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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 NO. 21 05-0580
ACN 06101047
DATE 01-06-2006
REV~154"3 EX AFP (09-00) I
r) [-c -'"""-:'
TYPE OF ACCOUNT
o SAVINGS
fi1 CHECKING
o TRUST
o CERTIF.
EST. OF LORETTA I RICE
5.5. NO. 199-07-4208
DATE OF DEATH 06-22-2005
COUNTY CUMBERLAND
FREDERICK D RICE
801 MYERSTOWN RD
GARDNERS PA 17324
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE~ PA 17013
ADA/'IS COUNTY NATIONAL BANK has provided the Depart.ent with the inforeaUon 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 froo the financial institution, attach a copy
to this feno and return it to the above address. This account is taxable in aCcordance with the Inheritance Tax Laws of the Co.eonwealth
of PennsYlvania. Questions may be answe:-ed by calling (717) 787-'8327.
COMPLETE PART 1 BELOW · · . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 2020629 Date 04-25-2001
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
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
959.13
50.000
479.57
.045
21.58
TAXPAYER RESPONSE
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
x
PART
[!J
A.
[ CHECK ]
ONE
BLOCK B.
ONLY
c.
c=J The above information and tax due is correct.
1. Vou eay choose to reeit payeent 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.
c=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 inforeation is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
PART
~
TAX RETURN - COMPUTATION
LINE 1. bate 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
If yOU indicate a different tax rate~ please state your
relationship to decedent:
OF
1
2
3
4
5
6
7
8
TAX ON JOINT/TRUST ACCOUNTS
x
x
PART
[!J
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUNT PAID
TOTAL CEnter on Line 5 of Tax Computation)
$
perjury, I declare that the facts I have reported above are true, correct and
knowledge and belief.
.' .....
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