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COMMONWEALTH OF PENNSYLVANIA rCOO R .\
DEPARTMENT OF REVENUE ~.n"_ INFORMATION NOTICE FILE NO. 21 - 1.1~)- . . U
BUREAU OF INDIVIDUAL TAXES AND
DEPT. 280601 TAXPAYER RESPONSE ACN 04143946
HARRISBURG, PA 17128-0601 ~ ':-: ' :- ' -', !.' .
. DATE 11-04-2004
!iEv-i~4~ HAHlU9-Qoi-'
TYPE OF ACCOUNT
. f;" 25 t,j' 1: ;:;0 EST. OF HANNAH 0 SMITH o SAVINGS
\ j ~
"',- .. 5.5. NO. 292-14-4343 iXI CHECKING
DATE OF DEATH 08-22-2004 o TRUST
COUNTY CUMBERLAND C CERTIF .
,,1-'"
i,---; REMIT PAYMENT AND FORMS TO:
,.-.1
EUGENE N SMITH REGISTER OF WILLS
509 B SOUTHWEST ST CUMBERLAND CD COURT HOUSE
CARLISLE PA 17013 CARLISLE, PA 17013
ORRSTQWN BANK has provided the Department with th~ 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 fElel 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 IE IE IE SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 106001704 Daie 10-23-2000 To insure proper credit to your account, two
Established eZl copies of this notice must accompany your
2,165.10 payment to the Register of Wills. Make ch!:i!ck
Account Balance payable to: "Register of Wills, Agent".
Percent Taxable X 50.000
1,082.55 NOTE: If tax payments are made within thr~e
Amount Subject to Tax (3) months of the decedent's date of death,
Tax Rate X .15 you may d~duct a 51. discount of the tax dUi::!.
Potential Tax Due 162.38 Any inheritance tax due will become delinquent
nine (9) months after the date of death.
Nn TAXPAYER RESPONSE
[2], f'AILURE, TO RESPOND IftU. ,RESULT IN AH OFFICIAL ,TAX ASSESSIIENT,BASED ON THIS,NOTICE I
.. c=J 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 c::heck 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.
BLOCK B. c=J Thf:! above asset has been or will be reported and tax paid with the Penns~lvania Inheritance Tax return
ONLY to be filed by the decedent's representative.
C. ~ Th~ above information is incorrect and/or debts and deductions were paid b~ you.
Yaw must complete PART 0 and/or PART ~ bE!low.
PART If you indicate a different tax rate~ please state your
~ relationship to decedent:
TAX RETURN - COMPUTATION OF TAX qN JOINT/TRUST ACCOUNTS
LINE 1. Date E~tablishad 1 11.-/1.0<''''
2. Account Balance 2 -'L. { &;;-, I C
3. Percent Taxable 3 X
4. Amount Subject to Tax 4 6
5. Debts and Deductions 5 "-'1 Si'~ .5-'-
6. Amount Taxable 6 ..?"'
7. Tax Rate 7 X
8. Tax Due 8 -Q-
PART DEBTS AND DEDUCTIONS C~AIMED
~
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
;; i'-'f I 0 '-{ i ~f cU,h"",,~/ ~"~~ I IV '-"'-'~ "'_c. ct....~, - x..~ ",:u. /11 U(a.~ I 'iSc"J',
/r:/~/{}'i Ii+~~,", -Ii.YL h..~.,.y s..~ IF4.><'-.o:t......:.::--.4::::.J!:~~ F-f 9~~, G (1
I I
I I
TOTAL [Enter on Line 5 of Tax Computation) $
Under penalties of perjury, I declare that the facts I have reported above are true~ cor~ect and
complete to the best of my knowledge and beli~f. HOME ( '7,1 ) 'Z,1 '1- 3J"Y"L
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