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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
FURST DOUGLASS EVANS
260 SILVER SPRINGS ROAD
MECHANICSBURG, PA 17050
____un fold
ESTATE INFORMATION: SSN: 167-14-1868
FILE NUMBER: 2105-0858
DECEDENT NAME: FURST ANNA E
DA TE OF PAYMENT: 12/06/2005
POSTMARK DATE: 12/06/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 09/10/2005
NO. CD 006067
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
05151252 I $297.13
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TOTAL AMOUNT PAID:
REMARKS:
DOUGLAS E FURST
CHECK# 466
SEAL
INITIALS: RSK
RECEIVED BY:
REGISTER OF WILLS
$297.13
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE NO. 21 05-0858
ACN 05151252
DATE 11-08-2005
REV-15U EX AFP ID9-DDJ I
EST. OF ANNA E FURST
S.S. NO. 167-14-1868
DATE OF DEATH 09-10-2005
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
0Cl CHECKING
o TRUST
o CERTIF.
** DOUGLAS E FURST
260 SILVER SPRINGS RD
MECHANICSBURG PA 17055
REHIT PAYMENT AND FORHS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE. PA 17013
VARTAN NATIONAL 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 ~ay bs anSWGiad by calling (717) 787-a3Z7.
COMPLETE PART 1 BELOW · . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 1918184 Date 04-04-2005
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
52.368.05
100.00
52.368.05
.045
2.356.56
TAXPAYER RESPONSE
To insure proper credit to your account, two
(2) copies of this notice IIUSt accollpany your
pay.ent to the Register of Wills. Make check
payable to: "Register of Wills, Agent".
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
ill
A.
[ CHECK ]
ONE
BLOCK B.
ONLY
c.
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 "An and return this notice to the Register of
Wills and an official assessment will be issued by the PA Department of Revenue.
c=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.
If yOU indicate a different tax rate. please state your
relationship to decedent:
~The above inforllation is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
PART
~
TAX RETURN - COMPUTATION
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
PART
[!]
DATE PAID
DEBTS AND DEDUCTIONS
OF
1
2
3
4
5
6
7
8
TAX ON JOINT/TRUST ACCOUNTS
~~ 30 -0 "f
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.so
;;l. '7 c.~ 'to t:!J.3
~o7.s3 ," 7
~9::)o.3C:.
X , {)'Yr'
?12.7'1-SZ c> $'~97.1]
X
PAYEE
DESCRIPTION
AMOUNT PAID
C'n -
TOTAL (Enter on Line 5 of Tax Computation)
$
of perjury. I declare that the
of my knowledge and belief.
{~
facts I have reported above are true. correct and
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