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COHHONWEALTH OF PENNSVLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
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INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE NO.
ACN
DATE
21-D5 -31 t
04146544
12-17-2004
~ .__ ,.__ ,.-'.... ,_ ."_ ':.:; t-
REY-l&45 EX AF, (.Di-OJl
t.,r'
11
. ! j
TYPE OF ACCOUNT
EST. OF MYRTIS S MCMILLEN 0 SAVINGS
S.S. NO. 171-16-1123 lXlCHECKING
DATE OF DEATH 06-29-2004 0 TRUST
COUNTY CUMBERLAND 0 CERTIF.
REHIT PAYHENT AND FORHS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
GAIL M BLACK
60 CONWAY ST
CARLISLE PA 17013
ORRSTOWN BANK has provided the Depart.ent with the inforsation 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 infor~tian is incorrect, please obtain written correction fro. the financial institution, attach a COpy
to this far. and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Co..onwealth
of Pennsylvania. Questions say be answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 108006372 Dat. 11-06-2002
Established
x
1,764.32
50.000
882.16
.15
132.32
TAXPAYER RESPONSE
To insure proper credit to your account, two
(2) copies of this notice .ust acco.pany your
pay.ent to the Register of Wills. Make check
payable to: "Register of Wills, Agent".
Account Balance
Percent Taxable
A.ount Subject to
Tax Rate
Potential Tex Due
x
NOTE: If tax pay.ents are .ade within three
(3) sonths of the decedent's date of death,
you .ay deduct a SiC discount of the tax due.
Any inheritance tax due will beco.e delinquent
nine (9) .onths after the date of death.
Tax
PART
[!]
A.
[ CHECK ]
ONE
BLOCK B.
ONLY
c.
c=l The above infor.ation and tax due is correct.
1. Vou .ay choose to r..it pay.ent to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest, or you .ay check box "A" and return this notice to the Register of
Wills and an official assesssent will be issued by the PA Depart.ent of Revenue.
c:J The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
to be filed by the decedent's representative.
lii The above infor.ation is incorrect and/or debts and deductions were paid by you.
~ou .ust co.plete PART ~ and/or PART ~ below.
PART If you indicate a different rr~.5 rate, ,Plea~ state your
~ relationship to decedent: ~~ f t1~
TAX RETURN - COMPUTATION OF TAX ~~OI~l./JRUST ACCOUNTS
LINE 1. Date Established l l:m: li.f-~--Z-
2. Account Balance 2 ~
3. Percent Taxable 3 X 5" () /t)
it. A.ount Subject to Tax it I
5. Debts and Deductions 5
6. Allount Taxable 6
7. Tax Rate 7
8. Tax Due 8
PART
[!]
DATE PAID
PAYEE
DESCRIPTION
AMOUNT PAID
~ 7n 8Ud-
"'T"U^TIID~
I
$
I
TOTAL (Enter on Line 5 of Tax COIJPUtationJ
Under penalties of perjury, I declare that the facts I
COIIPlete to the best of IIY knowledge and belief.
and
- - ...._ ."....n
HOME ( )
WORK (11 t ) 7.(i -I'4o(j
TELEPHON NUMB ~s.o~
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DATE
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128,0601
REV,l162 EX(11,96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
BLACK GAIL M
60 CONWAY STREET
CARLISLE, PA 17013
______u fold
ESTATE INFORMATION: SSN: 177-16-1123
FILE NUMBER: 2105-0318
DECEDENT NAME: MCMILLEN MYRTIS S
DA TE OF PAYMENT: 04/05/2005
POSTMARK DATE: 04/05/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 06/29/2004
NO, CD 005164
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
04146544 I $ 40.00
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$ 40.00
REMARKS: G M BLACK
CHECK# 441
SEAL
INITIALS: VZ
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS