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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
ACN
DATE
NO. 21 05- 0654
05154487
12-16-2005
REV-1543 EX AFP (D~-DDl
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EST. OF LLOYD M NYE
S.S. NO. 199-32-1249
DATE OF DEATH 07-12-2005
COUNTY CUMBERLAND
TYPE OF ACCOUNT
[i] SAVINGS
o CHECKING
o TRUST
o CERTIF.
r',
DIAN LANDER
492 MOUNTAIN RD
NEWVILLE PA 17241
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
F & M TRUST 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 answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 08-18464 Date 01-05-2005
Established
Account Balance
Percent Taxable
Anount Subject to
Tax Rate
Potential Tax Due
x
.00
100.00
.00
.15
.00
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 570 discount of the tax due.
Any inheritance tax due will become delinquent
nine (9) months after the date of death.
Tax
PART
[!]
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.
[CHECK ]
ONE
BLOCK
ONLY
B. [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.
C. [J The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
If you indicate a different tax rate, please state your
relationship to decedent:
PART
(!J
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PART
~
TAX RETURN - COMPUTATION
LINE 1. Date Established
2. Account Balance
3. Percent Taxable
4. Anount Subject to Tax
5. Debts and Deductions
6. Anount Taxable
7. Tax Rate
8. Tax Due
OF
1
2
3
4
5
6
7
8
x
TAX ON JOINT/TRUST ACCOUNTS
x
PAYEE
DESCRIPTION
AMOUNT PAID
TOTAL (Enter on Line 5 of Tax ConputationJ
I
$
Under penalties of perjury, I declare that the
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Rxp~TG ~RE(1. 1.._
facts I have reported above are true, correct and
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