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Home My WebLink About04-12-12COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: SMITH CRYSTAL M 25 IRISH GAP ROAD NEWVILLE, PA 17241 PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT ACN ASSESSMENT CONTROL NUMBER fold ESTATE INFORMATION: ssN: 20~-22-2is6 FILE NUMBER: 2112-0432 DECEDENT NAME: SHOFF ELSIE J DATE OF PAYMENT: 04/12/2012 POSTMARK DATE: 04/1 1 /201 2 couNTY: CUMBERLAND DATE OF DEATH: 01 / 1 3/ 201 2 AMOUNT 12122902 ~ 546.05 TOTAL AMOUNT PAID: REMARKS: SEAL CHECK#1270 INITIALS: CJ RECEIVED BY: 546.05 GLENDA EARNER STRASBAUGH REGISTER OF WILLS REV-1162 EX(11-96) NO. CD 015832 REGISTER OF WILLS ~ PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE ~~~ BUREAU OF INDIVIDUAL TnxES FILE N0. 21 '-/v2 -1i PO BOX 280601 ' ! r A N D HARRISBURG PA 17128-0601 per~s~il'n~a li ;~ ~~ ACN 12122902 DEPARTf~rE+fILT,QF,RSVENUE ,,~ 1) ~ ~, TAXPAYER RESPONSE DATE 04-02-2012 REV-1543:E:LARP. [5.17 )''. ~1 ~ '..t-l.l TYPE OF ACCOUNT ''~~` ~'~~ 4 ~ ~~' ~~~ ~~ EST. OF ELSIE J SHOFF ~ SAVINGS SSN 207-22-2196 ® CHECKING p C~E~~ ~~ DATE OF DEATH 01-13-2012 ~ TRUST C~O{'1FCiiVVAA G~rJ~ia~~ ROUNTYYMENT ANDMORMSLAOND CERTIF. CRYSTAL M SMITH REGISTER OF WILLS 25 IRISH GAP RD 1 COURTHOUSE SQUARE NEWVILLE PA 17241-9548 CARLISLE PA 17013 PNC BANK NA 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. 5000004872 Date 10-17-2007 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance 00 1 561 ~` Payment to the Register of Wills. Make, check " . , payable to Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to TaX $` 780 50 NOTE: If tax payments are made within three . months of the decedent's date of death, Tax Rate ~( , lrj deduct a 5 percent discount on the tax due. Potential Tax Due ~` 117.08 Any inheritance tax due will become delinquent nine months after the date of death. PART TAXPAYER RESPONSE 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 co pies 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 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 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 If indicating a different ta~r~a;e~`, pleaes'~state OFFICIAL USE ONLY ~ AAF relationship to decedent: PA DEPARTMENT DF REVENUE TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Date Established 1 1 2. Account Balance 2 $ ~~ ~, 0 D 2 3. Percent Taxatrie 3 ~X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 ~ ~ 5 6. Amount Taxable 6 $ d 6 7. Tax Rate 7 X ~ ~ 7 8. Tax Due 8 $ ~~ g PART DEBTS AND DEDUCTIONS CLAIMED ^3 DATE PAID PAYEE DESCRIPTION AMOUNT PAID .3 I ~ i ~ ~ l r e.t d ~ t ~ ~ ~. r rs ~ ~ IUIHL ltnier on Line S or IaX GOmpULaLlOnJ $ /~,~/ (`~U /) Under penalties of perjury, I declare that the facts I reported above a re true, correct and plete to the best of my knowledge and belief. / ~7 HOME C ~~ ~ ~ ~ ' ~ ~ ( WORK b ! ~ - ~ C ~ ) ~ - ~ ~ ~D ~ AXPA ER SI AT RE TELEPHONE NUMBER AT ;,omments f you have any questions regarding your statement, please contact the Business Office at (717)776-8256. ___~ - Date .. "r~1k j+s r.~ .tad, l - ;Descripfion JJ ,tR r'~ e 1nr ;,,_ f ? ~ Days/ i : i ^~sr',, .v 5R -Units # ,Rate- I ~ C- . ~ y (fi"`" e)/ ~ :per; ~~ (fir ~t ..~?.~_ . Pa meets ~ .:.Balance y 12/16/11 - 12/31/11 Room/Board-Self Pay 16 $148.00 $2,368.00 12/27/11 - 12/27/11 Glucometer Strips 1 $52.50 $52.50 12/31/11 - 12/31/11 Telephone 1 $13.09 $13.09 )1/01/12 - 01/31/12 Room/Board-Self Pay 31 $155.00 $4,805.00 TOTAL BALANCE DUE: $7,238.59 /~~fi-~f ~-~,-~,-~ . ~S~U-va l~`e~h~- /~,oy -------- ~ 3~ 3. y9 C~c. ao« i-.3-. z ~ ~g-~:4q =AGILITY NAME RESIDENT NAME ACCOUNT NUMBER SWAIM HEALTH CENTER ELSIE J SHOFF 20722GRVPC { GREEN RI';.:~E VILLAGE 210 BIG SPRING ROAD NEWVILLE PA 17241 (717)776-8200 ELSIE J SHOFF c/o BARBARA KEEPER 679 SHIPPENSBURG RD NEWVILLE PA 17241 Comments Statement Date Due Date Account Number 01/31/2012 U on Recei t 61799GRV ' = ' ~ $351.77 AMOUNT PAID $ ~~ 3 Please make check payable to GREEN RIDGE VILLAGE Remit To: Presbyterian Homes Inc/Green Ridge/Swaim P O Box 416825 Boston MA 02241-6825 Please detach and return this portion with your remittance to the address above. ~ ~ ~~~ .r `tio ~ ~ r1~~;; ~, L~ I Days'/ .I ~~ ~ ~y e s"" _ I ~ ~PJ~`~s I~ a~~~ `+~ Balance Forward $0.00 01/12/12 01/12/12 Telephone 1 $5.44 $5.44 01/12/12 01/12/12 Room/Board -Self Pay 1 $309.00 $309.00 01/12/12 01/12/12 Glucose 1 $0.99 $0.99 01/12/12 01/12/12 Oxygen Daily 2 $7.50 $15.00 01/12/12 01/12/12 Rented Med Equip -concentrator 1 $17.50 $17.50 01/12/12 01/13/12 Syr Ins Salty 1CC 29gx1/2 4 $0.96 $3.84 Total Balance Due $351.77 T g,~+~ ~ ~ f'1,~,u~~lb~o n ~ i crl. ~-c.~c l ~ C 0 m ~;, FACILITY NAME RESIDENT NAME ACCOUNT NUMBER GREEN RIDGE VILLAGE Elsie J Shoff 61799GRV Ewing Brothers Funeral Home, Inc. 630 South Hanover Street Carlisle, PA 17013- (717)243-2421 January 17, 2012 Crystal M. Smith 25 Irish Gap Rd. Newville, PA 17241 The Funeral Service for Elsie J. Shoff We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel flee to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES Direct Cremation , $2085.00 FUNERAL HOME SERVICE CHARGES $2085.00 SELECTED MERCHANDISE: $10.00 Acknowledgement cards , ~ $40.00 Register Book(s) ~ $85.00 Memorial folders , THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE $2220.00 THAT YOU HAVE SELECTED Cash Advances Certified Copies of the Death Certificate , $42.00 $25.00 Coroners Fee ~ ~ $120.21 The Sentinel Obit , ShippNalley Time obit $60.00 $100.00 Z Keepsakes $347.21 TOTAL CASH ADVANCES AND SPECIAL CHARGES . Total $2567.21 Total Cost , SUB-TOTAL $2567.21 ~y'~ INITIAL PAYMENT /DISCOUNT /CREDITS 2086.85 ~pr ~e,/~~/''~j~~~ TOTAL AMOUNT DUE $4 SQ ~~jA l.H~uG~,gpLCX~ The unpaid balance over 30 days is subjected to a 1.50 % service charge per month - 18.0000 %per annum. z ,~~i~ .~~-~~v ~ s~,~.~li.~ ~ o'ff' ~ ~~~~s.~.~~>~r <5 ~y~ ~a j ~o . ~•~ ~l'~p~ ~ C_ 'v'" ~~~~ °~ ~~ a~ ~2/ _ ~~~~ ~~ ~~ >P --; ;:;~ r.,~ '.c. ~~ ~~, '.-~ r~~~ ~~ !' ,~ L~ . 'i ;;~ ~~ r.'~ -.-1 ~;~` -.- ~ .. ,~ .~ -p r LQr N:?~ . ,J N C =j Z` ~ N (~ cv.Z ~~ o __ ^_ "-T` Q ~ S~) ~ (~- T ~ ~/ ~ / `~ ~ v D ^~ dd i)~ t~tw~~ .f ~~~~(1~ iii t~~ ~,I~~ld~l0 ~Q ~~31~ ~~ 4a, ~i ,1 ~ r r,.,,.~.i ~?J a {T~ (~) f*? t'h .r+ 1~„~