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COK~ONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128,-.0601
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
REVISED NOTICE * * *
FILE
ACN
DATE
NO. 21 05-0858
05151252
12-08-2005
*
- (i r;. [1 -'..'
~:;'i (I! t~..~ : j
EST. OF ANNA E FURST
S.S. NO. 167-14-1868
DATE OF DEATH 09-10-2005
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
OCJ CHECKING
o TRUST
o CERTIF .
DOUGLAS -E FURST
260 SILVER SPRINGS RD
MECHANICSBURG PA 17055
REMIT PAYMENT AND FORMS 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 Pennsy!vsnia. Questions may be ans~~!~d b~ ~allina (717) 7S7-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 1918184 Date 06-30-2004
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
55,368.05
50.000
27,684.03
.045
1.245.78
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".
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.
Tax
PART
[!]
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.
~ The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
TAX ON JOINT/TRUST ACCOUNTS
If you indicate a different tax rate, please state your
relationship to decedent:
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
OF
1
2
3
4
5
6
7
8
x
PART
~
DATE PAID
~7 " 8 t.(c03
:2J:I> 73 $" , (, 7
695b.3b
x,,04~
3 t '2." 77 - s--1. -: 2....97. l.9
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
s-cf
TOTAL (Enter on Line 5 of Tax
DESCRIPTION
~-I-r~l-e~
AMOUNT PAID
:
Computation)
$
Under penalties of perjury. I declare that the
comPlete~ the,best of my k~le~~a~~elief.
TAXPAYER SI~J
facts I have reported above are true, correct and
HOME C7/7 ) (,,97-- '200
WORK () rz..- t,. -ss-
TELEPHONE NUMBER DATE
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U'.' .___m___ ... ____ __.___ _____. ___.., ________._....._.___ _________________
-- ----."---.. --.-...--.- _._----._--~----_...._-_. ---
. ______L~J~L~ 1/-s~:'!..1---C; ~......_i}:+~~Y_~~.70 0 _'__ <9 ~____u_________{l='_~l3__
2 , ; l e ~-a-+-------------= ~'; __!: 00 ----------- t4ih---
3. (J~a..,^-"> - ~ 7~ .DO c.~{.._
l..(. P LU-.er.sr - Q' I ~ 0, :?-? ----_~_____.if:.._~2_.~____
___________~__ A-'-<..-&!,_~, -era.( (+Ci4.€..~ .d 9/, !>_Q___ A__~L_~_
____c;._"-____6~_~r:'-~~---M~~J4.(---= ~O, Dc ________'D~____
------------------------------____D'-_~/1#_~7~______________ ____
~-=-==~=- tii~~~,:;-~f~p~~--~~~=~~~;~--=~~~~f+e~-d Ei.a&?-~~-~~_rct~--
-----{~-Ho7y ~r~-r~-t--H-OSf~*"~( ~=~_i .2;2,~;=~- ~ 4S4
-____.-Z. LA.) '€ ~ +-__F~ocr-e__E: ~ .5"._ _______1 -57. 7 ( .It: ;L /(,..
:3 . LA-' It!. S .{- ___~_~c:~~ __ E tv( s:______1-G ~_____~2:z~
_______~________~~5'+- ~t:..O.r1lZ E:" (vt s- -1SJ7. 6 ~________~d_~e-___.
u_.____5:-'-_9 L<-~_t_I:yV~C~~ c'-<2~~___~_J. 7.?lQ. 3L__________#:...2-]E___
_________~:..__Ch<o.i.C~ N'k,S ~~_ g'.Ii'2-72~ 7..)" . $- 2-80
______ 7:.._____ C:_C. _~t ~_l'i. '-<!:~i_ ~-~-------.5'-/.!!.-S''-!.LS9..----.df-<-:e--
$9772. '-/0
------- ----_._.~ ---- .-. _.....~-_._- ---.-...--------
!flt. f$c. . ..... .. ._______ _d__. ._. __.______________________ ._______
____ ~ n~~_:.--. 1~'CC'\ ~~.k- ~~ I~Q_~_~r:o~ J)'~_~*~ _AI a:it~_V\_Qt ._~~t:__
----~----- -- ____.To_ _-.!_~J\~__ .s:..~l.t-~I~V"...-t+ev,___~C6.._____~~.i-~f-~~r--
. ------- .---. _~dn___Gc?::sJ....g,d__4' '0---~i-J.7t ::2:.QQ,5:_____ _____._____ _____
---.-.---..------.-----..--------.-------.-- -------.--.------.-- -.---- -.....-.----
-~ -~n____n_ _ ~.. ____________.__....__.. .__
-------.---.--. ... (G~ [ ~ $":2-0 '733.. (:, 7 ,'; '.-J
--------.-----...----.-.-----..- ..- -'-'---"-- -.....----,----.----.--.. _.- .-.,--..-...-.. -- '. .... --~_. ~~__4_----~"'-r--
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COMMONWEALTH OF PENNSYLVANIA
DEPA\1TMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 2B0601
HARRISBURG. PA 171 2B-0601
REV-1162 EX111-961
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 006067
FURST DOUGLASS EVANS
260 SILVER SPRINGS ROAD
MECHANICSBURG, PA 17050
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
~_h____ fold
05151252
$297.13
ESTATE INFORMATION: SSN: 167-14-1868
FILE NUMBER: 2105-0858
DECEDENT NAME: FURST ANNA E
DATE OF PAYMENT: 12/06/2005
POSTMARK DATE: 1 2/06/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 09/10/2005
TOTAL AMOUNT PAID:
$297.13
REMARKS:
DOUGLAS E FURST
CHECK# 466
SEAL
INITIALS: RSK
RECEIVED BY:
GLENDA FARNER STRASBAUGH
-" (_._) I
REGISTER OF WILLS': ,;
r.....)
~...~.J
TAXPAYER
i.:-::J
CERTIFICATION OF NOTICE UNDER RULE 5.6~a)
Date of Death:
,4/1 V) a.
5' ~p+. /0 I 20({)s-
(/.
FC-A US+-
Name of Decedent:
Will No.
::L{05 -025'&
Admin. No.
c D 00 CO 0'" "7
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5 .6( a) of the O+bans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on S"'cz.p, (5 I ~ 00 5 :
Name
Address
Yl.>-( i a.... 5""'-"i +t-
t^1 a:fC, ei..U 5'~ ~ ~
~--e2l D\~'I S-~~ t(".
3?/o Lod
LUes/- D~-iy >I. 1ft,
'12 $? ::f'a,l\o\es ColAl.+ Ifp+1 Fcr4
~ \rDve Koa..d
S;16'-t5
g rook -He..U LuT
512
MaJ;s.oIA wz S3703
Co lllns Co
&05"2./
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date:
J)-.ec
'7. ZooS-
.
~~ ~ ::L.+
Signature
Name
Address
Telephone?i?) t 97- <:; 200.)
ii
Capacity: ~ Personal Representative
1.__':)
_Counsel for personal representative
,:=::)
_ ,Ff..-"-r>+
s: !(/'e'- sf~\'-ifS Rd.
t'ct... P4 170S'O
HA.RRISBURG PA 171.
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