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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 ell,; (L-f 6 I
06121001
05-12-2006
REV-1543 EX AFP 'D9-DDJ
EST. OF SARA R STOMBAUGH
S.S. NO. 160-20-6346
DATE OF DEATH 12-25-2005
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
[X] CHECKING
o TRUST
o CERTIF.
THOMAS J HOLTZMAN
28 LONGWOOD DR
MECHANICSBURG PA 17050
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
MEMBERS 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 answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 83712-11 Date 07-09-1997
Established
x
731.18
50.000
365.59
.045
16.45
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".
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
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 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 "AI' 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.
~ The above information 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. 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
OF
1
2
3
4
5
6
7
8
TAX ON JOINT/TRUST
07-CC']- 697
7:3J.2S
ACCOUNTS
If you indicate a different tax rate, please state your
relationship to decedent:
x
is,)
)&~/t.,'I
tog, 1..7
o
I tl'l";-
D
x
PART
@J
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
(
C'
',-It -.?,,-'cL VI ftL.PiZ 7- 2/ F ';NCt?ftL- NcH1iZ B/)~I~i- t; }Lf'(;;).,:'1;; S-qS-.77
J" 1-/- '4',' ". CltMP tflW- cARC /1 -:2-~-)-C)(lc &EflU1'iCIfIN ",PJik.:.J: I' , 1-<;'-
C) - 16' .leu,.- Cffrll' (1//..L L~ I). - :>-:;L '"Jc)O~ BE{tUrtCiriJ,; c)..~AJ-:;E /I. .:2-$-
TOTAL (Enter on Line 5 of Tax Computation) $ 60~..J..1
PAYEE
DESCRIPTION
AMOUNT PAID
Under penalties of perjury, I declare that the facts I
complete to the best of my knowledge and belief.
.....-----, l ( /)!-"'
!fit!W4A.. .. . ~A'l1.<..v{
have reported above are true, correct and
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