HomeMy WebLinkAbout12-27-06
Ct:JIIUIIIWEAL TH OF PEllfSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
1J6iIlr. 28MI
HARRISBURG~ PA 171Z8-0601
*R
INFORMATION NOTICE
AND
ED ~~ER RESPONSE
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FILE NO. 21 o\...Q l \Sd-
ACN 06156612
DATE 11-15-2006
SUSAN M APPLEBY
4715 SEARS RUN DR
MECHANICSBURG PA 17050
TYPE OF ACCOUNT
2006 DEe 21 PM ~9r6 OF CARRIE M MOORE IXl SAVINGS
S.S. NO. 100-12-8532 DCHECKING
CLERK OF DATE OF DEATH 09-27-2006 D TRUST
ORP~.{A.N'S COUR~OUNTY CUMBERLAND D CERTIF.
CUtvF:;!:'''~;I/t'iD ')'J, Pi~ REMIT PAYMENT AND FORMS TO:
RESISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE1 PA 17013
AMERICHOICE FCU has provided the o.parbent with the InfoMlat1on llsted below which has been used In
c:elculat1ng the potential ux due. Their records indicate that at the death of the ebove decedent~ you were a joint owner/beneficiary of
this account. If you feel this inforntlon is incorrect~ pleaSll obuin written correction froe the fimmcial institutlon~ attach a copy
to this foMl and return it to the above address. This account Is Uxable In accordance with the Inheritanc.. Tax LaNS of the COIIIIOnw..alth
of PannsyIVllnia. Qu..stlons _y be IHlSWtlMld by call1ng (717) 787-83Z7.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
AccOWlt No. 35109 o.te 05-21-2003
Est.blished
AccOWlt SelBnCe
Percent Tex_le
AIIount Subject to Tex
Tex Rete
Potentiel Tex Due
x
161959.95
50.000
81479.98
.045
381.60
TAXPAYER RESPONSE
To insure proper credi t to your account, two
(Z) copies of this notice .ust BCC08peny your
payaent to the Register of Wills. Milke check
payable to: "Register of Wills~ Agent".
x
NOTE: If ux payaents are .ade wi thin thr....
(3) aonths of the decedent's date of d..th~
yoU .ay deduct a SiC discount of the tax due.
Any InheritBnce Ux due will becoae delinquent
nine (9) .onths after the date of death.
PART
[!]
~:c~:_~~r.;~'l~_:~JI:~-:~-or:;~::~~"':)r:"pf~~~:.z:1<!:1P;~r~'~-~:'J~~-r7~~rfr.lf~~~]?:r:~:rf::':~'?~~!T~:-"::1Hf:]~'ti~.(f7Ji~~~~
"-"=""-'li--'"_"or_*_-_"......ww_=..._"4...-jih_"--'"_w-'"-'"J2.;""_..,-'"_,,_-tii.r__-~ft_-:!'"",1iJl!liif~4H:~j*-~Jil:*j"*Z'.J!iii"-"...>;j-:Jlll:-Jil'_'W_'ll'_...'ll'",iJn!_"q:=illi__,,'--'ilil-:w.r:J!R~-'Ji!i-.illf-iAA:-__"~:jjffi 'M$-_-~~_'lli::;J;.Q-:MF_'llt=t!jj;~.l!
A. 0 The llbove Inforntlon and tax due is correct.
I. You..y choose to re.it plly..nt to the Register of Wills with two copies of this notice to obtain
II discount or avoid interest, Dr yoU ..y check box "A" IHld return this notice to the Register of
Wills and an official assesseent will be issued by the PA Depllrtaent of Revenue.
B. 0 The above asset hilS been or NUl be reported and tax paid with the PennSYlvania Inheritance TIlX return
to be filed by the decedent's representative.
C. 01 The above infor.ation is Incorrect and/or debts and deductions I118re pllid by you.
You BUst coaplete PART [!] and/or PART ~ below.
[CHECK ]
ONE
BLOCK
ONLY
If you indicate. different tex retel pleese stete your
reletionship to decedent:
PART
~
TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS
LINE 1. IhIt. EstllbUshed 1 81!!{/ Q, J ~]J
2. ACCOWlt Selenee 2 1(; I q a q s
. ..........t T_l. . ~ ~ o~
f ~f:~=~~ ;; ~~~:i~
8. Tex Due 8 :o~&)R. .s-g
DEBTS AND DEDUCTIONS CLAIMED
PART
[!]
DATE
PAYEE
DESCRIPTION
AMOUNT PAID
Under penelties of perjury 1 I declere thet the
caep ete to the best of ~ know e and belief.
HOME
WORK
. - --
Continuation of Part 3 - DEBTS AND DEDUCTIONS CLAIMED
DATEPAID PAYEE DESCRIPTION
10/23/06 John's Carpet apartment carpet cleaned
10/26/06 Holy Spirit Hospital hospital bill
10/26/06 Cocklin Funeral Home, Inc funeral expenses
10/26/06 MEDeO prescription bill
10/26/06 PPL Electric Utilities Corp electric bill
10/26/06 Holy Spirit Hospital hospital bill! Aug cataract surgery
10/26/06 Quantum Imaging & Therapeutic xrays
10/26/06 Schein Ernst Eye Associates eye doctor bill
10/27/06 deposit deposit on sale of Cavalier
10/27/06 deposit payoff on sale of Cavalier
11/01/06 PPL Electric Utilities Corp final electric bill
11/01/06 Holy Spirit Hospital hospital bill
11/01/06 Internists of Central P A doctor bill
11/0 1/06 West Shore Anesthesia medical bill
11/01/06 P A Gastroenterology Consultant doctor bill
11/01/06 American Home Patient oxygen services
11/07/06 Heritage Cardiology Associates doctor bill
11/22/06 deposit - refunds State Farm Ins-$18.72/Comcast-$2.79
11/24/06 West Shore Anesthesia medical bill
11/24/06 Hershey Kidney Specialists doctor bill
11/24/06 Central P A Pulmonary Assoc. doctor bill
11/27/06 Quantum Imaging & Therapeutic xrays
12/01/06 deposit apartment security deposit refund
AMOUNT PAID
$ 90.10
22.77
1585.00
36.16
16.44
497.34
9.65
65.32
+ 450.00
+2000.00
8.99
1296.89
61.83
21.73
62.95
133.20
94.59
+21.51
25.34
53.59
835.97
54.98
+300.00
Sub-Total from this page:
$2,201.33
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
APPLEBY SU SAN M
4715 SEARS RUN DR
MECHANICSBURG, PA 17050
__nnn fold
ESTATE INFORMATION: SSN: 100-12-8532
FILE NUMBER: 2106-1152
DECEDENT NAME: MOORE CARRIE M
DATE OF PAYMENT: 12/27/2006
POSTMARK DATE: 12/27/2006
COUNTY: CUMBERLAND
DATE OF DEATH: 09/27/2006
NO. CD 007617
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $258.58
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$258.58
REMARKS:
CHECK#1348
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS