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Home My WebLink About03-01-07 ..J 15056051058 REV-1500 EX (06-05) PA Department of Revenue '*' Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-D601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death r.........................................,.............................................. m. [' 199-07-2446 ............................................................... Decedent's Last Name INHERITANCE TAX RETURN RESIDENT DECEDENT Date of Birth 10/10/2006 07/31/1919 OFFICIAL USE ONLY County Code Year 'mm';'1.mm. [....06 I File Number 10999. Hilda Decedent's First Name Suffix Clawser (If Applicable) Enter Surviving Spouse's Information Below Last Name ,~Jl<lLJ~f)'~~i~~~~.IiI.'.!1f). Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS c::> 4a. Future Interest Compromise (date of death after 12-12-82) c::> 7. Decedent Maintained a Living Trust (Attach Copy of Trust) c::> 10. Spousal Poverty Credit (date of death c::> 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECnON MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENnAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ...........................................mm._....._.__.....__.................................... . FILL IN APPROPRIATE OVALS BELOW <a> 1. Original Return c::> 2. Supplemental Return c::> 4. Limited Estate c::> 6. Decedent Died Testate (Attach Copy of Will) c::> 9. Litigation Proceeds Received Dissinger and Dissinger First line of address 400 South State Road Second line of address City or Post Office sville 17053 ZIP Code Correspondent's e-mail address: c::> 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Retum Required c::> ...:Q:.:...... 8. Total Number of Safe Deposit Boxes : (717) :5!~~~!.~.~. . f"'o-.) = = ...........--.1...... REGISTER OF wili ; SE ONL~ 'IO :=0 ",-,r- 7fT! I . ....:.....- ~.,.....,. cr)~ (J 0 -0 _ ~;~~~Tl :x ~ -~ =? ::.:~ DATE FILED .ml I ....1 MI M MI .~LJ l !....f '..-. j " - -,) 'J ~-:;8 ,- ") o DDRESS 2158 MerrimacAvenue, Mechanicsburg, PA 17055 ~EOFPO~~. _.... ADDRESS ~ 400 South State Road, Marysville, PA 17053 PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051058 DATE ~,/..2 if;/ CT7 15056051058 ---I -I 15056052059 REV-1500 EX Decedent's Social Security Number Decedent's Name: RECAPITULATION Hilda M Clawser 199-07 -2446 1. Real estate (Schedule A). ............................................ 1. 0.00 0.00, 0.00 : 0.00 ! 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3. 4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5. 18,525.00 ! 13,914.061 6. Jointly Owned Property (Schedule F) c:::J Separate Billing Requested .. . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) c:::J Separate Billing Requested.. . . . . .. 7. 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 0.00. 32,439.06 1 6,985.42 i 67 . 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 & 10). . . . . . .. . . . . . .. . . . . . . . . . . . . . . . . .. . . 11.1 7,663.77 24,775.29 0.00 24,775.29 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. TAX COMPUTATION. SEE INSTRUCTIONS FOR APPUCABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 16. Amount of line 14 taxable at lineal rate X.O 45 17. Amount of line 14 taxable at sibling rate X .12 18. Amount of line 14 taxable at collateral rate X .15 0.00 15. 0.00 1,114,89 0.00 0.00 1,114.89 24,775.29 16. 0.00 0.00 17. 18. 19. TAX DUE... .. ......... .,. ... ...... . ....... .. . ....... . ......... . .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT <8> L 15056052059 Side 2 15056052059 -.J REV-1500 EX Page 3 File Number 0~ Decedent's Complete Address: 21 06 1109999 I DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER Hilda M Clawser 199-07 -2446 STREET ADDRESS 3545 Rolo Court CITY I STATE I ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 1,114.89 0.00 1,632.48 85.92 Total Credits ( A + B + C ) (2) 1,718.40 3. InterestlPenalty if applicable D. Interest E. Penalty 0.00 0.00 TotallnterestJPenalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Une 20 to request a refund. (4) 0.00 603.51 0.00 0.00 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;.......................................................................................... 