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COMMONWEALTH OF PENNSVLVANIA
DEPARTMENT DF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21 Ou:- II~~
06004021
12-20-2006
REY-1543 EX AFP <09-00l
EST. OF LOIS A HARRIS
5.5. NO. 174-01-6553
DATE OF DEATH 11-06-2006
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
[X] CHECKING
o TRUST
o CERTIF .
RONALD L HARRIS
196 MCALLISTER CHURCH
CARLISLE PA 17015
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CITIZENS BANK OF PENNSYLVANIA 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. Que~tions may be answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 6102314739 Date 08-01-1970
Established
x
4,340.69
50.000
2,170.35
.045
97.67
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 5Z 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.
[] The above information is incorrect and/or debts and deductions were paid by }
You must complete PART ~ and/or PART ~ below.
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PART
~
TAX RETURN - COMPUTATION
If you indicate a different tax rate, please state your
relationship to decedent:
TAX ON JOINT/TRUST ACCOUNTS
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
I
2
3
4
5
6
7
8
x
PART
~
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUNT PAID
I
TOTAL (Enter on Line 5 of Tax Computation)
I
$
Under
complete
perjury, I declare that the facts I
now ledge and belief.
have reported above are true, correct and
HOME ('117) 0 ~3-317S
WORK ( )
TELEPHONE NUMBER DATE
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT 280601
HARRISBURG, FA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLV ANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
HARRIS RONALD L
196 MCALLISTER CHURCH
CARLISLE, PA 17015
---~---- fold
ESTATE INFORMATION: SSN: 174-01-6553
FILE NUMBER: 2106-1144
DECEDENT NAME: HARRIS LOIS A
DA TE OF PAYMENT: 12/27/2006
POSTMARK DATE: 12/27/2006
COUNTY: CUMBERLAND
DA TE OF DEATH: 11/06/2006
NO. CD 007608
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
06004021 I $97.67
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARI<S: CITIZENS BANK
CHECK# 902737790 3
SEAL
INITIALS: AJW
RECEIVED BY:
REGISTER OF WILLS
$97.67
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS