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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 2B060l
HARRISBURG, PA 17128-0601
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21 06-1036
06161740
12-15-2006
REV-1545 EX AFP (09-00l
EST. OF ANNA M SMITH
S.S. NO. 166-14-5663
DATE OF DEATH 10-06-2006
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
[X] CHECKING
o TRUST
o CERTIF.
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 1701~
(j =
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PNC BANK has provided the Department with the information listed below which. h~::-~en u~ in . .... _,
calculating the potential tax due. Their records indicate that at the death of the above decedent, you were-aA'/Jnt ownou:e>enef'lc;(a<;:;:;Of
this account. If you feel this information is incorrect, please obtain written correction from the financiaL_~.:~~utio~ttach.B._ ~..~.
to this form and return it to the above address. This account is taxable in accordance with the Inheritanc.:,~ Laws of:lbe Co~'e~th
of Pennsylvania. Questions may be answ..red by cailing (717) 787-8327. . - :::0 f'o.) ;__..u.__
COMPLETE PART 1 BELOW. . . SEE REVERSE SIDE FOR FILING AND PAYMENT:-;iNSTRUC~ONS-';'-;
CD
Account No. 5140117828 Date 01-01-1980 To insure proper credit to your account, two
Established (2) copies of this notice must accompany your
payment to the Register of Wills. Make check
payable to: "Register of Wills, Agent".
JEAN L HYSSONG
2720 DICKINSON AVE
CAMP HILL PA 17011
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
41,599.85
50.000
20,799.93
.045
936.00
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
[!]
[CHECK ]
ONE
BLOCK
ONLY
A. D 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.
B. D 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
[!]
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
TAX ON JOINT/TRUST ACCOUNTS
}_J./_) 9 <;jo
rJ':799,'d5
.50,000
:10799,7'3-
1 w J /0" i b
:2b 'i?9,,? '/
,,0'1.5
I ~J, 07'-- 6,tJ5 /:JJ;;,c..r== JJ1I/r')~
DEBTS AND DEDUCTIONS CLAIMED
x
If you indicate a different tax rate, please state your
relationship to decedent:
x
PART
~
DATE
PAID
PAYEE
~/
(Enter on Line 5 of Tax Computation)
Under penalties of perjury, I declare that the
complete to the best of my knowledge and belief.
$
TAVDA.V~D C'T~"IATII
facts I have reported above are true, correct and
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