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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
*'
INFORMATION
AND
TAXPAYERitES ONSE
ES'LiJ'OR :PA
S.S. NO.
DATE ,'Of;>>'::
\ .'....
C~\"
FILE NO.
ACN
DATE
21 05-053~
05121927
06-01-2005
REV-1543 EX AFP 109-00)
TYPE OF
ACCOUNT
o SAVINGS
[Xl CHECKING
o TRUST
o CERTIF.
n:WE ~ltKIMMEL
191-01-6721
H 01-01-2005
CUMBERLAND
CATHERINE KIMMEL
531 FAIRWAY DR
CAMP HILL PA 17011-2023
. REHIT PAYHENT AND FORHS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
PSECU has provided the Department with the information isted below which has been used in
calculating the potential tax due. Their records indicate that at the death of the above d cedent, you were a joint owner/beneficiary of
this account. If you feel this information is incorrect, please obtain written correction rom the financial institution, attach a copy
to this form and return it to the above address. This account is taxable in accordance wi the Inheritance Tax Laws of the Commonwealth
Qf Pennsylvania. ~u~~tions may be an~w3red ~y ~911ing (717) 787-83~7
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 0191016721 Date 02-18-1987
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
371. 70
50.000
185.85
.045
8.36
TAXPAYER RESPONSE
To insure proper credit to your account, two
(Z copies of this notice must accompany your
pa ment to the Register of Wills. Make check
pa able to: "Register of Wills, Agent".
x
NO E: If tax payments are made within three
(3 months of the decedent's date of death,
yo may deduct a 5Z discount of the tax due.
An inheritance tax due will become delinquent
ni e (9) months after the date of death.
Tax
PART
[!]
A.
[ CHECK ]
ONE
BLOCK B.
ONLY
c.
"'sKllO!1i::iBAsll:moNiiiil1!Hils::mlli!fitcli:m::
.......-....................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
~ The above information and tax due is correct.
1. You may choose to remit payment to the Register of Will with two copies of this notice to obtain
a discount or avoid interest, or ~ou may check box "An nd return this notice to the Register of
Wills and an official assessment will be issued by the A Department of Revenue.
[] The above asset has been or will be reported and tax paid w th the Pennsylvania Inheritance Tax return
to be filed by the decedent's representative.
[] The above information is incorrect and/or debts and deducti ns were paid by you.
You must complete PART ~ and/or PART ~ below.
OF TAX ON JOINT/TRUST ACCOUNTS
PART
@]
TAX RETURN - COMPUTATION
If you indicate a different tax rate, please state your
relationship to decedent:
LINE 1. D.t. Est.blished 1
2. Account Balance 2
3. Percent Taxable 3 X
4. Amount Subject to Tax 4
5. Debts and Deductions 5
6. Amount Taxable 6
7. Tax Rate 7 X
8. Tax Due 8
PART
~
DATE PAID
PAYEE
DESCRIPTION
AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Co
$
Under penalties of
complete to the best of
c?~~~ ~
TAXPAYER SIGNA URE
perjury, I declare that the facts I have repo
my knowledge and belief.
ted above are true, correct
HOME ( /}- ) 7-6/-,j-g-tJ6
WORK (I )
TELEPH NE NUMBER
and
\J'
DATE
COMMONWEALTH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA '7'28-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 005433
KIMMEL CATHERINE
531 FAIRWAY DR
CAMP HILL, PA 17011-2023
Acr~
ASSESSr /lENT AMOUNT
CONT~OL
NUMBf-R
u____n fold ---------- --------
051219~7 I $8.36
ESTATE INFORMATION: SSN: 191-01-6721 I
FILE NUMBER: 2105-0538 I
DECEDENT NAME: KIMMEL PAUL INE R I
DATE OF PAYMENT: 06/15/2005 I
POSTMARK DATE: 06/14/2005 I
COUNTY: CUMBERLAND I
DATE OF DEATH: 01/01/2005 I
I
TOTAL AMOUNT PAID: $8.36
REMARKS:
CHECK# 6059
SEAL
INITIALS: JA
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS