HomeMy WebLinkAbout08-03-05
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
DELOZIER GENEVIEVE A
1297 lETCHWORTH RD
CAMP Hill, PA 17011
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ESTATE INFORMATION: SSN: 157-09-5164
FILE NUMBER: 2105-0693
DECEDENT NAME: CHOMICKI GENEVIEVE M
DATE OF PAYMENT: 08/03/2005
POSTMARK DATE: 08/02/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 04/20/2005
NO. CD 005647
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
05134773 I $33.47
I
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TOTAL AMOUNT PAID:
$33.47
REMARKS: G A DELOZIER
CHECK# 5275
SEAL
INITIALS: VZ
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVEI<<IE
BUREAU OF INDIVIDUAL TAXES
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
* INFORMATION NOTICE
_ (Y 'f', 0- AND
H'" ~ u' I'vE ~AXPAYER RESPONSE
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FILE NO.
ACN
DATE
21 -05- (it?>
05134773
07-27-2005
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TYPE OF ACCOUNT
PH 12: 2l, EST. OF GENEVIEVE M CHOMICKI 0 SAVINGS
5.5. NO. 157-09-5164 IX] CHECKING
DATE OF DEATH 04-20-2005 0 TRUST
COUNTY CUMBERLAND 0 CERTIF.
REHIT PAYHENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CD COURT HOUSE
CARLISLE, PA 17013
2UG5 WG-3
GENEVIEVE A DELOZIER
1297 LETCHWORTH RD
CAMP HILL PA 17011
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PNC BANK has providsd the Departll8t1t with the inforBation listsd below which has bliltH1 usBd in
calculating ths potential tax due. Their records indicate that at thll death of the: above decBd."t, you wers a joint owMlr/beneficiary of
this account. If you fael this infor_tion is incorrect, pleaSll obtain written correction frOll the financiel institution, attach a copy
to this fOMl and rsturn it to ths above address. This account is taxsblll in accordance with the Inheritance Tax Laws of the COIlIlOMlaalth
of Pennsylvania. Qullstions BBY be 8nswered by calling (111) 181-8321.
COMPLETE PART 1 BEL ON . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 5140010342 D.t. 08-16-1999
Est.bUshBd
Account Balance
Percent Taxable
~ount Subject to
Tax Rate
Potential Tax Due
To insure proper cradi t to your eccoLl'lt, two
(Z) copias of this notice ....st 8CCQllPany your
paYBant to the Register of Wills. Hekll check
payable to: "Register of WillS, Agan~.
x
x
NOTE: If tax P8YIIBnts are Bade within three
(3) Nonths of the decedant.s datil of dllath,
YOU Bay deduct a 5;( discount of ths tax dus.
Any inhllritance tax due will beeo.. delinquent
nins (9) Bonths after the date of dsath.
Tax
PART
[!]
A.
[ CHECK ]
ONE
BLOCK B.
ONLY
c.
00 The above infor.ation and tax dus is correct.
1. You .ay choose to rs.it paYBent to ths Registsr of Wills with two copiss of this noticII to obtain
a discount or avoid interest, or YOU Nay check box "A" I!Ind return this notice to the RegistBr of
Wills and an official assas~ent will be issued by the PA Dapart.snt of RliIVBnUlil.
D The: above aSSllt has been or will be reported and tax paid with ths PennsylvBIlie Inhllritancs Tax return
to be filsd by ths d&cedsnt's reprasantati"s.
[] The abovlI infor.ation is incorrect and/or debts and daductions WBre paid by you.
You Bust co.plate PART ~ and/or PART ~ bslow.
PART
~
TAX RETURN - CDMPUTATION
LINE 1. o.t. Estab11shod
2. Account Balance
3. Percent Taxable
4. ADOUnt Subject to Tax
5, Debts and Deductions
6. A.aunt Taxable
7. Tax Rate
8. Tax Due
TAX ON JOINT/TRUST ACCOUNTS
If you indicate a different tax ratel please state your
relationship to decedent:
OF
1
2
3 X
...
5
6
7 X
8
PART
~
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUNT PAID
I
$
I
TOTAL (Enter on Line .5 of Tax Computation)
Under penalties of perjury I I declare that the facts I
complete to the best of my knowledge ~d belief.
G A .})..el.AJl.~
TAXPAYER-sl~ATURE
heye reported
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