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HomeMy WebLinkAbout08-02-2005 ~ wfB ;:))(z E m~g 8 ~asa i a:;:)~ ... u.cc t:: os:~ ~ ....iSt=: 0; ffi~w...~ :I u.(,) I;:) ....OzCi5CD ~;:)~C'lsa ffi:5a:--=~ c~~fh~ ~_ZQ 0;-- I ~ !:1 ;i; i.....) \ ~d .. \. I.~"}- ,: J- ~,..J "I , (. () t= . . - ~ , -' : .,-C..:.. ':::-'_"_'_:~ i .II' -' 1\.:)iJ3JdU~)J::J , ..J'J, ~ II) i ..' ,_., , . 1...... -. ~' - -= - -= - 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - =E - - g z ~ 00 c: ::s:Z ~ ~!:< i ~c: o~ II oi-t <: m 5;!; 6 OW ri\ ",m 1ft OJ.~ -< ." m 0 .,,5 c: ~." ~ ~m m ... - == ." ,.. -I -< 2S z :s: g g ~ ,.. ~ ~ ;;c: -< == g II ... l\@ 0- .'. ~'7/()~- ~~.. ac G~~ /~ 7A;( !J d. c::. !l-Cc,/ -:It- 56000 bJ 9~31 . /CJ2. 97 ~J;t:> . ~Ys-... I 03. 5J.....> iF ~ooo 0 ?g~6 93-.t.,,~ .~-.S~ !! 9.3 Y3, b7 =#soooo '7S'76"~ ~ -5',% 2 3, f~ 1-7:2. 3=<~ (""'J U') .. 1-- U I . 0: h? :t:f $v 0;(:;'0 0 V..:<? ~~~~~;' _ Ii:_ I~."_) \_, _ c....: I . C'~ t? .r(i> LJ.' I ~ ,'~ .~ (I: (.;:-, C ) ;~~ q;~; ; ~.~ ~~ c.~__ g C"~l /cf-~o . C; :1. /7~b " ., '--..' , '" "O~ CO:::~ v..:.::~ >'~~ ~e:A.. Cv " .:9 o:l e.n ~"O;:l ~.D :Ii 0 ;!l ..="'::: ~NO r-o "'~ CO #~~ 0=1<(-1 st".{ g- /0 tV ~.S.o/O .SO 7--s~ ToT~L fA-X j)vl ii. ~ t 9. 97 ~-S'?<J ~ ~6b fj 1 . "Love one another. n Jolin I5; 12 COMMONWEALTH Of PENNSYLVANIA DEPARTMENT Of REVENUE BUREAU Of INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 ~)n (}~~~~~ATlJ'DN NonCE 'W6". '-'T~,XFtAYER RESPONSE FILE ACN DATE NO. 21 D"':) d1.o'81t7 05133668 07-21-2005 REY-1545 EX AFP 109-001 ?n;'1~ i~ ":" 'l .... '.'....' l." ,'~'..., '...:.~ - c:. ("'::':)1/ Or:'~~ ~'r",~~~ ' (" ...., f, !ell I; : i~. OF GINOR HESS S.S. NO. 195-20-6762 DATE OF DEATH 04-29-2005 COUNTY CUMBERLAND TYPE OF ACCOUNT o SAVINGS [X] CHECKING o TRUST o CERTIF. MARY AVERY 6725 OLD BERWICK RD BLOOMSBURG PA 17815 RE"IT PAY"ENT AND FOR"S TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 COLU"BIA CNTY FAR"ERS NATL BK 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 ot Pennsylvania. Questions may be 3n~wcred by calling (7\7) 787-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 2202418618 Date 10-20-2000 Established x 2,666.29 8.333 222.18 .045 10.00 TAXPAYER RESPONSE To insure proper credit to your account, two (2) 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 may deduct a 5% 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. [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 obtein a discount or 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. [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. [J The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART ~ below. PART ~ TAX RETURN - COMPUTATION OF LINE 1. Date E~teblished 1 2. Account Balance 2 3. Percent Taxable 3 4. Amount Subject to Tax 4 5. Debts and Deductions 5 6. Amount Taxable 6 7. Tax Rate 7 8. Tax Due 8 TAX ON JOINT/TRUST ACCOUNTS If you indicate a different tax rate, please state your relationship to decedent: x x PART ~ DATE PAID DEBTS AND DEDUCTIONS CLAIMED PAYEE DESCRIPTION AMOUNT PAID I TOTAL (Enter on Line 5 of Tax Computation) I $ co~te ;./7 TAXPAYER facts I have reported above are true, correct HOME (-.!>10) 7-..6'1 -1& ;;L '-> WORK ( ) TELEPHONE NUMBE and l.b.r~1) DAT GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. Z. Inheritance tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even though the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) which the decedent put in joint names within one year prior to death are fully taxable as transfers. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with your check for the amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. Z. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one COpy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept Z80601, Harrisburg, PA 171Z8-0601 in the envelope provided. 3. BLOCK C - If the notice information is incorrect and lor deductions are being claimed, check block "c" and complete Parts Z and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter NOTE: the date the account originally was established or titled in the manner existing at date of death. For a decedent dying after lZ/IZl8Z: Accounts which the decedent put in joint names within one (1) year of death are taxable fully as transfers. However, there is an exclusion not to exceed $3,000 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk (**) appears before your first name in the address portion of this notice, the $3,000 exclusion already has been deducted from the account balance as reported by the financial institution. Z. Enter the total balance of the account including interest accrued to the date of death. 3. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent end two other persons. 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY Z (SURVIVORS) = .167 X 100 16.770 (TAXABLE FOR EACH SURVIVOR) B. The percent taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT OWNERS DR TRUST BENEFICIARIES X 100 PERCENT TAXABLE Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY Z (SURVIVORS) = .50 X 100 5070 (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (line 4) is determined by multiplying the account balance (line Z) by the percent taxable (line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (line 6) is determined by subtracting the debts and deductions (line 5) from the amount subject to tax (line 4). 7. Enter the appropriate tax rate (line 7) as determined below. *The tax rate Imposed on the net value of transfers from a deceased ChIld twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is OX. The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The "Collateral" class of heirs includes all other beneficiaries. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3X 6X 15X 15X 01/01/95 to 06/30/00 OX 6X 15X 15X 07/01/00 to present OX 4,5XII 12X 15X CLAIMED DEDUCTIONS - PART 3 DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paper 8 l/Z" x 11". Proof of payment may be requested by the PA Department of Revenue. COMMONWEALTH OF PENNSYLVANIA OEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 _,.....*:r\, :<'.-'"". " , - -. ',--'-"., "', , INFORMATION NOTICE I": AND TAXPAYER RESPONSE FILE ACN DATE NO. 21 () S - Ol.o'R'lp 05133679 07-21-2005 REY-1545 EX AFPlD9-00> ;~:1S:~,l ~~ ... ~ "').< ,. .~- - _':.1 '- j:, t ~ ~ r0 ,-,V TYPE OF ACCOUNT o SAVINGS o CHECKING o TRUST [Xl CERTIF. C n",-, ~;l-',r (~. i -, ' ~ ~.,,~ EST. OF GINOR HESS S.S. NO. 195-20-6762 DATE OF DEATH 04-29-2005 COUNTY CUMBERLAND MARY AVERY 6725 OLD BERWICK RD BLOOMSBURG PA 17815 REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 COLUMBIA CNTY FARMERS NATL BK has provided the Departm..nt with the inforllation listed below which has be..n used in calculating the potential tax du... Their r..cords indicate that at the death of the above d..ced..nt, you w..r.. a joint own..r/b..n..ficiary of this account. If you f....l this information is incorr..ct, pl..as.. obtain writt..n corr..ction from th.. financial institution, attach a copy to this form and r..turn it to th.. abov.. addr..ss. This account is taxable in accordanc.. with the Inheritance Tax Laws of the COllmonw..alth of Pennsylvania. Questions may b.. answ..r..d by calling (717) 787-8~27. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 5000009231 Date 11-10-2000 Established x 29,060.12 8.333 2,421.58 .045 108.97 TAXPAYER RESPONSE To insur.. prop..r cr..dit to your account, two (2) copies of this notic.. lIust accompany your payment to th.. Register of Wills. Make ch..ck payable to: "R..gister 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 d..ath, you may deduct a 5% discount of th.. tax du... Any inh..ritanc.. tax du.. will b..colI.. d..linquent nine (9) months after the date of deeth. PART IT] A. [ CHECK ] ONE BLOCK B. ONLY c. [J Th.. above information and tax du.. is corr..ct. 1. You may choose to r..mit payment to th.. Register of Wills with two copies of this notice to obtain a discount or avoid int..rest, or you lIay check box "A" and return this no tic.. to the Register of Wills and an official assessment will be issued by the PA Depart...nt of R..venue. [J Th.. above ass..t has been or will b.. reported and tax paid with the Pennsylvania Inheritanc.. Tax return to be fil..d by the dec..dent's repr..s..ntative. [J The abov.. information is incorrect and/or debts and deductions wer.. paid by you. You must compl..t.. PART ~ and/or PART ~ below. PART ~ DATE PAID DEBTS AND DEDUCTIONS CLAIMED PART [!] TAX RETURN - COMPUTATION If you indicate a different tax rate, please state your relationship to decedent: LINE 1. Date Established 2. Account Balance 3, Percent Taxable 4. Amount Subject to Tax S. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF 1 2 3 4 S 6 7 8 x TAX ON JOINT/TRUST ACCOUNTS x PAYEE DESCRIPTION AMOUNT PAID I $ I TOTAL (Enter on Line S of Tax Computation) perjury, I declare that the facts I kno ledge and belief. have reported above are true, correct and HOME rS7-0) '7s-rt- / (, ;)....0 WORK () '7~7/~ TELEPHONE NUM ER B'A E / GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSHENT with applicable inte..est based Dn infD..matiDn submitted by the financial institutiDn. Z. Inhe..itance tax becDmes delinquent nine mDnths afte.. the decedent's date Df death. 3. A jDint aCCDunt is taxable even thDugh the decedent's name was added as a matte.. Df cDnvenience. 4. AccDunts (including thDse held between husband and wife) which the decedent put in jDint names within Dne year priDr tD death a..e fully taxable as transfe..s. 5. AccDunts established jDintly between husband and wife mD..e than Dne yea.. p..iD" tD death a..e nDt taxable. 6. AccDunts held by a decedent "in t..ust fD.... anDthe.. D" Dthe..s a..e taxable fully. REPORTING INSTRUCTIONS PART 1 TAXPAYER RESPONSE 1. BLOCK A - If the infD..matiDn and cDmputatiDn in the nDtice are cD....ect and deductiDns a..e nDt being claimed, place an "X" in blDck "A" Df Pa..t 1 Df the "Taxpayer RespDnse" sectiDn. Sign tWD cDpies and submit them with YDU" check fD" the amDunt Df tax tD the Registe.. Df Wills Df the cDunty indicated. The PA Department Df Revenue will issue an Dfficial assessment (FD..m REV-1548 EX) upDn receipt Df the ..etu..n f..Dm the Registe.. Df Wills. Z. BLOCK B - If the asset specified Dn this nDtice has been Dr will be repDrted and tax paid with the Pennsylvania Inhe..itance Tax Retu..n filed by the decedent's rep..esentative, place an "X" in blDck "B" Df Part 1 Df the "Taxpaye.. RespDnse" sectiDn. Sign Dne CDPY and ..etu..n tD the PA Department Df Revenue, Bu..eau Df Individual Taxes, Oept Z80601, Ha..risburg, PA 171Z8-0601 in the envelDpe p"Dvided. 3. BLOCK C - If the nDtice infD..matiDn is incDr..ect and/D" deductiDns are being claimed, check blDck "C" and cDmplete Pa..ts Z and 3 accD..ding tD the inst..uctiDns belDw. Sign tWD cDpies and submit them with YDur check fD" the amDunt Df tax payable tD the Registe.. Df Wills Df the cDunty indicated. The PA Depa..tment Df Revenue will issue an Dfficial assessment (FD..m REV-1548 EX) upDn ..eceipt Df the ..etu..n f..Dm the Register Df Wills. TAX RETURN PART 2 TAX COMPUTATION LINE 1. Ente.. NOTE: the date the accDunt D..iginally was established D" titled in the manne.. existing at date Df death. FDr a decedent dying after lZ/IZ/8Z: AccDunts which the decedent put in jDint names within Dne (1) yea.. Df death a..e taxable fully as t..ansfe..s. HDweve.., there is an exclusiDn nDt tD exceed $3,000 pe.. t..ansfe..ee ..ega..dless Df the value Df the accDunt D" the numbe.. Df accDunts held. If a dDuble aste..isk (MM) appea..s befDre YDU" first name in the add..ess pD..tiDn Df this nDtice, the $3,000 exclusiDn al..eady has been deducted f..Dm the aCCDunt balance as ..epD..ted by the financial institutiDn. Z. Ente.. the tDtal balance Df the aCCDunt including inte..est acc..ued tD the date Df death. 3. The pe..cent Df the aCCDunt that is taxable fD" each su..vivD" is dete..mined as fDIIDws: A. The pe..cent taxable fDr jDint assets established mDre than Dne yea.. p..iD" tD the decedent's death: DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A jDint asset ..egiste..ed in the name Df the decedent and tWD Dthe.. pe"SDns. 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY Z (SURVIVORS) = .167 X 100 16.7Z (TAXABLE FOR EACH SURVIVOR) B. The pe..cent taxable fD" assets c..eated within Dne yea.. Df the decedent's death D" aCCDunts Dwned by the decedent but held in t..ust fDr anD the.. individual(s) (trust beneficia..ies): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT OWNERS OR TRUST BENEFICIARIES X 100 PERCENT TAXABLE Example: JDint accDunt registe..ed in the name Df the decedent and tWD Dthe.. pe"SDns and established within Dne yea.. Df death by the decedent. 1 DIVIDED BY Z (SURVIVORS) = .50 X 100 50Z (TAXABLE FOR EACH SURVIVOR) 4. The amDunt subject tD tax (line 4) is dete..mined by multiplying the aCCDunt balance (line Z) by the pe..cent taxable (line 3). 5. Enter the tDtal Df the debts and deductiDns listed in Part 3. 6. The amDunt taxable (line 6) is dete..mined by subt..acting the debts and deductiDns (line 5) f..Dm the amDunt subject tD tax (line 4). 7. Ente.. the apprDp..iate tax ..ate (line 7) as dete..mined belDw. MThe tax ..ate ImpDsed Dn the net value Df t..ansfe..s frDm a deceased ChIld twentY-Dne yea..s Df age D" YDunger at death tD D" fD" the use Df a natu..al parent, an adDptive pa..ent, D" a steppa..ent Df the child is oz. The lineal class Df hei..s includes grandpa..ents, pa..ents, child..en, and lineal descendents. "Child..en" includes natu..al child..en whethe.. D" nDt they have been adDpted by Dthe..s, adDpted children and step child..en. "Lineal descendents" includes all children Df the natu..al pa..ents and thei.. descendents, whether D" nDt they have been adDpted by Dthe..s, adDpted descendents and thei.. descendants and step-descendants. "Siblings" a..e defined as individuals whD have at least Dne parent in CDmmDn with the decedent, whethe.. by blDDd D" adDptiDn. The "CDllate..al" class Df hei..s includes all Dther beneficia..ies. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3Y. 6Y. 1SY. 1SY. 01/01/95 to 06/30/00 Oy. 6Y. 1SY. 1SY. 07101/00 to present Oy. 4.Sy'1I 12Y. 1SY. CLAIMED DEDUCTIONS PART 3 DEBTS AND DEDUCTIONS CLAIMED AIIDwable debts and deductiDns are dete..mined as fDIIDWS: A. YDU legally a..e ..espDnsible fD" payment, D" the estate subject tD administ..atiDn by a pe"sDnal rep..esentative is insufficient tD pay the deductible items. B. YDU actually paid the debts afte.. death Df the decedent and can fu..nish prDDf Df payment. C. Debts being claimed must be itemized fully in Pa..t 3. If additiDnal space is needed, use plain pape.. 8 l/Z" xli". PrDDf Df payment may be ..equested by the PA Depa..tment Df Revenue. COMMONWEALTH OF PENNSVLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 ...w.. . 'W'f. ... . ,. INFORMATION NOTICE r,- ~_ AND IT~XPAYER RESPONSE FILE ACN DATE NO. 21 C 5 CS\o 05133671 ~ 07-21-2005 REV-1545EXAFP {Q9-00l. C" '~'!..r-" , l:' ' ,JEST. OF GINOR HESS S.S. NO. 195-20-6762 DATE OF DEATH 04-29-2005 COUNTY CUMBERLAND TYPE OF ACCOUNT o SAVINGS o CHECKING o TRUST [Xl CERTIF. 'I fl, .n r"r.., " 1 ~ ,.... .-, i"".__._,.;;..,;" -:e.:. ("',1 , MARY A AVERY 6725 OLD BERWICK RD BLOOMSBURG PA 17815 REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 COLUMBIA CNTY FARMERS NATL BK has provided the Departllent 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 inforllation is incorrect, please obtain written correction from the financial institution, attach a copy to this forll and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questiu"s ....y b.. answarad by "aIling (717) 787-11327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 4000078406 Date 10-01-2002 Established x 26,300.12 8.333 2,191.59 .045 98.62 TAXPAYER RESPONSE To insure proper credit to your account, two (2) 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 lIay deduct a SZ discount of the tax due. Any inheritance tax due will become delinquent nine (9) months after the date of death. PART [!] A. [ CHECK ] ONE BLOCK B. ONLY c. c=l The above information and tax due is correct. 1. You may choose to remit paYllent to the Register of Wills with two copies of this notice to obtain a discount or 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 Departllent of Revenue. c=l 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. c=J The above inforllation is incorrect and/or debts and deductions were paid by you. Vou must complete PART ~ and/or PART ~ below. TAX ON JOINT/TRUST ACCOUNTS PART ~ TAX RETURN - COMPUTATION If you indicate a different tax rate, please state your relationship to decedent: LINE 1. Dat9 Established 2, Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF I 2 3 4 5 6 7 8 x x PART @] DATE PAID DEBTS AND DEDUCTIONS CLAIMED PAYEE DESCRIPTION AMOUNT PAID I TOTAL CEnter on Line 5 of Tax Computation) I $ perjury, I declare that the facts I ledge and belief. have reported above are ~e, c;rrect and HOME 610) 1..!J 7 - 0~ {) i-:f / WORK () ~ 71 oS" TELEPHONE NUM ER AT GENERAL INFORMATION 1. FAILURE TO RESPOND WIll RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based Dn infDrmatiDn submitted by the financial institutiDn. 2. Inheritance tax becDmes delinquent nine mDnths after the decedent's date Df death. 3. A joint aCCDunt is taxable even thDugh the decedent's name was added as a matter Df cDnvenience. 4. AccDunts (including thDse held between husband and wife) which the decedent put in jDint names within Dne year priDr to death are fully taxable as transfers. 5. AccDunts established jDintlY between husband and wife mDre than one year priDr tD death are nDt taxable. 6. AccDunts held by a decedent "in trust fDr" anDther or Dthers are taxable fully. REPORTING INSTRUCTIONS PART 1 TAXPAYER RESPONSE 1. BLOCK A - If the infDrmatiDn and cDmputation in the nDtice are cDrrect and deductiDns are nDt being claimed, place an "X" in blDck "A" Df Part 1 Df the "Taxpayer RespDnse" sectiDn. Sign tWD copies and submit them with your check fDr the amDunt Df tax tD the Register Df Wills Df the cDunty indicated. The PA Department Df Revenue will issue an Dfficial assessment (FDrm REV-1548 EX) upDn receipt Df the return frDm the Register Df Wills. 2. BLOCK B - If the asset specified Dn this nDtice has been or will be repDrted and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in blDck "B" of Part 1 Df the "Taxpayer RespDnse" sectiDn. Sign Dne CDPy and return tD the PA Department Df Revenue, Bureau Df Individual Taxes, Dept 280601, Harrisburg, PA 17128-0601 in the envelDpe prDvided. 3. BLOCK C - If the nDtice infDrmatiDn is incDrrect and/Dr deductiDns are being claimed, check blDck "C" and cDmplete Parts 2 and 3 accDrding to the instructiDns belDw. Sign tWD cDpies and submit them with YDur check for the amDunt Df tax payable tD the Register Df Wills Df the cDunty indicated. The PA Department Df Revenue will issue an Dfficial assessment (FDrm REV-1548 EX) upDn receipt of the return frDm the Register Df Wills. TAX RETURN PART 2 TAX COMPUTATION LINE 1. Enter NOTE: the date the accDunt DriginallY was established Dr titled in the manner existing at date Df death. FDr a decedent dying after 12/12/82: AccDunts which the decedent put in jDint names within Dne (1) year Df death are taxable fully as transfers. HDwever, there is an exclusiDn nDt tD exceed $3,000 per transferee regardless Df the value Df the accDunt Dr the number Df accDunts held. If a dDuble asterisk (MM) appears befDre YDur first name in the address pDrtiDn Df this nDtice, the $3,000 exclusiDn already has been deducted frDm the account balance as repDrted by the financial institutiDn. 2. Enter the tDtal balance Df the aCCDunt including interest accrued tD the date Df death. 3. The percent Df the accDunt that is taxable fDr each survivDr is determined as fDllDws: A. The percent taxable fDr jDint assets established mDre than Dne year prior tD the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A jDint asset registered in the name Df the decedent and tWD Dther persDns. 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) = .167 X 100 16.7% (TAXABLE FOR EACH SURVIVOR) B. The percent taxable fDr assets created within Dne year Df the decedent's death Dr accDunts Dwned by the decedent but held in trust fDr anDther individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT OWNERS OR TRUST BENEFICIARIES X 100 PERCENT TAXABLE Example: JDint aCCDunt registered in the name Df the decedent and tWD Dther persDns and established within Dne year Df death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) = .50 X 100 50% (TAXABLE FOR EACH SURVIVOR) 4. The amDunt subject tD tax (line 4) is determined by multiplying the accDunt balance (line 2) by the percent taxable (line 3). 5. Enter the tDtal Df the debts and deductiDns listed in Part 3. 6. The amDunt taxable (line 6) is determined by subtracting the debts and deductiDns (line 5) frDm the amDunt subject tD tax (line 4). 7. Enter the apprDpriate tax rate (line 7) as determined belDw. MThe tax rate ImpDsed Dn the net value Df transfers frDm a deceased ChIld twentY-Dne years Df age Dr YDunger at death tD Dr fDr the use Df a natural parent, an adDptive parent, Dr a stepparent Df the child is 0%. The lineal class Df heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether Dr nDt they have been adDpted by Dthers, adDpted children and step children. "Lineal descendents" includes all children Df the natural parents and their descendents, whether Dr nDt they have been adDpted by Dthers, adDpted descendents and their descendants and step-descendants. "Siblings" are defined as individuals whD have at least Dne parent in CDmmDn with the decedent, whether by blDDd Dr adDptiDn. The "CDllateral" class Df heirs includes all Dther beneficiaries. Date of Death Spouse lineal Sibling Collateral 07/01/94 to 12/31/94 3% 6% 15% 15% 01/01/95 to 06/30/00 0% 6% 15% 15% 07/01/00 to present 0% 4.5%11 12% 15% CLAIMED DEDUCTIONS PART 3 DEBTS AND DEDUCTIONS CLAIMED AllDwable debts and deductiDns are determined as fDllDws: A. YDU legally are respDnsible fDr payment, Dr the estate subject tD administratiDn by a persDnal representative is insufficient tD pay the deductible items. B. YDU actually paid the debts after death Df the decedent and can furnish prDDf of payment. C. Debts being claimed must be itemized fully in Part 3. If additiDnal space is needed, use plain paper 8 1/2" x II". PrDDf Df payment may be requested by the PA Department Df Revenue. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 *eo ,! . w.'_ , '..d ".., './ INFORMATION NOTICE r-r,,.. r-~ AND - ~tAXPAYER RESPONSE FILE ACN DATE NO. 21 O~ Olo~1o 05133676 07-21-2005 REV- lm EX AFP <09- O&l 1 TYPE OF ACCOUNT o SAVINGS o CHECKING o TRUST [X] CERTIF . .; r,I~::'''' - 2 r: 'I ~ : : ...,~ ::: '- EST. OF GINOR HESS S.S. NO. 195-20-6762 DATE OF DEATH 04-29-2005 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 MARY AVERY 6725 OLD BERWICK RD BLOOMSBURG PA 17815 COLUMBIA CNTY FARMERS NATL BK has provided the Departllent 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 forll and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questlons may be answGred by ~~lling (717) 787-8317. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 5000009228 Date 02-26-1998 Established x 4,907.82 8.333 408.97 .045 18.40 TAXPAYER RESPONSE To insure proper credit to your account, two (2) copies of this notice lIust accompany your paYllent 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 NOTE: If tax payments are made within three (3) 1I0nths of the decedent.s date of death, you may deduct a 5Z discount of the tax due. Any inheritance tax due will becolle delinquent nine (9) months after the date of death. Tax PART ill A. [ CHECK ] ONE BLOCK B. ONLY c. c=l The above information and tax due is correct. 1. You lIay choose to remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or you may check box "A" and return this notice to the Register of Wills and an official assessllent will be issued by the PA Department of Revenue. c=l 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. c=l The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART ~ below. x If you indicate a different tax rate, please state your relationship to decedent: PART [!J TAX RETURN - COMPUTATION LINE 1. Oat. ES~9blished 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due TAX ON JOINT/TRUST ACCOUNTS OF 1 2 3 4 5 6 7 8 x PART I!l DATE PAID DEBTS AND DEDUCTIONS CLAIMED PAYEE DESCRIPTION AMOUNT PAID I TOTAL (Enter on Line 5 of Tax Computation) I $ I declare that the facts I have reported above are true, correct and ge and belief. HOME (T:;? 