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~ . PENNSYLVANIA INHERITANCE TAX
BUREAU OF INDIVIDUAL TAXES ~4~'!'iL?"~ ti'
PO BOX 280601 ~ l-
1 INFORMATION NOTICE
AND
FILE
N0. 21 11-1250
HARRISBURG PA 17128-0601 f~1~~ 1
~, DEPAF~'hM6NT-0F AE,1Jl~IU~
TAXPAYER RESPONSE ACN 12107975
REV 1543 E% AFP (05 11 )' DATE 02-03-2012
;'~~ j `'a;~r'~ 2~ ~~ ~~. ~~~ TYPE OF ACCOUNT
EST. OF ROBERT A NICHOLS ^ SAVINGS
CI C17~ n~ SSN 161-32-3667 ^ CHECKING
ORPHq~~~ Vt~U~iT DATE OF DEATH 09-15-2011 ^ rRUSr
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~`~ COUNTY CUMBERLAND ~ CERTIF.
' REMIT PAYMENT AND FORMS T0:
SHIRLEY A NICHOLS REGISTER OF WILLS
423 HILLSIDE RD 1 COURTHOUSE SQUARE
NEW CUMBERLAND PA 17070-1863 CARLISLE PA 17013
SOVEREIGN 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 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" in PART 2.
If you believe the information is incorrect, please obtain written correction from the financial institution, attach a coDY 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. 0775543457 Date 08-19-2008 To ensure proper credit to the account, two
Established copies of this notice oust accompany
ACCOUnt Balance $ 10, 134.40 payment to the Register of Wills. Make check
payable to "Register of Wills, Agent".
Percent Taxable X 50.000
AmOUnt Subject t0 Tax NOTE: If tax payments are made within three
$ 5, 067.20 months of the decedent's date of death,
TaX Rate ~( ~ lrj deduct a 5 percent discount on the tax due.
Potential Tax Due Any inheritance tax due will become delinquent
$ 760 • 08 nine months after the date of death.
P~T TAXPAYER RESPONSE
1
iUR R F? WI#1.- ZN ~ IC L X ES NT~
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
0 N E an official assessment will be issued by the PA Department of Revenue.
BLOC 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. ~he above informs ion is incorrect and/or debts and deductions were paid.
Complete PART ~ and/or PART 3 low.
PART If indicating a differen ra plea s
relationship to decedent: ~ ~,~
PA DEPARTMENT OF REVE#,?UE
TAX RETURN - CALCULATION OF TAX ON JO T/TRUST ACCOUNTS PAD
LINE 1. Date Established 1 ~
2. Account Balance 2 $ 2 s
3. Percent Taxable 3 X 3
4. Amount Subject to Tax 4 $ 4
5. Debts and Deductions 5 - °° 5
6. Amount Taxable (, $ 6
7. Tax Rate 7 X 7 x
8. Tax Due g $ $ ~~„ ~ ..~ ~ ~ ~ n
PART DEBTS AND DEDUCTIONS CLAIMED
Under penalties of perjurR~y~\~I declare that the facts I
comple to the b st of `
nowle ge and belief.
, ~ ~
\ reported above a e true
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TAXPAYER SIGNA \ V
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TELEPHONE NUMBER ~.
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DATE PAID PAYEE DESCRIPTION eMniiur pwrn