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COMMONWfALTH OF PENNSYLVANIA
DEPARTMENl OF REVENUE
BUREAU OF INDIVIOUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
*'
INFORMATION NOTICE
-- - AND
TAXPAY.E~, RESPONSE
FILE
ACN
DATE
NO. 21
06118856
04-24-2006
REV-15~5 EXAFP (D9-DDl
1....-'", ,.
/-'. '
EST. OF EVELYN FULFER
S". S 9 NO. 342-24-3172
DATE OF DEATH 11-05-2005
COUNTY CUMBERLAND
TYPE OF ACCOUNT
[X] SAVINGS
D CHECKING
D TRUST
D CERTIF.
~~ CURTIS W FULFER
609 E KELLER ST
MECHANICS BURG PA 17055
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 hy calling r717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 264729-00 Date 05-13-2005
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
20,434.75
100.00
20,434.75
.045
919.56
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 57. 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 "A" 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.
PART
~
TAX RETURN - COMPUTATION
lINt 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
x
TAX ON JOINT/TRUST ACCOUNTS
~/~4%.7,C;-
'2.q ~1~.1..c:;
1.11..~ I. DO
I ~I '2.03. 7S
.Oc..J.S
P1,Q.I'
DEBTS AND DEDUCTIONS CLAIMED
If you indicate a different tax rate, please state your
relationship to decedent:
x
PART
[!]
DATE PAID
<I
PAYEE
DESCRIPTION
AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation)
perjury, I declare that the facts I
y knowledge and belief. HOME
$
TAXP
correct and
~
E-143 EX (3-99)
-i Curtis lJJ. & XarBn S. ruller
l '. 609 t. X8Iler StrSBt
~~J"II;"'~lq FA .'Tg5?-U'~
Attention: TIC 340
Zip Code
E-l43 EX (3-99)
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Attention: TIC 340
Zip Code
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HARRISB_~R~ PA 1J
08 JU N 2~J06 PM 21
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PA DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPl: 280601
HARRISBURG PA 17128-0601
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HARRISBURG PA 17U
08 JUN 2006 PM 4 fl
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PA DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPl: 280601
HARRISBURG PA 17128-0601
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