HomeMy WebLinkAbout11-21-12COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 1 7 1 28-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
MICHAEL ZIFCAK FAMILY_TRUST
C/0 EDWARD SEEBER
260 ST JOHNS DR
CAMP HILL, PA 1701 1
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ESTATE INFORMATION:
FILE NUMBER: 2112-1219
DECEDENT NAME: ZIFCAK MARY D
DATE OF PAYMENT: 1 1 /21 /201 2
POSTMARK DATE: 1 1 /21 /2012
COUNTY: CUMBERLAND
DATE OF DEATH: 08/27/2012
REV-1 162 EX(1 1-96)
NO. CD 016819
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
101 540,841 .15
TOTAL AMOUNT PAID: 540,841 .15
REMARKS: RECEIPT TO ATTY
CHECK# 1004
INITIALS: HMW
SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
REV-346 EX (03-09) 3 4 6 0 0 0 712 0
ESTATE INFORMATION
SHEET
pennsylvania FOR REGISTER'S OFFICE USE ONLY
DEPARTMENT OF REVENUE County Code Year File Number
DECEDENT INFORMATION: Enter data as it will appear on all
documents submitted to the Department. 21 12
Last Name Suffix First Name MI
ZIFCAK MARY D
TYPE FILING: Enter mark (x) to indicate the nature of the return to be filed with the department.
^ Probate Return ^ Joint Assets Only ® Non-probate Assets Only ^ Litigation Purposes (No Other Assets)
LETTERS GRANTED: Enter mark (x) to indicate the nature of the proceedings at the register of wills office.
(Attach additional sheets if explanation is necessary.)
^ Testamentary ^ Administration ® No Letters ^ Other (Please Explain)
ATTORNEY /CORRESPONDENT INFORMATION: Enter all data concerning the attorney or other individual to receive all tax
information and correspondence.
Last Name Suffix First Name MI
SEEBER EDWARD P
Supreme Court I.D.# Telephone Number
76084 717 533 3280 Attorney / Corrrespondent's a-mail address:
eps@jsdc.com
First line of address
SUITE C-400
Second line of address ~ 6^
~~
555 GETTYSBURG PIKE >~ --~-`=T
City or Post Office State ZIP Code .T~ ~~ ~ ~ -`
_~~ , f~ - -_,:
-,--
MECHANICSBURG PA 17055 ~-4°" '~" - ~~
--~-,
PERSONAL REPRESENTATIVE INFORMATION: Enter all data concerning the person ' ~ resentativ°e~s) of t.~e ~s~ate
authorized by the Register of Wills. -_':, ~;`:~ ~,~ ' ~ '
Executor/Administrator ~ r.~ ~~ O
Social Security Number Telephone Number ~
717 737 5382
Last Name Suffix First Name MI
ZIFCAK MARK A
First line of address
2 60 ST . JOHNS DRIVE OFFICIAL USE ONLY
Second line of address TRANSACTION COUNT I
~~,,.~~
City or Post Office State ZIP Code
CAMP HILL PA 17011
Complete general estate information questions, and indicate additional personal representatives on reverse side.
PLEASE USE ORIGINAL FORM ONLY
Side 1
3460007120 3460007120 J
J
Decedent's Name: MARY D . Z I FCAK
Co-Executor/Administrator
Social Security Number Telephone Number
Last Name
ZIFCAK
First line of address
646 ANGELL STREET
Second line of address
City or Post Office
PROVIDENCE
Co-Executor/Administrator
Social Security Number
Last Name
First line of address
Second line of address
City or Post Office
Telephone Number
3460007220
Suffix First Name
MICHAEL
State ZIP Code
RI 02906
Suffix First Name
State ZIP Code
General Instructions:
This form should be filed with the Register of Wills of the county of which the decedent was a resident at death.
MI
MI
Please be aware the correspondent identified will receive all correspondence from the department. It is the responsibility of the
personal representative to notify the department if the correspondent contact information changes.
The department is authorized by law, 42 U.S.C. §405 (c)(2)(C)(i), to require disclosure of Social Security numbers in connection
with administering state tax laws. The department uses the Social Security number to identify the decedent and personal representatives
of the estate. The commonwealth may also use the information in exchange-of-tax-information agreements with federal
and local taxing authorities. State law prohibits commonwealth personnel from disclosing confidential tax information except
for official purposes.
Decedent's Social Security Number
Side 2
3460007220 3460007220 J