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COMMONWEALTH OF PENNSYLVANIA
DEPARTMEN~ OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
*
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21-~~ - Q\ ~~l
06104332
02-07-2006
REY-1545 EX AFP 109-00l
; .......
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EST. OF GERALD K WOLTZ
S.S. NO. 186-09-0551
DATE OF DEATH 10-30-2005
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
[i] CHECKING
o TRUST
o CERTIF.
LISA K WOLTZ
115 BRIGHTON DR
CARLISLE PA 17013
REHIT PAYHENT AND FORHS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
HEHBERS 1ST FCU 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 ar.swered by calling {?l?) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 5337-11 Date 04-17 -1980
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
479.12
50.000
239.56
.045
10.78
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 5Z 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.
[] 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.
[] 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.
~he 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
~
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 PAYEE DESCRIPTION AMOUNT PAID
l( ( "'{ "" 1(;' T{ ,,"'- 'F\.., '" ~." \ I-t> -] F~ ~" "--" I F'<-f <ro '0,,,- ~ I &eu t& ltl" (1 i> to.:J- ':i . "" (
TOTAL (Enter on Line 5 of Tax Computation) $
DEBTS AND DEDUCTIONS CLAIMED
OF
1
2
3
4
5
6
7
8
x
TAX ON JOINT/TRUST ACCOUNTS
x
of perjury, I declare that the facts I
of my knowledge and belief.
have reported above are true, correct and
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