HomeMy WebLinkAbout12-19-05
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-961
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 006122
BLOOM CAROLYN I
4392 VALLEY ROAD
SHERMANSDALE, PA 17090
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
___hh_ fold
05150334
$174.27
ESTATE INFORMATION: SSN: 157-07-6328
FILE NUMBER: 2105-1092
DECEDENT NAME: V ANDERWEIDE JOE J
DATE OF PAYMENT: 12/19/2005
POSTMARK DATE: 1 2/19/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 05/08/2005
TOTAL AMOUNT PAID:
$174.27
REMARKS:
CAROLYN BLOOM
CHECK# 431
SEAL
INITIALS: RSK
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
COMMONWEALTH OF PENNSVLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21 ..~ S . \~~~
05150334
1l-01-2005
REV-1543 EX AFP <09-0DI I
EST. OF JOE J VANDERWEIDE
S.S. NO. 157-07-6328
DATE OF DEATH 05-08-2005
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
IX] CHECKING
o TRUST
o CERTIF.
CAROLYN I BLOOM
4392 VALLEY RD
SHERMANSDALE PA 17090
REHIT PAYHENT 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 Pen~sYlv9nia. Qug~tio~s may be answ8rQd by r.~l!ing (7171 787-~3?7.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 106003447 Date 03-22-2004
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
2,323.66
50.000
1,161.83
.15
174.27
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".
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
[!J
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.
Vou must complete PART ~ and/or PART ~ below.
If you indicate a different tax rate, please state your
relationship to decedent:
PART
~
TAX RETURN - COMPUTATION
L1NE 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 CLAIMED
OF TAX ON JOINT/TRUST ACCOUNTS
1
2
3
4
5
6
7
8
x
x
PAYEE
DESCRIPTION
AMOUNT PAID
Under penalties of perjury, I declare that the facts I have reported above are true, correct and
06mplete to the best of my knowledge and belief.
.' " /1
?A~~~~~~iGNA~(a?;,/l
t/
I
TOTAL (Enter on Line 5 of Tax Computation)
I
$
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