HomeMy WebLinkAbout09-28-12 (6)COMMDNWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
HARRISBURG60PA 17126~6~~~i %~~F~CE`
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JUDY A ER
570 DOGWOOD DR
MECHANICSBURG PA 17055-6176
INFORMATION NOTICE FILE N0. 21 -~ 2 - /U7U
AND ACN 12503584
TAXPAYER RESPONSE
DATE 08-22-2012
TYPE OF ACCOUNT
EST. OF PAULINE F CHRONISTER ^ SECURITY
S.S. N0. 186-01-4678 X^ SEC ACCT
DATE OF DEATH 07-01-2012 ^ STOCK
COUNTY CUMBERLAND ^ aoNDs
REMIT PAYMENT AND FORMS TD:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
AMERIPRISE has provided the Department with the information listed below which has been used in
calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a beneficiary of this asset.
If you feel this information is incorrect, please obtain written correction from the transfer agent, attach a copy to this form and
return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania
Questions may be answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW * ~ ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
PART DEBTS AND DEDUCTIONS CLAIMED
Under penalties of perjury, I declare that the facts I have reported above are true, correct and
complete to the best of my knowl 9e and belief. H 0 ME C ~ ) / /- ~ a
7
PA S GNA UR TELEPHONE NUMBER AT
DATE PAID PAYEE DESCRIPTION AMOUNT PAID