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INSTRueTIONS
ASSETS:
TYPE OF ASSEl _Indicate whether the O!J5Ct is reul estatc, pcr~onal property, transferor iointly.owncd.
DESCRIPTION _ List 011 ossels owned solely by the decedent or owned jointly with another party or porties as tenants in
common or os joint tenants with right of survivorship ot the time of death. Include the decedent's percentage of ownership,
the name (5) and relationship to the decedent of the surviving joint owners and the estimated market volue of the decedent's
interest os of the dote of death. Include intangible personal property titled in the nome of the decedent but payable at death
to another porty or parties including but not limited to P,O,D. U.S. Savings Bonds and tentative trust accounts. List any
property transferred by the decedent within two years of death for which he/she did not receive valuable and adequate
consideration.
Describe 011 real estate located in Pennsylvania by lot and block number, street address, number of acres and include 0
general description of the land and buildings Also, include the book and page number in which the deed is recorded and the
exact title as indicated on the deed.
DEBTS & DEDUCTIONS - Unsatisfied liabilities incurred by the decedent prior to his/her death ore deductible against
his/her taxable estate. In additic.n to debts incurred by the decedent, other items ore claimable including the cost of
administration, attorney fees, fiduciary fees, funeral and burial elCpcnses including the cost of 0 burial lot, tombstone or
grove marker. List the dote on which each debt was incurred and/or paid and the names of each payee. Provide 0 brief
el(planation of the nature of each debt claimed and the amount being claimed,
Evidence to support the decedent's or the estate's liaLility for the debts being claimed should be attached to this return
A family el(~mption may be claimed by a spouse of a decedent who died domiciled in Pennsylvania. If there is no spouse,
or if the spouse has forfeited his/'her rights, then any child of the decedent who is a member of the same household can claim
the eyeo11ption. In the event there is no such spouse or child, the exemption can be cloimed by a parent or parents who ore
members of the same household os the decedent.
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INFORMATION
PLAeE FOR FILING - The relurn is to be filed in duplicate with the Register of Wills of the county wherein the decedent
resided.
TIME FOR FILING - The return is duc nine months after the decedent's death, unless on extension for filing has been applied
tor and granted by the Secretory of Revenue within the nineamonth period.
FAILURE TO FILE RETURN _ Section 791 of the 1961 Statute provides that" " ,any person who willfully foils to file 0
return or other report required of him sholl be personally liable. . .to 0 penalty of 25~o of the tax ultimately found to be
due or Sl,OOO whichever is the less to be recovered by the Department of Revenue os debts of like amount ore recoverable
by law."
NOTE: Fees paid to an estate representative; namely, an executor or administrator, for 5ervices performed in ad-
ministering an estate is reportable for Pennsylvania Income Tax purposes. This taxable income item shoud be reported on
form PA.40-lndividuallncame Tax Return.
INFORMATION
To insure proper credit to your C1CCDunl, thu namo 01 tllo estate and filo number should be clearly print.
ed on tho check or monov ordor.
This assessment is made in accordanco with Suction 708 of Iho Inheritance and Estate Tax Act of
1961 (72 P.S. 9 2485.708).
To the extent that inheritance ta)', is paid within threo (31 months nfler tho dealh of the decedent, a
discount of five 15) percent is allowed (72 P.S. 9 2485.716).
lnheritanco Tax, other than tax on a future interest. is duo at the dall1 of tho decedent's death nod becomes
delinquent at the expiration of nino (9) months after the decedent's dcath (72 P.S. 9 2485.71'), Inheritance
TaK on a future interest is payable within three (3) months after the lransf~r takes effect in possession and
enjoyment and is delinquent thcreaftN (72 P.S. 9 2485.712). Calculate interest from the delinquent dale shown
on the face at this form to the date of actual payment using the following interest table:
--------------------- ---------- --- ------------- - - --- - --- -------- -- ---- -----
1 month .005 4 months .020 7 months .035 10 months .050
2 months .010 5 months .025 8 months .040 11 months .055
3 months .015 6 months .030 9 months .045 12 months .060
1 days .00017 11 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 16 days .00267 26 days .00437
7 days .00118 17 days .00284 27 days .00454
8 days .00135 18 days .00301 28 days .00471
9 days .00152 19 days .00318 29 day. .00488
10 days .00169 20 days .00335 30 days .00500
-- --------- ---------- -- - --- - - - -- - -- - - ---- -- - --- ---- - - - - ------- -- -----.
Any party in interest. including the CommC"nwealth and the personal re~resentative. not satisfied with
the assessment may object thereto within sixty (60) days after receipt of Ihis Notice as provided by Section
1001 of the Inheritance and Estate Tax Act of 1961172 P.S. S 2485.1001).
Make check or money order payable to:
"Register of Wills, Agent"
Mail to the address listed below: