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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
FORNEY EARLENE M
APT 5
99 W PORTLAND ST
MECHANICSBURG, PA 17055
_u_____ fold
ESTATE INFORMATION: SSN: 179-18-0820
FILE NUMBER: 2106-0222
DECEDENT NAME: WEIKEL EARL S
DATE OF PAYMENT: 03/13/2006
POSTMARK DATE: 03/10/2006
COUNTY: CUMBERLAND
DATE OF DEATH: 12/27/2005
NO. CD 006426
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
05157512 I $29.78
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS:
CHECK#08445416023
SEAL
INITIALS: MG
RECEIVED BY:
REGISTER OF WILLS
$29.78
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
~:.'.'."\....~;........
.' . 'W6"
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
F~LE NO. 21
A~N 05157512
D~TE 12-27-2005
TYPE OF ACCOUNT
\
EST. OF EARL S WEIKEL \ D SAVINGS
S. S. NO. 179-18- 0820\ [X] CHECKING
DATE OF DEATH 06-08-20P5 D TRUST
COUNTY CUMBERLAND \ D CERTIF.
REHIT PAV~ENT AND FORHS TO:
REGISTER OF ILLS
CUMBERLAND C COURT HOUSE
CARLISLE, PAl 17013
!
REV-15lf5 Ell AFP 9-00)
. 11 ?,:\ L~
rJ:S\ \ .J
EARLENE M FORNEY
APT 5
99 W PORTLAND ST
MECHANICSBURG PA 17055
HEHBERS 1ST Feu has provided the Department with the information listed below which hals 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 answerpd bv call;"g (7171 78?-83l7.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 152461-11 Date 06-30-1995
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
1,323.38
50.000
661.69
.045
29.78
TAXPAYER RESPONSE
To insure proper credit ~o your account, two
(2) copies of this notic~ must accompany your
payment to the Register 9f Wills. Make check
payable to: "Register of\Wills, Agent".
NOTE: If tax payments ale made within three
(3) months of the decede tIs date of death,
you may deduct a 57. disc unt of the tax due.
Any inheritance tax due ill become delinquent
nine (9) months after the date of death.
Tax
x
PART
[!]
he above information and tax due is correct.
1. You may choose to remit payment to the Register of Wills with two copies of th.s 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 Revenu~.
B. [J The above asset has been or will be reported and tax paid with the Pennsylvania In~eritance Tax return
to be filed by the decedent's representative.
C. [] The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
[CHECK ]
ONE
BLOCK
ONLY
PART
l!I
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
If you indicate a different tax rate, please state your
relationship to decedent:
PART
~
TAX RETURN - COMPUTATION OF
LLNE 1. Uate Established I
2. Account Balance 2
3. Percent Taxable 3
4. Amount Subject to Tax 4
5. Debts and Deductions 5
6. Amount Taxable 6
7. Tax Rate 7
8. Tax Due 8
TAX ON JOINT/TRUST ACCOUNTS
x
x
PAYEE
DESCRIPTION
AMOUNT PAID
I
TOTAL (Enter on Line 5 of Tax Computation)
I
$
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Under penalties of perjury, I declare that the facts I have reported above are true, correct and
complete to the best of my knowledge and belief.
HOME ( )
WORK ( )
TELEPHONE NUMBER
DATE
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