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~~ PENNSYLVANIA INHERITANCE TAX
~~~
INFORMATION NOTICE
BUREAU OF INDIy7,~UAC`~(Jt~~ .`ii~~ AND FILE N0. 21 11-1250
PO BOX 280681 ~?t_vti.( ~ ~ ` ~ b~ lvania
HARRISBURG PA 1 ~$~g681 "; • ~ ~'~ y ACN 12107972
~` W de,aw ~NTDFHEYENUE TAXPAYER RESPONSE DATE
02-03-2012
REY-1543 EX AFP (OS-11)
t;t2 ~~~ ~~ ~~~ (~' (~~ TYPE OF ACCOUNT
EST. OF ROBERT A NICHOLS ~ SAVINGS
CI Cf31ly ~~ SSN ~ CHECKING
ORPn(~~~e ~(~k.iRT DATE OF DEATH 09-15-2011 ~ TRUST
Cl)M~?.,~~,1 ~y,~n ~n. ~A, COUNTY CUMBERLAND ~ CERTIF.
REMIT PAYMENT AND FORMS TD:
SHIRLEY A NICHOLS REGISTER OF WILLS
423 HILLSIDE RD 1 COURTHOUSE SQUARE
NEW CUMBERLAND PA 17070-1863 CARLISLE PA 17013
SDVE REIGN B ANK 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 yoD 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 FILINr AND PAYMENT INSTRUCTIONS
Account No. 0775280811 Date 01-02-2001
To ensure proper credit to the account, two
Established copies of this notice must accompany
Account Balance $ 10 ~ 284.26 payment to the Register of Wills. Make check
"
payable to
Register of Wills, Agent".
Percent Taxable X 50.000
Amount Subject to Tax 13 NOTE: If tax payments are made within three
$ 5 A 142
.
months of the decedent's date of death,
Tax Rate X ~ 15 deduct a 5 percent discount on the tax due.
Potential TaX DUe 7 7 1 .3 2 Any inheritance tax due will become delinquent
nine months after the date of death.
P
T TAXPAYER RESPONSE
~
1
FLUR~ Tfl PU I LT
~~'S1Ff T C L TAX
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
0 N E 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.
[ 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 2~ and/or PART ~ below.
PART tr indicating a different tax r 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
8. Tax Due
OF TAX ON JOINT/TRUST ACCOUNTS
1
2 $
3 X
4
5 -
6
7 X
8 $
~ OFF7~i U
PA DEPARTMENT OF
AD
1
2
3
4
5
6
7
O~JL1' ~ AAF ,
REVENUE ~r
a
PART DEBTS AND DEDUCTIONS CLAIMED
^3
DATE PAID PAYEE DESCRIPTION nMniiNT porn
Under penalties of p jury, I declare that the facts I
Q.pmpie a to the est o` my k\ w dge nd belief.
\\`~ ~
AXPAYER SIG TURE
reported above are true, co^rlr~ec/t and
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