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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF EXAMINATION
OFFICIAL NOTICE OF
INHERITANCE TAX
ASSESSMENT
.
COUNTY FILE NO:
DATE
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ESTATE
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FILE NO,
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COUNTY
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OATE OF DEATH
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Appraised Value of Estate:
Real Estate
$
Personal Property
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Jointly Held PropertylTransfers
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Total Gross Estate
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Tolal Approved Deductions
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Clear Value of Estate
$ -._-_._-'--~
Less: Approved Charitable Exemptions
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Clear Value of Estate Subject to Tax
$
Amount Taxable @ 6% Rate
$
tax due
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Amount Taxable @ '5% Rate
tax due
TOTAL PENNSYLVANIA INHERITANCE TAX'9\l~'--'-v$/:, .~" ,4-
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.. 'It ... ,. .. .. A five percent discount totaling S
will be granted if the Inheritance Tax is paid by
lass Credits:
DATE OF PAYMENT
AMOUNT PAID
DISCOUNT
INTEREST
TAX CREDIT
$
+
$
$
=
$
+
=
+
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Interest accrues at the rate of six (6) percent per annum
on the unpaid balance of Inheritance Tax from
to date of payment. Interest due if paid bv
is
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BALANCE OF PENNSYLVANIA INHERITANCE TAX DUE;,
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As.e..edby: / , I ; " I (~
Agent fOf the Commonwtllth
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See In'ormation on Reverse Side
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COMMONWEALTH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
INHERITANCE TAX OIVISION
INHERITANCE TAX RETURN
FOR INSOLVENT ESTATES ONLY
OF RESIDENT DECEDENTS
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COUNTY OF .I!~~iJ
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RCC.'OJ U.731
This ralurn mUlit bo completod In datail and filad In dupllcato, with ,he Register of Wills in Iho Count.,. whole tho docudont rosidad within nino
monlh. aftor doto of dOCllh. unla.,.. on o)llonslon is glonted by tho Socratory of ROYonua,
Will';? /. Ril '/'.;2.,;1;
Adnm. Nil. 11)_
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e:..-ttv
f.!w-II/IVV
Misc.
being duly s\\'nrllllcctlnl~;, HI 1l.1\\'. "CIHlSC~ :and sa~s Ihul he is the
of Ihe cslBle of _tlL.d~LIJ1~ - -~~
late of
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'CITY, BOROUOl<,----.-ToWNSHih ____L~_
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INAMI:1
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consislctl of the assets lislet! heluw unu th"l ullnwahlc dchts and deductions exceeded the fair market value of lhe .Issets and
dcceuscd. nnd that the whule of the estale uf Solid deccdl'l1l. whll dieu nn
no Pcunsylvnnia Transfer Inheritance 'fax is tlue.
Sworn and subscribod be for., m~::';i~~Sct::: ~t..\:"~!; t:;"":,~~"'..ll~'_~': tt: ,F a~~
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Y - (,1- (SIGNATURE)
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Typa Auet:
Rtol Estate, Perl.
Prape'ty, Jointly
Held P,ap. or
Transfers
ASSETS
(Atlach addlllono~1l neceua,y)
Ducrlption of Anet
Estlmoted
Market
Value
Department
Valuation
CAUTION
(Do notwrlto
In ,hi, Ice)
1979
1977
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I, the undersigned duly appointed Inheritancc Tax Appraiser in and for the above County do respectfully reporlthall have
appraised Ihe real and personal property as reported in the foregoing schedule atlhe \'alues set rorth opposite each item in
Ihe IBSI column In the right. .'1' , 'J ';Ii'" " I I
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Dated: Nov.m'b"'" 20, 1980 (INHERITANCE TAX APPRAISER)
TOTALS
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stT'O
REPORT OF INllERITANCE TAX APPRAISER
Nome of Poyee
DEBTS AND DEDUCTIONS
Noture of Claim
Amount
Cloimed
Amount Approved
by Register
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TOTALS
5'.rro
REPORT OF TilE REGISTER OF WILLS
1, the undersigned duly electcd Register of Wills in and for the above County, do respcctrully rcpUrl thai I have allowcd
deductions in the amounts set rorlh in the abnve schedule as claimed, except where I have set forth a greater ur lesser amount
in the last cnlumn to the righi, which grciHer or lesser amount represenls lhc t::f allowcd llS a dcduc . n.
DBte of ApprovBI: -17 tTVt!1nl~J .;( tJ) ) 1f2J /./'..<.. - {!.
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