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INSTRUCTIONS
ASSETS - Describa all Real Estata lacatad in Pannsylvania and hold salaly by do cadent or held jointly with another party
or parties as tenants in conmon or as joint tenants with right of survivorship. Include the decedent's percentage of ownership
and the estimated market value. List all tangible and intangible personal property owned individually by the decedent or
jointly with another party or parties as joint fenants 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. List any property transferred by tho decedent, within two yoars
of death for which he/she did not receive valuable and adequate consideration.
DEBTS & DEDUCTIONS - Unsatisliad liabilitias incurrad by tho decedent prior to his/har death ora deductibla against
his/her taxoble estote. In addition to debts incurred by the detedent, 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 to support tho dacadent's or tho Estate's liability far tho debts being claimed should be attached to this return.
A family axamptian of $2,000.00 may be c1aimad by u spouse of a decedent who diad damicilad in Pannsylvania. If thera
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 ovent, 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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INFORMA TION
PLACE FOR FILING - Tho raturn is to balilad in duplicate with the Register of Wills of the county wharain the dacedent
res; ded.
TIME FOR FILING - Tho raturn is duo nino months aftar tho decadant's death, unlass an extansian far filing has boon
applied for and granted by the Secretory of Revenue within the nineamonth period.
FAILURE TO FILE RETURN - Sactian 791 of tho 1961 Statuto pravidas that", . .any parson who willfully fails to Iile
a return or other report required of him shall be personally liable. . .to 0 penalty af 25% of the tax ultimately found
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 low."
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,
DATE OF DEATH
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COUNTY
Appraised Value of Estate:
Real Estate
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Personal Property
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Jointly Held PropertylTransfers
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Total Gross Estate
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Totsl Approved Deductions
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Clear Value of Estate
less: Approved Charitable Exemptions
Clear Value of Estate Subject to Tax
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Amount Taxable @ 6% Rate
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Amount Taxable @ '5% Rate
tax due
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TOTAL PENNSYLVANIA INHERITANCE:.I,\~P.\J~-l~ 17':,,,..t: ,;;;~/7J?(.t'-/
.. .. '* * .. * A five percent discount totaling $
will be granted if the Inheritance Tax is paid by
Less Credits;
DATE OF PAYMENT AMOUNT PAID DISCOUNT INTEREST TAX CREDIT
G + G $ = $
+ =
+ =
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Interest accrues at the rate of six {51 percent per annum
on the unpaid balance of Inheritance Tax from
to date of payment. Interest due if paid by is' /
BALANCE OF PENNSYLVANIA INHERITANCE TAX OUr! i ,)!.{f't.:..,(.,.t.:
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Assessed by: /
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