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~ PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE FILE N0. 21 1 ~- l~ l~~
BUREAU OF INDIVIDUAL TAXES
Po Box 280601 ~K ~j
HARRISBURG PA 17128-0601 ~~'~~~~~~~
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AND
R R E S P O N S E
Y
ACN
12131597
T AX P A
E DATE 05-16-2012
TYPE OF ACCOUNT
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itJ~ - I PM 3- Z
i EST. OF CATHERINE B BUNJEVAC ~ SAVINGS
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. SSN 182-16-1084 ^ CHECKING
~~~ nC DATE OF DEATH 04-28-2012 ~ TRUST
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~~~~j COUNTY CUMBERLAND ~ CERTIF.
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~~ CO., PA REMIT PAYMENT AND FORMS T0:
TRAVIS WHI REGISTER OF WILLS
1521 INVERNESS DR 1 COURTHOUSE SQUARE
MECHANICSBURG PA 17050-8329 CARLISLE PA 17013
FU LT ON BANK NA provided the department with the information below, which was used is 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 I 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 INSTRUCTIUNS
Account No. 3626-84078 Date 03-29-2005 To ensure proper credit to the account, two
Established copies of this notice must accompany
Account Balance 979.87 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 ~` 489.94 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 $ 22.05 nine months after the date of death.
PART TAXPAYER RESPONSE
FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT
A. ^ lfhe 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 and
C 0 N E ~ an official assessment will be issued by the PA Department of Revenue.
BLOCK B
ONLY
C
1( above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return
"filed by the estate representative.
lfhe above informs ion is incorrect and/or deb s and deduct-on_s were paid. 11
Complete PART 2 and/or PART ~ below. '\ r,, j ~{,~~
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PART If indicating a different tax rate, please state Of CIAL iISE ONLY ~ AAF
^D relationship to decedent:
PA DEPARTMENT OF REVENUE
TAX RE TURN - CALCULATION OF TAX ON.. JOINT/TRUST ACCOUNTS PAD
LINE 1. Date Established 1 1
2. Account Balance 2 $ 2
X ~~
3. Percent Taxable 3 ~
" 3 ,
4. Amount Subject to Tax 4 $ ~ ~
~ ~ 4
5. Debts and Deductions 5 T
f ~.~. > > 5
6. Amount Taxable 6 $ ~~ 6
7. Tax Rate 7 X L-' 7
8. Tax Due 8 $ ~yl $
PART DEBTS AND DEDUCTIONS CLAIMED
0
DATF~ PAID ~ PAYEE n DESCRIPTION AMOUNT PAID
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~TALvCEnter on"Liprg 5 of Tax CompUtatio'Fl) S /~r ,~~
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 r ) ~ - -,~
~r ~ .. l r l WORK C ) <_~"3
~XA PAYE°SIG ATUR TELEPHONE NUMBER DAT
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