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BUREAU OF INDIVIDUAL TAXES
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HARRISBURG PA 17128-0601 DEPARTMENT OF REVENUE
REV-1543 E% AFP (OS-11)
PENNSYLVANIA INHERITANCE TAX'...
INFORMATION NOTICE
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FILE ND. 21 - ~~' C~~-1(C,~
ACN 12114647
DATE 02-29-2012
.'.~'!~ ~"~~ ~~ ~,t~~ J(aF MARY PADELSKY
SSN 181-05-2350
C(E~K ;~~r DATE OF DEATH 0 2 - l o - 2 012
~P~A~~S {~~~~(JNTY CUMBERLAND
CUMRF~~` ,.',•~,~~t (~j~tEr~I PAYMENT AND FORMS T0:
CATHERINE E WALL REGISTER OF WILLS
1323 OAK LN 1 COURTHOUSE SQUARE
NEW CUMBERLAND PA 17070-1335 CARLISLE PA 17013
TYPE OF ACCOUNT
SAVINGS
® CHECKING
TRUST
CERTIF.
FIRST NATIONAL BANK OF MINERSV 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 farm and return
it to the above address. Please call 717-787-8327 with QuestiDns.
COMPLETE PART 1 BELOW * SEE 4EYERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 328588 Date 03-04-2004 7o ensure proper credit to the account, two
Established copies of this notice must accompany
payment to the Register of Wills. Make check
Account Balance $ 4,626.66 payable to "Register of Wills, Agent".
Percent Taxable X 50.000
NOTE: If tax payments are made within three
Amount Subject to Tax $ 2,313.33 months of the decedent's date of death,
TaX Rate X .045 deduct a 5 percent discount on the tax due.
Any inheritance tax due will become delinquent
Potential Tax DUe $ 104 • 10 nine months after the date of death.
PART TAXPAYER RESPONSE
F ~- ~ , T A~ T S~ESSltENT
~T
.
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.
ONE
C
BLOC K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return
O N L Y filed by the estate representative.
C. ~ The above informs ion is incorrrec~t and/or debts and deductions were paid.
Complete PART 2~ and/or PART 3LJ below.
PART If indicating a different tart L ~~ state
^ relationship to decedent: ZQ•y
2
TAX RETURN - CALCULATION OF TAX OW~N J~~OppINT/TRUST ACCOUNTS \P AD
LINE 1 . Date Established 1 ~'/~ •/t~c.~t, ~ [2 y'~'~
2. Account Balance 2~,~ a oZ~i. ~ le
3. Percent Taxable 3 X ~A D /7 T7
4. Amount Subject to Tax 4
5. Debts and Deductions 5 .3.~ ~l y G y
6. Amount Taxable 6 $ d
7. Tax Rate 7 X
8. Tax Due 8
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PA DEPARTMENT OF REVENUE
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PART DEBTS AND DEDUCTIONS CLAIMED
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
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IUTAL ttncer on Dine n or iax 1.VmPULdt1VfU ,~ ~ y o , ~
Under penalties of perjury, I declare that the facts I reported above are true, correct and
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TAXPAYER SIGNATURE TELEPHONE NUMBER DATE
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