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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
HAHN SUELLEN
612 LYMAN AVE
WOMELSDORF, PA 19567
____un fold
ESTATE INFORMATION: SSN: 194-24-2208
FILE NUMBER: 2106-1063
DECEDENT NAME: BURKETT JANE F
DA TE OF PAYMENT: 12/15/2006
POSTMARK DATE: 12/14/2006
COUNTY: CUMBERLAND
DATE OF DEATH: 09/16/2006
NO. CD 007566
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $142.79
I
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TOTAL AMOUNT PAID:
$142.79
REMARKS: SUELLEN HAHN
CHECK# 1001
SEAL
INITIALS: WZ
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
OCo -IO&~
FILE NO. 21
ACN 06159510
DATE 12-05-2006
REY-1545 EX AFP lD9-DDl
TYPE OF
ACCOUNT
D SAVINGS
D CHECKING
D TRUST
[Xl CERTIF.
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS ~
~~:~~~t:~D r~~~~~~!OUSE ;~::i
;~O ~ ~~~
I ~t:,. r- r::~J)
''-;7101 '
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MEMBERS 1ST FCU has provided the Depertllent with the inforllation listed below WhiCh~~~lln usilil::in , " ~
calculating the potential tex due. Their records indicate that at the death of the above decedent, you wera ~~int owne~nefiCi~~~f
this account. If you feel this inforllation is incorrect, please obtain written correction fro," the financial ~titution;-ettach~a'qOp'
to this forll and return it to the above address. This account is taxable in accordance with the InheritanoaJrax Laws of'~e Co"onwealth
of Pennsylvania. Questions lIay be answered by callirg (717) 787-8327. ,~.-> O' ~~
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUC~ONS
Account No. 203464-41 Dat. 08-31-2005
Established
~K
SUE E HAHN
612 LYMAN AVE
WOMELSDORF
~
EST. OF JANE F BURKETT
S.S. NO. 194-24-2208
DATE OF DEATH 09-16-2006
COUNTY CUMBERLAND
PA 19567
x
20,041. 01
16.667
3,340.24
.045
150.31
TAXPAYER RESPONSE
To insure proper credit to your account, two
(Z) copies of this notice !lUst accolIPany your
paYllent to the Register of Wills. Make check
payable to: "Register of Wills, Agent".
Account Balance
Percent Taxable
A.ount Subject to
Tax Rate
Potential Tax Due
x
NOTE: If tax paYllents are lIade lIithin three
(3) 1I0nths of the decedent's date of death,
you _y deduct a SX discount of the tax due.
Any inheritance tax due lIill bBCOlle delinquent
nine (9) lIonths after the date of death.
Tax
PART
[]
A.
[ CHECK ]
ONE
BLOCK B.
ONLY
c.
~he above inforllation and tax due is correct.
1. You lIay choose to rellit paYllent to the Register of Wills with tllO copies of this notice to obtain
a discount or avoid interest, or you lIay check box "A" and return this notice to the Register of
Wills and an official assessllent will be issued by the PA Departllent of Revenue.
[] The above asset has been or will be reported and tax paid with the Pennsylvanie Inheritance Tax return
to be filed by the decedent.s representative.
[] The above inforllation is incorrect and/or debts and deductions were paid by you.
You lIust complete PART ~ and/or PART ~ belOll.
x
If you indicate a different tax rate, please state your
relationship to decedent:
PART
~
TAX RETURN - COMPUTATION
LINE 1. Date Established
2. Account Balance
3. Percent Taxable
4. A.ount Subject to Tax
5. Debts and Deductions
6. A.ount Taxable
7. Tax Rate
8. Tax Due
TAX ON JOINT/TRUST ACCOUNTS
OF
1
2
3
4
5
6
7
8
x
PART
[!]
DATE PAID
/Z. /I<~
I
DEBTS AND DEDUCTIONS CLAIMED
1
TOTAL (Enter on Line 5 of Tax Co.putationJ
DESCRIPTION
f5 o;a OMC6u4'7-f
AMOUNT PAID
lif;;J 7V
PAYEE
/al
I
$
perjury, I declare that the facts I
.y knowledge and belief.
have reported above are true, correct
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