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~~ PENNSYLVANIA INHERITANCE TAX'
r[ ~~~~ INFORMATION NOTICE ~-
BUREAU OF INDIVIDUAL TAXES~I { '~.~ ~~~~ ~ I~~7E ~ FILE ND. 21 .- ~,~- ~L('C'
Po sox zso6ol A N D
HARRISBURG PA 17128-0601 !"1EriertnsylV~~~a~ ACN 1212072$
C EvnaTMEwroFREVEn`UE TAXPAYER RESPONSE DATE 03-23-2012
RrEV-15L4~3 EX AFP (05-11)
1 ~ a.7 ~I I ~' 4' V
EST. OF CONCETTA R A(:RI
- SSN
Q~il"{;~~'v ~ ',;'~~i , r DATE OF DEATH 1 1 - 06 -• 2011
CUMBERLA~~D CO, PA COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS T0:
ERCOL 0 ACRI REGISTER OF WILLS
3 SILVER SPRING RD 1 COURTHOUSE SQUARE
MECHANICSBURG PA 17050-2855 CARLISLE PA 17013
TYPE OF ACCOUNT
SAVINGS
® CHECKING
TRUST
CERTIF.
SOVE REIG N BANK provided the department with the information below, whicF 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 ydu 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 tc 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. 1681790025 Date 04-01-2006 To ensure proper credit tp the account, two
Established copies of this notice must accompany
Account Balance 20 882.84 payment to the Register of Wills. Make check
~ payable to "Register of Wills, Agent".
Percent Taxable X 50.000
NOTE: If tax payments are made within three
Amount Subject to Tax $` 10,441.42 months of the decedent's date of death,
Tax Rate ~( 1Gj deduct a 5 percent discount on the tax due.
Any inheritance tax due will become delinquent
Potential Tax Due y` 1 , 566.21 nine months after the date of death.
PART TAXPAYER RESPONSE
FAILUitE TO RESP(}ND WILL RESULT IN AN OFFICIAL TAX AS5ES5MENT
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 a discount or avoid interest, or return this notice to the Register of Wills anti
0 N E an official assessment will be issued by the PA Department of Revenue.
B L 0 C K ~ g, ~ 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, plea a tote OFFICIAL USE ONLY
^ ^ AAF
2 relationship to decedent: ~~ PA DEPARTMENT OF REVENUE
TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS PAD
LINE 1. Date Established 1 1
2. Account Balance 2 $ 2
3. Percent Taxable 3 X 3
4- Amount Subject to Tax 4 $ (f
5. Debts and Deductions 5 - sj
6. Amount Taxable 6 $ 6
7. Tax Rate 7 X -~
8. Tax Due 8 $ 8
PART DEBTS AND DEDUCTIONS CLAIMED
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
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 ) ~ ~ 7 ~r
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TAXPAYER SIGNATURE TELEPHONE NUMBER DAT
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IuIAL tinter on Line 5 of Tax Computation) $
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