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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG I PA 17128-0601
*'
INFORMATION NOTICE
AND
T AXPA't.'E~ :=:~~BrS E
FILE NO. 21 ()~ S5~
ACN 06125427
DATE 06-02-2006
REV-1545 EX AFP (09-00)
2UU[
EST. OF H~'~E~nK KEYS
S.S. NO. 112-01-1735
DATE OF DEATH 02-11-2006
COUNTY CUMBERLAND
-rYPE OF ACCOUNT
D SAVINGS
lXJ CHECKING
D TRUST
D CERTIF .
(
CU
REMIT PAYMENT AND FORMS TO:
,-REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
MICHAEL R KEYS
14 JOSEPH DR
BOILING SPGS PA 17007
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 decedentl you were a joint owner/beneficiary of
this account. If you feel this information is incorrect I please obtain written correction from the financial institutionl 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
UT Pam.syl"'c.i1,ia. ;;!u....tiu..;i ina::; blit answii,ed by ,;;alliiig (717} 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 1 7 0 169 - 11 Date 08- 2 0 - 1 997
Established
PART
[!]
3,054.36
50.000
1,527.18
.045
68.72
TAXPAYER RESPONSE
!lllll~~I~~.III!IIIII!II!I~~m;:......,,;,j~~~li!II~;;;;;;:;:,,::::~iijL:::::::;~llllllililll~I~~I~~~illli~~~i!ijll~~~~!~I~~!ijill~~~~!ij!lllljl!!I~!!!!il~~~I~~IIII!j!
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
To insure proper credit to your accountl two
(2) copies of this notice must accompany your
payment to the Register of Wills. Make check
payable to: "Register of Willsl Agent".
x
x
NOTE: If tax payments are made within three
(3) months of the decedent's date of deathl
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
[CHECK ]
ONE
BLOCK
ONLY
A. D 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 interestl 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.
B. D 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. ~ The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
x
4-.5 '70
If you indicate a different tax rate, please state your
relationship to decedent:
PART
[!]
TAX
LINE
RETURN - COMPUTATION OF
1. Date Established 1
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
1~IQ!l.~. 6i~~ ~~~
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_"'31 () r <6 ..S~
o
PART
~ ~..13.0G,
DATE PAID
- 13 .0
Auer M~Mor:o...t
PAYEE
()
DEBTS AND DEDUCTIONS CLAIMED
Hol'Y\e. Cr-€W\Q-h'0 n ~ U.- "'"'
DESCRIPTION
3.5~.50
AMOUNT PAID
$
perjury, I declare that the facts I have reported above are true, correct and
knowledge and belief.
(717 ) ~ 4-1 - Co Q 33
Cell \1JOR (711 ) 5 f Lf-- 518' S
TELEPHONE NUMBER
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