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COMMONWEALTH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
*
INFORMATION NOTICE
~ ,r-..,......r"'.r,--r, "1.~'-1':'.r;AJ:.I.D
':tcAX,P1A'I(~R.)!R ES PO N S E
REV-1545 EX AFP <09-001
FILE
ACN
DATE
NO. 21 05 -- 014 '8
05134608
07-21-2005
200 '
"
Es~::o~3ALBERTA E SHUEY
S.S. NO. 194-42-9758
(~ATE OF DEATH 05-16-2005
-COtJll1I'Y CUMBERLAND
TYPE OF ACCOUNT
iii SAVINGS
o CHECKING
o TRUST
o CERTlF .
" :-:-/
C
Cl
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
MARY R KENNEDY
628 TRUSH CT
MECHANICSBURG PA 17050
PSECU 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
O~ "Par.nIY'l\i"llnTa. WUI:I~ liufl::' ulEiY be anzwe.!"ed by c311 ir1!J (7171 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 0194429758-7 Date 10-03-1994
Established
x
27,934.07
50.000
13,967,04
.12
1,676.04
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
NOTE: If tax payments are made within three
(3) months of the decedent's date of death,
you may deduct a 57. discount of the tax due.
Any inheritance tax due will become delinquent
nine (9) months after the date of death.
Tax
PART
[!]
A.
[ CHECK ]
ONE
BLOCK B.
ONLY
c.
~ 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.
[] 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.
[] The above information is incorrect and/or debts and deductions were paid by you.
You Must COMplete PART ~ and/or PART ~ below.
LINE 1. D.t= 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
1
2
3 X
4
5
6
7 X
8
PART
~
TAX RETURN - COMPUTATION
If you indicate a different tax rate, please state your
relationship to decedent:
OF TAX ON JOINT/TRUST ACCOUNTS
PART
[!]
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUNT PAID
I
TOTAL (Enter on Line 5 of Tax Computation)
I
$
Under penalties of perjury, I declare that the facts I have reported above are true, correct and
~omplete to the best of my knowledge and belief. HOME (1/7) 7(;, It -7 / ~ ,p- ,pis/Or
WORK ( )
TELEPHONE NUMBER DATE
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
NO. CD 005716
KENNEDY MARY R
628 TRUSH CT
MECHANICSBURG, PA 17050
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
nn__u fold
05134608
$1,676.04
ESTATE INFORMATION: SSN: 194-42-9758
FILE NUMBER: 2105-0748
DECEDENT NAME: SHUEY ALBERTA E
DA TE OF PAYMENT: 08/22/2005
POSTMARK DATE: 08/1 5/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 05/16/2005
TOTAL AMOUNT PAID:
$1,676.04
REMARKS:
CHECK# 117
SEAL
INITIALS: JA
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS