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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
HAUN PAMELA J
19 SHARON RD
ENOlA, PA 17025
__n____ fold
ESTATE INFORMATION: SSN: 193-14-5081
FILE NUMBER: 2105-0240
DECEDENT NAME: SMITH WilLIAM F
DA TE OF PAYMENT: 03/14/2005
POSTMARK DATE: 03/11/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 05/05/2004
NO. CD 005051
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
05106438 I $7.06
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I
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TOTAL AMOUNT PAID:
$7.06
REMARKS:
CHECK# 4830
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WillS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. Z8D6Dl
HARRISBURG, PA 171Z8-D6Dl
*
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21 05 .;)40
05106438
03-01-2005
REY-ISO EX AFP (89-001
'tST. OF WILLIAM F SMITH
5.5. NO. 193-14-5081
DATE OF DEATH 05-05-2004
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
lXI CHECKING
o TRUST
o CERTIF.
PAMElA J HAUN
19 SHARON RD
ENOLA PA 17025
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
PNC BANK has providad tha DepartMant with the information listed below which has been used in
calculating the potantial tax due. Their records indicate that at the death of the above dacedent, you wera a joint owner/baneficiary of
this account. If you feel this infornation is incorrect, please obtain written correction fro. tha financial institution, attach a copy
to this forM and return it to tha above address. This account is taxable in eccordance with the Inheritance Tax laws of the CO.Monwealth
of Pennsylvania. Quastions May ba answered ~y calling (717) 787-83Z7.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTkUCTIONS
Account No. 5000931051 Date 05-27-1999
Established
x
940.76
16.667
156.80
.045
7.06
TAXPAYER RESPONSE
To insure proper credit to your account, two
(Z) copies of this notice Must aCCOMpany your
paYMent to the Register of Wills. Make check
payable to: "Register of Wills, Agent".
Account Balance
Percent Taxable
AMount Subject to
Tax Rate
Potential Tax Due
x
Tax
NOTE: If tax paYMents are made within three
(3) Months of the decedent's date of death,
you .ay deduct a S~ discount of the tax due.
Any inheritance tax due will beCOMe delinquent
nine (9) Months after the date of death.
PART
m
A.
[ CHECK ]
ONE
BLOCK B.
ONLY
c.
~ The above information and tax due is correct.
~ 1. You May choose to re.it payment to the Register of Wills with two copies of this notice to obtain
a discount Dr avoid interest, or you may check box "A" and return this notice to the Register of
Wills and an official assessment will be issued by the PA Department of Revenue.
[] The above asset has been Dr will be reported and tax paid with the Pennsylvania Inheritance Tax return
to be filed by the decedent.s reprasentative.
[] The above inforMation is incorrect and/or debts and deductions were paid by you.
You Must complete PART ~ and/or PART ~ below.
If you indicate a different tax rate, please state your
relationship to decedent:
PART
~
TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS
LINE 1. Dat. Established '____
2. Account Balance 2
3. Percent Taxable 3 X
4. AMount Subject to Tax 4
5. Debts and Deductions 5
6. Allount Taxable 6
7. Tax Rate 7 X
8. Tax Due 8
PART
[!]
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUNT PAID
I
$
I
TOTAL (Enter on Line S of Tax COllputation)
perjury, I declare that the
~~nO"ledge and belief.
facts I
have reported
( ~r '1
(
H
above are true, correct
lJ.l.-l1~ I
and f
03 -fl-Jfi;'C>
V'
R
DATE