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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVEHUE
BUREAU OF INDIVlmJAL TAXES
DEPT. 280601
HARRISBURG~ PA l7128-D601
*'
INFORMATION NOTICE
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FILE NO. 21 05-0438
ACN 05139092
DATE 08-23-2005
JEANNIE G KNOWLTON
8 CARLETON CT
CAMP HILL PA 17011
REHIT PAYHENT AND
REGISTER OF WILLS
CUMBERLAND CO COURT
CARLISLE, PA 17013
TYPE OF ACCOUNT
o SAVINGS
[X] CHECKING
o TRUST
o CERTIF.
FORNS TO:
2DD5 SEP 'EST PiOFl pjQi J POTAK
S.S. NO. 182-18-0086
(" 1)1\'l';&:ilF DEATH 05-06-2005
"-.-':" ,
Of'c;' ::'CO\lNfl\Y"," CUMBERLAND
n Ii .,,"v''-...': iJ
HOUSE
WACHOVIA BANk NA hils prf;lvided the DepartlHlnt with the infor.ation listed balow which hills baen us8d in
calculating the potential tax due. Their racards indic.te that at the da.th of the aboVB d8Cedant~ YOU were a joint owner/b8naficiar) of
this account. If you fael this infor.ation is incorract~ please obtain written correction f~ the financi.l institution, attach 8 copy
to this for. and return it to the above address. This account is taxable in accordance with the InhQrit.ncB T~ Laws of the C~.unwealth
of P'IiM'Insylvenb. au..tian. _y be answered by calling. (717) 787-8321.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR
Acco...t No. 1010084284323 Dat. 05-06-2005
Establishad
FILING AND PAYMENT INSTRUCTIONS
Account Balance
Percent Taxable
gaunt Subject to Tax
Tax Rate
Potent1.1 Tax D~
x
22,536.99
50.000
11,268.50
.15
1,690.28
To insure proper credit to your account~ two
(2) copies of this notic. aust acc~pany your
pay.ent to the Register of Wills. Make chack
payable to: "Ragister of Wills~ Agent...
x
NOTE: If tal( pSYII8Rts are II8da wJthin thr..
(3) IIOnths of the decechant"s date of d8ilth~
YOU BY deduct a SiC discount of the tax due.
Any inhllrl tance tax due wUI becoa.. deUnquent
nlM (9) .onths after the date of death.
PART TAXPAYER RESPONSE
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... ...",.. -"7~' .....~.,..... ........ ..~..... '" "'... ..~.~....... ..~ '..... .......-.. ..~..~~.~ ... ..h........~ -.. ................~~- -.... .. ". '. .......... ........~. .... .. ...- .. . ......~_...
[CHECK ]
ONE
BLOCK
ONLY
A, 0 The above inforlll!ltion and tax due is cornet.
1. You .ay choose to r..it p.y..nt ta the Regist.r of Wills with two copies of this notice to obtain
a discount or avoid inter.st~ or YOU aay check box "An and return this notice to the Register of
Wills and an official assesSIIant will bB issu8d by the PA Depsrtllent of Revenue.
B. ~ ThB above asset has b.,en or will be reported and tax paid ,dth the Pennsylvania Inhsritl!lnCIll Tax return
PJ to be fUsd by the dacedent"s rBpresentatlve.
C, r=J The .bove infor~tion is incorrect and/or debts and deductions were paid by you.
Vou .ust coaplata PART ~ and/or PART @] below.
If you indicate a diff.rent tax ret., please state your
relationship to decedent:
PART
[!]
TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS
LINE 1. Ilet. Establishad 1
2. Account Balance 2
3. Percent Taxable 3 X
4. ADOUnt Subject to Tax 4
S. Debts end Deductions S
6. Amount Taxable 6
7. Tax Rate 7 x
8. TIlX Due 8
PART
[!J
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUNT PAID
I
TOTAL (Enter on Line 5 of Tax Co~t.tion)
facts I
I
$
hay. reported above ar. tru., correct and
752. - 7ZC.Z-
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