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Home My WebLink About04-26-07 r COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 008076 SAURMAN PATRICIA A 431 HERMAN AVE LEMOYNE, PA 17043 ACN ASSESSMENT AMOUNT CONTROL NUMBER _ fold 06153171 $177.16 ESTATE INFORMATION: SSN: 163-07-6635 FILE NUMBER: 2106- 1 095 DECEDENT NAME: DIERICH ERNEST R DATE OF PAYMENT: 04/26/2007 POSTMARK DATE: 04/23/2007 COUNTY: CUMBERLAND DATE OF DEATH: 09/ 1 8/2006 TOTAL AMOUNT PAID: $177.16 REMARKS: CHECK# 233 INITIALS: DM SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS 60-1425 U~~' ERNEST R. DiERiCH, SR. 313 233 PH. 717-763-4077 362223353 431 HERMAN AVENUE LEMOYNE, PA 17043 DATE ~2-3- 0_7 i h w PAY TO THE /y ORDER OF L I'm / DOLLARS a 3 Fulton Bank • Capital Division Drovers Bank Division s • Great Valley Division • Lancaster/Chester Division MEMO 1:0313014221: 3622 233530 0233 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INFORMATION NOTICE (7cl ~ EPTAU2806D1DIVIDUAL TAXES AND FILE NO. 21 ()(3 HARRISBURG, PA 17128-0601 TAXPAYER RESPONSE ACN 06153171 * * REVISED NOTICE * * * DATE 10-27-2006 REV-1543 EX AFP (09-00) TYPE OF ACCOUNT EST. OF ERNEST R DIERICH ❑ SAVINGS S. S. NO. 162-07-6635 ® CHECKING DATE OF DEATH 09-18-2006 ❑ TRUST COUNTY CUMBERLAND ❑ CERTIF. REMIT PAYMENT AND FORMS TO: PATRICIA A SAURMAN REGISTER OF WILLS 431 HERMAN AVE CUMBERLAND CO COURT HOUSE LEMOYNE PA 17043 CARLISLE, PA 17013 FULTON BANK 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 joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, 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 Account No. 3622-23353 Date 06-30-2003 To insure proper credit to your account, two Established (2) copies of this notice must accompany your payment to the Register of Wills. Make check Account Balance 18,694.32 payable to: "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax _ 9,347.16 (3) months of the decedent's date of death, Tax Rate X .045 you may deduct a 5% discount of the tax due. Any inheritance tax due will become delinquent Potential Tax Due 420.62 nine (9) months after the date of death. PART TAXPAYER RESPONSE z €€~A:I URC! ::::RESP-10 1~::::III:1c:::;:R. A -1-;T; IA 41 ~r c .ASE r::::BA c r~: ' TH s..x€I:.;.:. A. ❑ The above information and tax due is correct. 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or you may check box "A" and return this notice to the Register of ONE Wills and an official assessment will be issued by the PA Department of Revenue. B LOCK B. ❑ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return ONLY to be filed by the decedent's representative. C. The above information is incorrect and/or debts and deductions were paid by you. You must complete PART 2❑ and/or PART 3❑ below. PART If you indicate a different tax rate, please state your s € TI?G;It~lr::::tl~rE:::aI11EY relationship to decedent: ::::::.:;::::::::::..s::::::::::::::: €€€A =€lEA1 MENIi OF €s;REEN ' RETURN € € ;ss= s TAX COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LiNE 1. Date Established 1 2. Account Balance 2 3. Percent Tax ::::?::s :;:i::• .::.'::s :=;€;;s::;:€:::a is:i:is_ s:s:::::°:;::: able 3 :€'-_i':ii.;isiis€=~_ iissi_ 4. Amount Subject to Tax 4_ lli 5. Debts and Deductions 5 . :.t:::::.:::::::::::::::::::=::::.-[i::.:__ :.::s;i 6. Amount Taxable _:::::::::::::..:;.:a:a:s7;,:::::.:::::::ss e 6 _ . S 7. Tax Rate 7 X e::v::::::::;.::::::: . 8. Ta s.........; €:€:€:i['s: i........ Tax Due 8 / PART DEBTS AND DEDUCTIONS CLAIMED P DATE PAID PAYEE DESCRIPTION AMOUNT PAID TOTAL (Enter on Line 5 of Tax Computation) S _cf 17 Under penalties of perjury, I declare that the facts I have reported above are? true, correct and complet to the best of my nowledg and belief. HOME ( ) ~ 3 " )vd~& aa- 6~ Zo,,11-ln 4t4-L c WORK ( ) 2 G7 TAXPAYER SIGNATURE TELEPHONE NUMBER TE Attachement to ACN 06153171 Debts and Deductions Claim for Patricia A. Saurman, 431 Herman Ave., Lemoyne, PA 17043 Fulton Bank Acct. 3622-23353 Check #217 - Burick & Azizkhan Internal Medicine 09-18-06 Family Physician $ 44.43 Check #218 - Verizon 09-18-06 Telephone Bill $ 54.68 Check #219 - IMWRF (Susq. Club) 09-22-06 Funeral Luncheon $ 445.50 Check #220 - Stone & Murray, Funeral Director 09-22-06 Funeral Expenses $ 2,509.00 Check #221 - Millenium Phy. Sys. East 10-12-06 Medication $ 197.87 Check #222 - Chapel Pointe 10-13-06 Nursing Home Care $ 915.00 Check #223 - Quantum Imaging 10-14-06 X-ray $ 13.90 Check #224 - Associated Cardiologists 10-14-06 Heart Consultation $ 27.50 Check #225 - Burick & Azizkhan Internal Medicine 10-14-06 Family Physician $ 22.28 Check #226 - Susq. Breast Care Center 10-16-06 Dermatologist $ 23.06 Check #227 - Burick & Azizkan Internal Medicine 11-03-06 Family Physician $ 100.18 Check #228 - Philhaven 11-09-06 Psychiatric Evaluation $ 19.12 Check #229 - Belvedere Medical Corp. 11-17-06 Nursing Home Visit $ 12.75 Check #230 - Holy Spirit Hospital 12-09-06 Hospital Stay $ 952.00 Check #231 - U.S. Treasury 04-12-07 Federal Income Tax $ 73.00 TOTAL $ 5,410.27 Patricia Saurman 431 Herman Ave.. Lemoyne, PA 17043,., nytHNtN-`14~ 1-701-3 = I<<~ill.„ltl.,.+