HomeMy WebLinkAbout01-17-06
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
'*
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21 - ~~ . \)~i-.\l
05157523
12-27-2005
, REV-1543 EX AFP (09-00> I
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TYPE OF
ACCOUNT
o SAVINGS
[X] CHECKING
o TRUST
o CERTIF.
l,-,
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EST. OF EVELYN E TRESSLER
S.S. NO. 184-07-0543
DATE OF DEATH 05-06-2005
COUNTY CUMBERLAND
PATRICIA E CLARK
422 PAWNEE DR
MECHANICSBURG PA 17050
REHIT PAYHENT AND FORHS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
PNC 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
n~ P8~nsy]va"la. gup~tio"~ ~ay he ans~~rQ~ by cel!i~s (717) 7!7-832?
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 5004025232 Date 03-31-2003
Established
Account Balance
Percent Taxable
Anount Subject to
Tax Rate
Potential Tax Due
x
9,560.50
50.000
4,780.25
.15
717.04
TAXPAYER RESPONSE
To insure proper credit to your account, two
(Zl 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 became delinquent
nine (9l months after the date of death.
PART
m
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.
If you indicate a diffe
relationship to decedent:
[] The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
~o 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.
ease state your
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 TAX OINT/TRUST
1 S--~- <3 (-O~
2 '\ , 5lo0. <5 0
: X ~ 3~~~
6 __
7 X I ()":!.. ~
8
ACCOUNTS
PART
[!J
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
~
AMOUNT PAID
of perjury, I declare that the facts I
of ny knowledge a belief.
,
have reported
HOME (r-I
WORK (
TELEPHONE
ST SHORE EMS - ALS
5 GRANDVIEW AVE
SUITE 211
~MP HILL, PA 17011
'-0512 Federal Tax 10: 23-2463002
0543A
,84070543
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
37801
3042590A
04/17/2005
MOEN
B
CAMP Hill CARE CENTER
HOLY SPIRIT HOSPITAL
REASON(S)
FOR
TRANSPORT
ATRIAL FIBRillATION
DYSPNEA
INVOICE
QUANTITY UNIT PRICE AMOUNT
!99 1.0 512.49 512.49
,94 1.0 7.96 7.96
194 1.0 4.99 4.99
194 1.0 2.99 2.99
194 1.0 4.70 4.70
533.13
\
Total Charges
RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
nl C:A~;:: DAV TMI~ AMOUNT ~ $533.13
Hospice or Central Pennsylvania
98 South Enola Drive
P.O. Box 266
Enola, PA 17025
Invoice
Invoice Number:
Voice:
Fax:
853
Invoice Date:
717-732-1000
717-732-5348
4/26/05
Page:
1
Resident
Evelyn E. Tressler
c/o Patricia E. Clark
422 Pawnee Drive
Mechanicsburg, PA 17050
Resident ID: TresslerE
!
L_~~=_==-_=~---------t
Payment Terms
Net 30 Days
-~---j
I
i Due pat~__ '
------------j --I
i 5/26/05 i
__~___._____._._J
r Description
[Residential C-a.re-=--April 26-30, 2005
! Amount----'
----------------------------------!---------------------------[
i 1,500.00:
! I
,
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!
L-_________ ________._~____
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Total Invoice Amount
1,500.00
Check/Credit Memo No:
Payment/Credit Applied
TOTAL
1,500.00
Thank you for choosing Hospice of Central Pennsylvania.
Evelyn E. Tressler
c/o Patricia E. Clark
422 Pawnee Drive
Mechanicsburg, PA 17050
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Invoice
Hosprce or CenLral ?ennsylvanra
98 South Enola Drive
P.O. Box 266
Eno1a, PA 17025
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1,1
Invoice Number:
Voice:
Fax:
717-732-1000
71 7-7 32-534 8
970
Invoice Date:
5/26/05
Page:
1
Resident:
Resident ID: TresslerE
,-=-- --- ~F
------'--~-. .
Payment Terms
Net 30 Days
~
I
I Due Date
-~------~--- ...--...--
, 6/25/05
I
I Description
IResidential Care - May 6, 2005
_.J__~____ ..
_~n____,.__.______ __ __
r Amount
-1------360.06
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L.____
Total Invoice Amount
300.00
Check/Credit Memo No:
Payment/Credit Applied
TOTAL
300.00
Thank you for choosing Hospice of Central Pennsylvania.
C(f;tJ-(WM ?Benu:te;;y !3fC/fJWJCiabJ
39 Porter Road - Tower City, PA 17980
Phone: 717-647-2014
Artz Memorials - 570-682-9707
Minersvillel Pottsville Memorials. 570-544-0460
Millersburg Memorials - 717-692-0214
Date
No.
In agreement with
/; -
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Please enter my order for a memorial, with lettering as specified herein, for which J agree to pay you the sum of J tit) :.-;,",
Dollars in the manner specified hereinafter, to be erected on bot NO.1 " ) \.) ,
Cemetery I! L:'/ L Ii ,\ i ! L i v.,.. I) /-~ subject to the rules
f! !,.o> jJ, /I (City and State)
and Regulations of said Cemetery. Materials, design, dimensions, finish and 'lettering of the memorial are to be substantantially as follows:
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A reement of Pa ments:
$ j j f. jr .::: I , \. I ' '~..) ( lj ii-cash herewith:
,_,; :"_.: F t :'iJ~',i.:~+tj If!:';! i';)
Die
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$ /'1 /~_. .t ,,'Ii; i T(I!( In or within ten
days after erection of said 'memorial. *Excluding memorials
placed in any cemetery that does not have the foundation
in place when the memorial is in our possesion, require
payment in full upon notification to the customer of
compieted memorial, not necessarily erection of memorial.
Base
2. Ii )( I., '., )(' I '. (~
Color ,I:.> ti
i (.,">
Date Ordered
This order is not subject to cancellation after acceptance.
Cost
Accepted Date
Signed \/
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By
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Title
If not paid within 30 Days, 1.5% interest will be charged or 18% per year will be charged. Any other collection fees will be added to your account balance.