0) 7 ~-r:'i -I b }-o WORK ( ) TELEPHONE NUMBER "7jirl1oc;- TAXPA GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even though the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) which the decedent put in joint names within one year prior to death are fully taxable as transfers. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING INSTRUCTIONS PART 1 TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with your check for the amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the PennSYlvania Inheritance Tax Return filed by the decedent's representative, place an "x" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one COpy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept 280601, Harrisburg, PA 17128-0601 in the envelope provided. 3. BLOCK C - If the notice information is incorrect andlor deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN PART 2 - TAX COMPUTATION LINE 1. Enter NOTE: the date the account originally was established or titled in the manner existing at date of death. For a decedent dying after 12/12/82: Accounts which the decedent put in joint names within one (1) year of death are taxable fully as transfers. However, there is an exclusion not to exceed $3,000 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk (MM) appears before your first name in the address portion of this notice, the $3,000 exclusion already has been deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons. 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) = .167 X 100 16.7X (TAXABLE FOR EACH SURVIVOR) B. The percent taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT OWNERS OR TRUST BENEFICIARIES X 100 PERCENT TAXABLE Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) = .50 X 100 SOX (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (line 4) is determined by multiplying the account balance (line 2) by the percent taxable (line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (line 6) is determined by subtracting the debts and deductions (line 5) from the amount subject to tax (line 4). 7. Enter the appropriate tax rate (line 7) as determined below. MThe tax rate Imposed on the net value of transfers from a deceased ChIld twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is OX. The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The "Collateral" class of heirs includes all other beneficiaries. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3/0 6/0 15/0 15/0 01/01/95 to 06/30/00 0% 6% 15% 15% 07/01/00 to present 0% 4.5%11 12% 15% CLAIMED DEDUCTIONS PART 3 DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paper 8 1/2" x 11". Proof of payment may be requested by the PA Department of Revenue. - COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. Z80601 HARRISBURG, PA 171Z8-0601 ~.....~....r -." r' ~.'" INFORMATION NOTICE i"'-::n,I"', .~.C' AND \TAX~AVER RESPONSE ." '. . - ~ , FILE ACN DATE NO. 21 OS Olo'l5Co 05133682 07-21-2005 REY-1545 EX AFP 109-00) I TYPE OF ACCOUNT o SAVINGS o CHECKING o TRUST Iil CERTIF . ,., n i~ ~ L~i -2 ,~ ;. ~ ~ i .. L:'''-~ f.li , ''Es'fl. OF GINOR HESS 8.8. NO. 195-20-6762 (: DATE OF DEATH 04-29-2005 COUNTY CUMBERLAND ("',.. ,,.....,: REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 MARY R AVERY 6725 OLD BERWICK RD BLOOMSBURG PA 17815 COLUMBIA CNTY FARMERS NATL BK 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 lIey b.. ens..ered by calling []17l 787-83Z7. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 5000075782 Date 11-26-2001 Established x 9,061.37 8.333 755.08 .045 33.98 TAXPAYER RESPONSE To insure proper credit to your account, two (Zl 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 NOTE: If tax payments are made within three (3l months of the decedent's date of death, you may deduct a 5X discount of the tax due. Any inheritance tax due will become delinquent nine (9l months after the date of death. Tax PART [!] A. [ CHECK ] ONE BLOCK B. ONLY c. c=l 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 a discount or 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. c=l 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. c=l The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART ~ below. x If you indicate a different tax rate, please state your relationship to decedent: PART [3] TAX RETURN - COMPUTATION LINE 1. Dat. E5tab!is~.d 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax S. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 4 5 6 7 8 x PART [!] DATE PAID DEBTS AND DEDUCTIONS CLAIMED PAYEE DESCRIPTION AMOUNT PAID I TOTAL (Enter on Line 5 of Tax Computation) I $ perjury, I declare that the facts I ledge and belief. have reported above are true, correct and HOME r.570) 151-1 b ;J--cJ bs:- WORK () ~ TELEPHONE NUMBER A TAX GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSHENT with applicable interest based on information submitted by the financial institution. 2. Inheritance tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even though the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) which the decedent put in joint names within one year prior to death are fully taxable as transfers. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING INSTRUCTIONS PART 1 TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with your check for the amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept 280601, Harrisburg, PA 17128-0601 in the envelope provided. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN PART 2 TAX COMPUTATION LINE 1. Enter NOTE: the date the account originally was established or titled in the manner existing at date of death. For a decedent dying after 12/12/82: Accounts which the decedent put in joint names within one (1) year of death are taxable fully as transfers. However, there is an exclusion not to exceed $3,000 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk (MM) appears before your first name in the address portion of this notice, the $3,000 exclusion already has been deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons. 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) = .167 X 100 16.77. (TAXABLE FOR EACH SURVIVOR) B. The percent taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT OWNERS OR TRUST BENEFICIARIES X 100 PERCENT TAXABLE Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) = .50 X 100 507. (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (line 4) is determined by multiplying the account balance (line 2) by the percent taxable (line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (line 6) is determined by subtracting the debts and deductions (line 5) from the amount subject to tax (line 4). 7. Enter the appropriate tax rate (line 7) as determined below. MThe tax rate Imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 07.. The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The "Collateral" class of heirs includes all other beneficiaries. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3% 6% 15% 15% 01/01/95 to 06/30/00 0% 6% 15% 15X 07/01/00 to present OX 4.5%. 12X 15% CLAIMED DEDUCTIONS PART 3 DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paper 8 1/2" x II". Proof of payment may be requested by the PA Department of Revenue. . COMMONWEALTH OF PENNSYLVANIA OEPARTMENT 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 AVERY MARY 6725 OLD BERWICK RD BLOOMSBRUG, PA 17815 _~_h___ 10ld ESTATE INFORMATION: SSN: 195-20-6762 FILE NUMBER: 2105-0686 DECEDENT NAME: HESS GINOR DA TE OF PAYMENT: 08/02/2005 POSTMARK DATE: 08/02/2005 COUNTY: CUMBERLAND DATE OF DEATH: 04/29/2005 REMARKS: CHECK# 396 SEAL NO. CD 005644 ACN ASSESSMENT CONTROL NUMBER AMOUNT 05133668 I $9.50 05133679 I $103.54 05133671 I $93.69 05133676 I $ 1 7 .46 05133682 I $32.28 I I I I TOTAL AMOUNT PAID: $256.4 7 INITIALS: JA RECEIVED BY: REGISTER OF WILLS GLENDA FARNER STRASBAUGH REGISTER OF WILLS