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Home My WebLink About02-27-12COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: REV-1162 EX(11-961 PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT MAJERCHIK LISA ANN 168 CAROL STREET NEW CUMBERLAND, PA 17070 ACN ASSESSMENT CONTROL NUMBER fold ESTATE INFORMATION: ssN: 175-a4-1510 FILE NUMBER: 211 1-0657 DECEDENT NAME: MAJERCHIK NICHOLAS JON DATE OF PAYMENT: 02/27/2012 POSTMARK DATE: 02/25/201 2 COUNTY: CUMBERLAND DATE OF DEATH: 05/25/201 1 NO. CD 015629 AMOUNT 12109361 ~ 575.66 TOTAL AMOUNT PAID: REMARKS: SEAL CHECK# 4003 INITIALS: DMB RECEIVED BY: 575.66 GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS ~ PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE FILE N0. 21 11-0657 BUREAU OF INDIVIDUAL TAXES Po BDx zao6ol ~;n, ~~ j AND ACN 12109361 HARRISBURG PA lrizs-o6ol ~~ TAXP AY E R R E S P O N S E ?r' yQ,EPARTFIENT OFRU DATE U2-08-2U12 ~Y t-~I JtEY; I543 E~ AFP"~(~5 ~1~ TYPE OF ACCOUNT ! ~~~~ ~~$ Z7 Pty 2: ~ ~ EST. OF NICHOLAS J MAJERCHIK ® SAVINGS SSN 175-44-1510 ~ CHECKING (,'(_~~ ~~ DATE OF DEATH 05-25-2011 ~ TRUST ~1'f"~'S' L`~}UF1r COUNTY CUMBERLAND ~ CERTIF. C(IM~fi~f,`~Y~~ /~~ ~~ REMIT PAYMENT AND FORMS T0: JULIA MAJERCHIK REGISTER OF WILLS 724 EHMAN AVE 1 COURTHOUSE SQUARE BADEN PA 15005-2036 CARLISLE PA 17013 CITIZENS BANK OF PENNSYLVANIA 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 Sp0U5e 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 farm 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. 6141516734 Date 09-09-1999 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 $ 1 ~ ~ O8 . $4 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 504.42 months of the decedent's date of death> Tax Rate ~( , lrj deduct a 5 percent discount on the tax due. Any inheritance tax due will become delinquent Potential Tax Due $ 75.66 nine months after the date of death. PART TAXPAYER RESPONSE 0 L R~ IN AN L~ 5 ENT ~..; 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 assessment will be issued by the PA Department 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 informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state ~ ~ ~ ~ '~ OFF ~ ~ {~ AA relationship to decedent: , PA r, , DEPARTMENT DF REVENUE TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE I. Date Established I 1 2. Account Balance 2 $ ~ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 S 6 Amount Taxable 6 $ 6 . 7. Tax Rate 7 X 7 8. Tax Due 8 $ $ ~ W~ \ TOTAL (Enter on Line 5 of Taz Computation) S 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 ) woRK c ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIPTION AMOUNT PAID r3 %t~> t r t"~,~ ~; F~ YNS f~ .-:, ~ ~~ «~' ~ti ~~ !''~ Q n O n C ~_ 2 L ~ s~o ~'~ E T~ ~ I =~Z ~ ~ v ~ ~~ r ~ / ~ ~ .J 1 ,~= ~J