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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-C(vS73
06124306
05-25-2006
REV-1543 EX AFP [09-00)
EST. OF DANIEL J SIMS
S.S. NO. 211-58-8456
DATE OF DEATH 01-23-2006
COUNTY CUMBERLAND
TYPE OF ACCOUNT
[i] SAVINGS
o CHECKING
o TRUST
o CERTIF.
ADELE M SIMS
1007 BRIDGE ST
NEW CUMBERLAND PA 17070
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 Clbtain written correction from the financial insti tution, '~ttach a COpy',
to this form and return it to the above address. This 8CCOU,'~ i. taxable in accordance with the Inheritance Tax Laws of thS'CDmmonweal~h
of Pennsylvania. Questions may be answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCT!~NS
Account No. 21479-00 Date 04-28-1983 To insure proper credit to your acbci(.nt, two
Established (2) copies of this notice must acc"','l'j'any your
payment to the Register of Wills. ~ke check
payable to: "Register of Wills, Agent".
;
--~)
+~
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
2,720.50
50.000
1,360.25
.045
61. 21
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
[!]
A. r"i1 The above information and tax due is correct.
~l. 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 "Au and return this notice to the Register of
Wills and an official assessment will be issued by the PA Department of Revenue.
[CHECK ]
ONE
BLOCK
ONLY
B. [] 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.
PART
@]
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
If you indicate a different tax rats, please state your
relationship to decedent:
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
x
TAX ON JOINT/TRUST ACCOUNTS
x
PAYEE
DESCRIPTION
AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation)
I
$
Under penalties
complete to the best
of perjury, I declare that the
of I!IY~,k?,wl,dge?)and belief.
L ,(~{~;J.t/;JU<J
facts I
have reported above are true, cor~ect and
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