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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL ",!~~~~",~."'I_" r.
DEPT. 280601 . '., ".. '.'
HARRISBURG, PA 1712~"-o601' ,.
r' o.A.I_
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INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21 - ~ S - \~\Jl\
05150333
11-01-2005
REV-15~5 EX AFP '09-001 I
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EST. OF IRVIN B STEAGALL
S.S. NO. 231-38-0587
DATE OF DEATH 04-22-2005
COUNTY CUMBERLAND
TYPE OF ACCOUNT
[X] SAVINGS
o CHECKING
o TRUST
o CERTIF.
ROBERT R STEAGALL
1222 MOUNTAIN RD
NEWBURG PA 17240
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
ORRSTOWN BANK 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 may be answe~2d by cal!ing (717) 787-8~27.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 708700018 Date 03-11-1997
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
2,232.15
50.000
1,116.08
.15
167.41
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, Agene'.
Tax
x
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 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.
[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
[!J
TAX RETURN - COMPUTATION
If you indicate a different ta~~t~l~lease state your
relationship to decedent: 1<.0 I '1 c: Il.
LINE
1. Date 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
1
2
3
4
5
6
7
8
TAX ON JOINT/TRUST ACCOUNTS
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DEBTS AND DEDUCTIONS CLAIMED
OF
PART
~
DATE
-;1.
PAYEE
DESCRIPTION
TOTAL (Enter on Line 5 of Tax Computation)
$
perjury, I declare that the facts I
my knowledge and belief.
have reported above are true, correct
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