0 ~ b. retain the right to designate who shall use the property transferred or its income: ............................................ 0 ~ c. retain a reversionary interest; or.......................................................................................................................... 0 [iJ d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 ~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 [KJ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. ~9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. ~9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV.,... EX. (....) .. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHIDULI I CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Hilda M. Clawser FILE NUMBER Indude the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must b. disclosed on Schedule F. ITEM NUMBER DESCRIPTION Miscellaneous personal property (appraisal attached) 2. : Mobile Home (appraisal attached) TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) VALUE AT DATE OF DEATH 1,525.00 17,000.00 18,525.00 REV-1509 EX+ (..... COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF Hilda M. Clawser FILE NUMBER If an ..lit was made joint within one year of the decedent's date of death, It mUlt be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT 2158 MerrimacAvenue Mechanicsburg, PA 17055 A.. Patricia A. Hanshaw c. JOINTLY-OWNED PROPERTY: TOTAL (Also enter on line 6, Recapitulation) (If more space is needed, insert additional sheets of the same size) DATE Of DEATH VALUE OF DECEDENT'S INTEREST LETTER DATE ITEM FOR JOINT MADE NUMBER TENANT JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. 1. A. 02121102 . Acct #6100742474 with Citizens Bank 5,280.96 8,633.10 13,914.06 REV.1511 EX. (12-991* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Hilda M. Clawser FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION EUNEBALE~PENSES: Cocklin Funeral Home 1. B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant .. Robert Jr. Street Address 3545 RoJo Court, Mechanicsburg, PA 17055 City Mechanicsburg StatePA ,Zip 17055 Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Retum Preparer's Fees 7. Patriot-News Magee (appraisal) AMOUNT 330.7 0.00 TOTAL (Also enter on line 9. Recapitulation) (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12..03) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE UABIUTIES, & UENS FILE NUMBER ESTATE OF Hilda M. Clawser Report debtllncurnd by the decedent prior to death which remained unpaid al of the date of death, Including unrelmburaed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. West Shore EMS - ALS TOTAL (Also enter on line 10, Recapitulation) (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT leNIDULI J BENEFICIARIES FILE NUMBER ESTATE OF Hilda M. Clawser AMOUNT OR SHARE OF ESTATE RELATIONSHIP TO DECEDENT Do Not List Trustee(s) NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS pnclude outright spousal distributions, and transfers under , ..~13.~.:....~,1.1..~..(~1..{~..'?)] 1. James Clawser, 136 Walnut St., Rm. A, Harrisburg, PA 17101 Son Son 2. Robert Clawser, Jr., 3545 Rolo Ct., Mechanicsburg, PA 17055 25 Son John Clawser, 3145()"B S. Country Rd. 4370, Kinta, OK 74552 3. Daughter Patricia A. Hanshaw, 2158 Merrimac Ave., Mechanicsburg, PA 17055 4. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18. AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE II B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET (If more space is needed, insert additional sheets of the same size) DAVID I. MAGEE 320 Cameron Street MarysviUe, P A 17053 Mary Dissinger Attorney at Law 400 State Road MarysviUe,PA 17053 Re: Estate of Hilda Clauser Executrix Patricia Handshaw Address 3545 Rolo Court, Mechanicsburg In regard to the above property consisting of 1994 Fleetwood Double Wide manufactured home, this property which consists of living room, combination dining room and kitchen, small utility room, three bedl"O()ms and two baths. The living room and kitchen are an open floor plan. The house utilizes gas heat. After advertising costs and commission, I feel that this property could net 517,000 if sold at auction. This home is in good condition although the kitchen 000.. does need to be replaced. nSHERSTRUCTURESHED Shed is approximately 8 X 12 feet 5300.00 Three plastic Chairs; snow shovel, plastic table; hose reel and' Twelve inch table fan 510.00 LIVING ROOM Three cushion couch Recliner Rocking Chair Two Brass like table lamps Table Lamp Two End Tables C~.e.;CJ.I.li.o Cabinet and cOll{eQts Oak Entertainment Center - 4 X 4 feet Clock and other various wall decorations, various Ceramic wall decorations and religious figurines Small Painted Country Chest 550.00 550.00 535.00 520.00 515.00 525.00 550.00 535.00 . .~. ,.. . . I 575.00 540.00 BEDROOM ##1 and Bathroom Occupied by son of Hilda Clauser - did not appraise any items Page #2 ~ BEDROOM ##1 (SPARE ROOM) Card Table and two Chairs Approximately thirty pieces of milk glass And some Anchor Hocking Pieces Four Wan Decorations Dresser with five drawers End Table Christmas Decorations- Table Lamp Fiber Optic Christmas Tree Sman amount of garden tools Sewing Box Two Vacuum Cleaners KITCHEN Formica Table and four chairs Varioos Kitchen tools, dishes, small appliances, pots And pans, microwave BEDROOM #11Fonnerlv occuoied bv Hilda Clauser) Double Bed; Chest of Drawers; Dresser with Mirror; Two bedside tables; two lamps; box spring and mattress And various bed coverings Jewelry box containing variety of rings, earrings and Necklaces (please note one Bulova watch and Four Timex Watches Were gifted prior to Ms. Clauser's death) $20.00 $10.00 $ 5.00 $30.00 510.00 510.00 $ 5.00 5 5.00 S 5.00 $ 5.00 $25.00 $10.00 $30.00 $300.00 5350.00 . .."".,..~. TOTAL OF-.PERSONAL P~OPERTY INCLUDING SHED BUT EXCLUDING T _ _.~A~D~O~.IS5152S. a~~ . r a Citizens Bankw Account Number 6140-280990 Account Title HILDA M CLA WSER or PATRICIA A HANSHAW Date Opened 8/29/2001 Account Type Savings Principal Balance as ofDOD $17,263.88 Interest from Last Posting to DOD $2.13 Account Balance as ofDOD $17,266.01 YTD Interest to DOD $64.43 Already Joint before 06/21/2002 . __.0 "L"!";": . J...I "1 . . i a Citizens Bank- Account Number 6100742474 Account Title HILDA M CLA WSER or PATRICIA A HANSHAW Date Opened 10/18/1974 Account Type Checking Principal Balance as ofDOD $10,561.92 Interest from Last Posting to 000 $.00 Account Balance as of 000 $10,561.92 YTD Interest to ODD $.00 Already Joint before 06/21/2002 . .-.' .r.' .:::>:.':.t..i f. f" t COMMOMfllEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 Mi- INFORMATION NOTICE '-~-'I'_ '.." AND ~AX~~ER RESPONSE FILE NO. 21 06-0999 ACN 07104419 DATE 02-05-2007 REV-1543 EX ~p '(...'.') TYPE OF ACCOUNT [i] SAVINGS o CHECKING o TRUST o CERTIF. 2007 MAR - J PH 1!;1 D OF HILDA M CLAWSER s.s. NO. 199-07-2446 CLERK OF DATE OF DEATH 10-06-2006 ORPHAN'S COUf11OUNTY CUMBERLAND CUiW3r]'I_/!'.}") CO . PA REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 PATRICIA A HANSHAW 2158 MERRIMAC AVE HECHANICSBURG PA 17055 CITIZENS BANK OF PA has provided the Depart.ent with the info~ation 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 info~ation is incorrect, please obtain written correction fro. the financial institution, attach a cOPY to this fo~ and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Cu..onwealth of PennsYlvania. Questions .ay be answ~red by calling (717) 787-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 6140-280990 Date 08-29-2001 To insure proper credit to your account, two Established (2) copies of this notice .ust accapany your payaent to the Register of Wills. Make check payable t01 "Register of Wills, Agent". x 17,266.01 50.000 8,633.01 .15 1,294.95 NOTE I If tax pay.ents are .ade within three (3) .onths of the decedent's date of death, yOU .ay deduct a sn discount of the tax due. Any inheritance tax due will beco.e delinquent nine (9) aonths after the date of death. Account Balance Percent Taxable AMount Subject to Tax Rate Potential Tax Due x Tax PART r!I TAXPAYER RESPONSE &1!!i:::!!J~~!~:~:~~~.~:~1~:Jl~~~;~l;1!