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INSTRUCTIONS
ASSETS _ Describe all Raal Eslale located in Pennsylvania and hold solely by docodent or hold joinlly with anolhar parly
or parties as tenants in conmon or as joint tenants with right of survivorship. Include tho decedent's percentage of ownership
and Ihe esllmaled markel value. List all longiblo and intangiblo parsonal proporty awnad individually by Iho docadanl or
iaintly with another party or parties as joint tenants with right of survivorship at the time of death. Include intangible
personal property titled in the name 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 accounts. Li 5' any property iransferred by the decedent, within two years
of death for which he/she did not receive voluable and adequate consideration.
DEBTS & DEDUCTIONS _ Unsalisliad liabilities incurred by Iha docedanl prior 10 his/har daalh ora deductibla againsl
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, funeral and burial expenses including the cost of a burial lot, tombstone or
grave marker.
Evidence 10 supporl Iha decadanl's or tho Eslate's liability lor Ihe debls being claimed should be attached 10 Ihis relurn,
A fomily exemplion of $2,000.00 may be c1aimad by a spouse 01 a docadont who diad domicil ad in Pennsylvonia. II Ihera
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 event, there is no such spouse or child, the exemption can be claimed by a parent or parents
who ore members of the same household as the decedent.
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INFORMATION
PLACE FOR FILING _ Tha ralurn is 10 bolllad in duplicala with Iha Ragislar 01 Wills 01 Iha caunly wherein the dacedanl
rasi dod,
TIME FOR FILING _ Tha relurn is dua nina monlhs altar Iha docadanl's daolh, unlass an oxlansian for Iiling has been
oppliad for and granlad by Iha Sacralary 01 Ravanua within Iha nina-monlh pariad.
FAILURE TO FILE RETURN Saclion 791 01 tha 1961 SIatula pravidas Ihal .. , . ,ony parson who willlully lails 10 file
a ralum or alhar roporl requirad 01 him shall ba parsonally liabla . . ,10 a panollY of 25% 01 Iha lax ullimalely found
to be due or $1,000 whichever is the less to be recovered by the Deportment of Revenue 05 debts of like amount are
recoverable by law."
INFORMATION
To insura propar cradit to your OCCOUIII, the noma of tho estoto and 1110 number should be c1eorly print'
ad on the check or money order.
This ossessmen' is mode in accordonca with Secllon 708 of tha Inheritonco and Estate Tax Acl of
1961 172 P,S, !l 2485,708),
To the extent that inheritonca lax is paid wilhin Ihreo 131 months alter Iho deoth of Ihe decedont, a
discount of fiva (5) percent is allowed 172 P,S, !l 2485,716),
Inheritance Tax, other than tax on a futura intereSI. is due at the date of the decedent's death and becomes
delinquent at the expiration of nina (9) monlhs alter the decedent's death 172 P,S, 9 2485.711), Inheritance
Tax on a fUlUra interest is poyabla within three (3) months alter Ihe transfer takes eflect in possession and
enjoyment and is delinquent therealter (72 P,S,!l 2485.712), Calculate inlerest from the delinQuenl date shown
on tha face of this form to the date of actual payment using the following interest table:
--------------------- ------------. ------------- -' ---- -.----------- ---- -----
1 month .005 4 months ,020 7 months ,035 '0 months ,050
2 months .010 5 months ,025 B months ,040 11 months ,055
3 months .015 6 months ,030 9 months ,045 12 monthS ,060
1 days .00017 1 I days ,00186 21 days .00352
2 days ,00034 12 days ,00203 22 days .00369
3 days .00051 13 days ,00220 23 days .00386
4 days .00068 14 days ,00237 24 days .00403
5 days .00085 15 days ,00250 25 days .00420
6 days ,00101 I/; days ,00267 26 days .00437
7 days .00118 17 days ,00284 27 davs ,00454
8 days ,00135 18 days ,00301 28 days ,00471
9 days .00152 19 days ,00318 29 days .00488
10 days ,00169 20 days .00335 30 days ,00500
-- --- ------ --------.---- ---- - - .-- --- - ---- - - - -.------ - - - .-------- -----.
Any party in interest, including the Commonwealth and the personal representative, not satisfied with
Ihe assessment mav object thereto within sixty (60) days alter receipt of Ihis Notice as provided by Section
100101 the Inheritance and Estate Tax Act of 1961172 p,S, 9 2485,1001),
Make check or money order payable to:
"Register of Wills. Agent"
Mail 10 the address listed below: