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INSTRUCTIONS
ASSETS - Describe 011 Real Estate located in Pennsylvania and held solely by decedent or held jointly with another party
or parties as ttmants in conman or as joint tenants with right of survivorship. Include the decedent's percentage of ownership
and the estimated market value. List 011 tangible and intangible personal property owned individually by the decedent or
jointly with another party or parties os joint tenants with right of survivorship at the time of death. Include intangible
personal property titled in the nome of the decedent, but payable at death to another party or parties including but not limited
to P.O.D. U.S. Savings Bonds and tentative trust accoun's. List any property transferred by the decedent, within two years
of death for which he/she did not receive valuable and adequate consideration.
DEBTS & DEDUCTIONS - Unsatislied liabilities incurred by the decedent prior to hisiher death ore deductible against
his/her taxable estate. In addition to debts incurred by the decedent, other items arc claimable including the cost of
administration, attorney fees, fidUCiary fees, funcral and burial expenses including the cost of a burial lot, tombstone or
grave marker.
Evidence to support the decedent' 5 or the Estate's ll.bility lor tho debts boing claimed should be ."ached to this return.
A lamily exemption of $2,000.00 may be claimed by 0 Spouse 010 decedent who died domiciled in Pennsylvania. 1/ there
is no spouse, or if the spouse has forfeited his/her rights, then any child of the decedent who is member of the same household
can claim the exemption. In the cvent, there is no such spouse or child, the exemption can be claimed by a parent or parents
who are members of the same household as the decedent.
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INFORMATION
PLACE FOR FILING - Tho return is to be filed in duplicate with the Register 01 Wills 01 the county wherein the decedent
resi ded.
TIME FOR FILING - The return is due nine months alter the decedent's death, unless on extension lor filing has been
applied for and granted by the Secretary of Revenue within the nine.month period.
FAILURE TO FILE RETURN - Section 791 01 the 1961 Statute provides that". . .any person who will/ully loils to file
o retum or athor report reGuired 01 him sholl be personally liable. . .ta 0 penalty 01 2S% 01 the tax ultimately laund
to be due or $1,000 whichever is the less to be recovered by the Department of Revenue as debts of like amount are
recoverable by law."
.-- ..
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF EXAMINATION
OFFICIAL NOTICE OF
INHERITANCE TAX
ASSESSMENT
.
(
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COUNTY FILE NO:
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DATE
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TO:
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ESTATE "
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FILE NO.
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COUNTY
////. ...;?,
DATE OF DEATH '-///O/'/J/ /'i5tJ
, "
Appraised Valuo of Estate:
Real Estate
$ ,----
+ /"/I'() ,-'-(1
.. I '
Personal Property
Jointly Held PropertylTransfers
+
Total Gross Estate
$ / '~I i,'fi "r:'
. / '
-~. _~i '77 ,~,-7;
- r'
$
Total Approved Oeductions
Clear Value of Estate
less: Approved Charitable Exemptions
Clear Value of Estate Subject to Ta.
$
Amount Ta.abte @ 6% Rate
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ta. dUG,t/L./4'G~..., ,art.) ,I--/~
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Amount Ta.ab1e @ 15% Rate
ta. due .I
, , P.:. .--.-/
TOTAL PENNSYLVANIA INHERITANCE T~ p~E,~A~td:t: "it., )4t..,/;
1'~ --
... * ... * ... * A five percent discount totaling $
will be granted if the Inheritance Tax is paid by
Less Credits:
DATE OF PAYMENT
AMOUNT PAID
DISCOUNT
tNTEREST
TAX CREDIT
$
+
=
$
$
$
+
=
+
=
Interest accrues at the fate of six (6) percent per annum
on the unpaid balance of Inheritance Tax from
to date of payment. Interest due if paid by is, . . ' ~1 . .,J---..:-J
BALANCE OF PENNSYLVANIA INHERITANCE TAX DUejj~:J~~/J. a'''1)'~./'/j;'''
I
See Informalion on Reverse Side
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