
DESCRIPTION
AMOUNT PAID
s
TOTAL CEnter on Line 5 of Tax Computation)
7 ``///
Under penalties of perjury, I declare that the facts I repor HOME ov( /~7 ~y'J~rr~'L~~ ~
complete to the best of my knowledge and belief. 7~7 , ~ y3 - Z Z ,s~Z
WORK C
TELEPHONE NUMBER DATE
r ....,wvro rr_-dA Tll F
OF TAX ON JOINT/TRUST ACCOUNTS
1 I
2 $
3 X
4 $
5
6 '~
7 X
8
PAD
C1F4-il~1AL UJt UnL ~ LJ nn(
PA DEPARTMENT DF REVENUE
1
2
3
4
5
6
7
8
DEBTS AND DEDUCTIONS CLAIMED
BUREAU OF INDIVIDUAL TAXES
lvi
nns
PD BDX 2BB6111 y
pe
HARRISBURG PA 17128-0601 DEPARTMENT OF REVEN}}..~~ (
REV-1543 EX RFP (05 ~1 ~
PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE FILE
r AND ACN
~~- ~~?~1gc~C~YER RESPONSE DATE
l\^.
f~~.~. a!'I r \'
,_ A
~,,i~ ~~8 ~3 ~~~ ~' ~~ SSN OF MARY J TREGO
177-16-0188
C~~R~ ~~ DATE OF DEATH 02-01-2012
ORPHATa(~ J~j, ~^~ r COUNTY CUMBERLAND
COM~~(~'+; h1 ~, ~V~1' REMIT PAYMENT AND FORMS TD:
:. 't,.~r ~,.~ S a 1 ~F+.
KELLY REGISTER OF WILLS
~~ JOANN 1 COURTHOUSE SQUARE
16 MOUNTAINVIEW DPA 17013-1097 CARLISLE PA 17013
CARLISLE
12110945
02-16-2012
TYPE OF ACCOUNT
SAVINGS
CHECKING
TRUST
CERTIF.
MEMBERS 1ST 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 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.
it toutbelabove addresormaPleasesca11o717c787p8327ewithaquestionsn correction from the financial institution, attach a copy to this form and return
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Date 11-12-2011 To ensure proper credit to the account, two
Account No. 233525-49 copies of this notice must accompany
Established payment to the Register of Wills. Make check
7 r 842 , 22 payable to "Register of Wills, Agent".
Account Balance 50.000
Percent Taxable X NOTE: If tax payments are made within three
$ 3,921.11 months of the decedent's date of death,
Amount Subject to Tax , 045 deduct a 5 percent discount on the tax due.
TaX Rate X Anv inheritance tax due will become delinquent
176 , C{5 nine months after the date of death.
Potential Tax Due
TAXPAYER RESPONSE
PART
FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMf
CHECK
ONE
C BLOCK
ONLY
A. ^ The above information and tax 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
an official assessment will be issued by the PA Department of Revenue.
g, rn( The above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return
11r~~( filed by the estate representative.
C, ~ The above information is incorre-c~t belowr debts and deductions were paid.
Complete PART 2~ and/or PART
PART If indicating a different tax rate, please state
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
OF TAX ON JOINT/TRUST ACCOUNTS
1 ~
2 $
3 X
4
5 -
6 '~
~ X
8 $
PAD
urrl~~r.~
PA DEPARTMENT OF REVENUE
1
2
3
4
5
6
7
8
PART
DATE PAID PAYEE
DEBTS AND DEDUCTIONS GLAlPItL
DESCRIPTION
AMOUNT PAID
s i'
TOTAL (Enter on Line 5 of Tax Comp~uytation) ~
Under penalties of perjury, I declare that the facts I rePOrHOME oVC / ~~~ ei~~ect a~ `~~
wledge and belief. J
m lete to the best of my ~ ~ _ ~~ ._~~
C/_'Y/,y WORK
TELEPHONE NUMBER DATE
__......~r, crr_ueTIIRF
USE ONLY ~ AAF