~;~!:':1~~I~i!:MII~;f;r~;;;~~~:~~~II1~tI!dir:~~~;;[tl:~~~:ri~ [CHECK ] ONE BLOCK ONLY A. 0 The above infor.ation and tax due is correct. 1. You aay choose to re.it pay.ent to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or you .ay check box "A" and return this notice to the Register of Wills and an official assess.ent will be issued by the PA Depart.ent of Revenue. I. ~he 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 inforaation is incorrect and/or debts and deductions were paid by you. You aust co.plate PART 0 and/or PART ~ below. 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. AMount SUbject to Tax 5. Debts and Deductions 6. AMount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 4 5 6 7 8 x PART [!] DATE PAID DEBTS AND DEDUCTIONS CLAIMED PAYEE DESCRIPTION AMOUNT PAID TOTAL (Enter on Line 5 of Tax Computation) . perjury, I declare that the facts my knowledge and belief. have reported above are true, correct and HOME ('1/'1) kJ t} 1- tY 17 S WORK () ~ -;)..'8-a7 TELEPHONE NUMBER DATE COMMOMIIEAL TH OF PEtIISYLVAHIA DEPARTMENT OF REVENUE JUREAU OF INDIVIDUAL TAXES DEPT. 280'01 HARRIS8URG, PA 17128-0'01 *cs C!CF9i:p~".;E1NO~NEsNpO:NISCEE " ,..,l ; REV"l~~ ~,~..~qO..~V'~ i ~ FILE NO. 21 06-0999 ACN 07104418 DATE 02-05-2007 PATRICIA A HANSHAW 2158 HERRIHAC AVE MECHANICSBURG PA 17055 CLERK OF QRPHt'\N'S CQ~RT . [ n" : " ni\ CIUu, .~..), ,... ,', ' ,\'.. 1"1 \'1'., I .' . P\~ \: \ 0 EST. OF HILDA M CLAWSER S.S. NO. 199-07-2446 DATE OF DEATH 10-06-2006 COUNTY CUMBERLAND TYPE OF ACCOUNT D SAVINGS liJ CHECKING D TRUST o CERTIF. ZOOl MAR - \ REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CITIZENS BANK OF PA has provided the Depart.ent with the info,..ation listed below which has been used in calculating the potential tax due. Theil' records indicate that at the death of the above decedent, you were a joint owner/beneficia"y of this account. If YOU feal this info,..ation is incorrect, please obtain written correction fro. the financial institution, attach a copy to this fo,.. and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Co..onwealth of PennSYlvania. Qu..Ucns ..y be. an:JWe,.ad by calling (717) 787-8327. COMPLETE PART 1 BELOW II II II SEE REVERSE SIDE FOR FILINS AND PAYMENT INSTRUCTIONS Date 10-18-1974 Account No. 6100742474 x 10,561.92 50.000 5,280.96 .15 792.14 TAXPAYER RESPONSE To insure propel' credit to YOUI' account, two (2) copies of this notice .ust acco.pany YOUI' pay.ent to tha Regist.r of Wills. Make check payable tal "Register of Wills, Agent". Establ1shed Account Balance Percent Taxable A.ount SUbject to Tax Tax Rate Potential Tax Due x NOTE I If tax pay.ents are .ade within three (3) .onths of the decedent's date of death, YOU .ay deduct a SX discount of the tax due. Any inheritance tax due will beco.e delinquent nine (9) .onths after the date of d.ath. PART [!] SiJ~1J2:::~~i&;:i!::~7;:~:~;J{;!I;'tJ:li;Jiii~I~;JlZ;~lIJj::3i~~:-;tI~;r::I::~~iJ~~:~:=;!:;~!~tii~~:~~~~~~1:1 [CHECK ] ONE BLOCK ONLY A. [] The above info,..ation and tax due is correct. 1. You..v choose to re.it pay.ent to the Register of Wills with two copies of this notica to obtain a discount 01' avoid interest, 01' you .ay check box "A" and return this notice to the Register of Wills and an official assess.ent will be issued by the PA Depart..nt of Revenue. B. ~Th. above .sset has been or will be reported and tax paid with the PennsYlvania Inheritance Tax return ~o be filed by the decedent's representative. C. [] The above infor..tion is incorrect and/or debts and deductions were paid by YOU. You .ust co.plete PART 0 and/or PART [!] below. 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. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 4 5 6 7 8 x PART I!J DATE PAID DEBTS AND DEDUCTIONS CLAIMED PAYEE DESCRIPTION AMOUNT PAID I . I TOTAL CEnter on Line 5 of Tax Computation) Under penalties of perjury, I declare that the facts I co.plete to the best of my knowledge and belief. 1jtr;~~AA. fI~c. ' GJ.d.LA.( TAXPAY R SIGNATURE ' have reported above are true, correct and HOME (17/'t}) ~ 9/- () J 7~ WORK () ;a - ~~ ~()7 TELEPHONE NUMBER DATE y.