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Home My WebLink About01-29-09 (3)J 1505607120 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Po Box.2aosol INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 0 8 0 6 2 2 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 216 46 9161 05 13 2008 12 07 1916 Decedent's Last Name Suffix Decedent's First Name MI F~GTMAN ESTHER I (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW LXJ 1. Original Return ~ 1 2. Supplemental Return i~ -' 3. Remainder Return (date of death J prior to 12-13-82) ~ 4. Limited Estate qa. Future Interest Compromise L--~ (date of death after 12-12-82) L _J 5. Federal Estate Tax Retum Required I~ g Decedent Died Testate i'~ ~ Decedent Maintained a Living Trust (Attach Copy of Will) L_.: (Attach Copy of Trust) O 8. Total("l~~umber of Safe Deposit Boxes r ~ 9. Litigation Proceeds Received ~ j 10 betweeniz 3i si andtjdatae5~f deam ~_ j 11.EIect'On to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number MARIELLE F HAZEN 717 540 4332 Firm Name (If Applicable) HAZEN ELDER L A tiJ REGISTER OF WILLS USE ONLY first line of address C~ c ,., 2000 LINGLESTOWN RD. ~'~ U ~; _; ~~ ' Second line of address --- ' ~ rv SUITE 2 0 2 ~, , _, -~ ~'=' - .- _. DA7~,F~I~ED ?~ f.. - City or Post Office State ZIP Code -- ~ ' HARRISBURG PA 17110 -~~ `; ~.~ -=,i _. ;~ Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge. SIGNATURE OF PFRRr)N RFCOnn~e~oi a cno r.. ~.~1..,~r~ ~..., _ DATE Marielle F. Hazen _ , ~ A S 2000 Linglestown Road, Ste 202, Harrisburg, PA 17110 Side 1 1505607120 1505607120 27 Wetherburn Rd., Enola, PA 17025 SIGN U OF PREPA THE THAN REPRESENTATIVE REV-1500 EX Page 3 File Number 21-08-0622 Decedent's Complete Address: Esther I. Fogtman STREET ADDRESS 27 Wetherburn Rd. ~ cITY Enola STATE ;ZIP -_ 1 PA 17025 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 7,123.45 2. Credits/Payments ----------- - A. Spousal Poverty Credit B. Prior Payments 6,500.00 C. Discount 342.11 _ _- - --_ 3. Interest/Penalty if applicable Total Credits (A + g + C) (2) 6, 842.1 1 p. Interest E. Penalty Total InteresUPenalty (D + E) (3) 4. ine 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2 Line 20 to request arefund -- -- --- --- 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 281.34 ----- - A. nter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 2 $ ~ . 3 4 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.............................. ~ C b. retain the right to designate who shall use the property transferred or its income :.................................... r j a c. retain a reversionary interest; or ............................................................................................................... .. '~ I x d. receive the promise for life of either payments, benefits or care? ............................... ~ ~' ............................ I -~ , xJ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without J receiving adequate consideration? ....................................................................................................................... ~ x 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... ', ~ ` x' _, 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiarydesignation? ...................................................................................................................... i_J X IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. _... For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)j. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)j. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. J REV-1500 EX oecedenYs Name: EStllel' I. Fogtman RECAPITULATION 1 . Real Estate (Schedule A) ....................................................................................... ... 1. 2. Stocks and Bonds (Schedule B) ............................................................................ ... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)....... ... 3. 4. Mortgages & Notes Receivable (Schedule D) ....................................................... ... 4. 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .............. .. 5. -, ointly Owned Property (Schedule F) L~ Separate Billing Requested ........... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ........... .. 7. 8. Total Gross Assets (total Lines 1-7) ..................................................................... .. g. 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. .. 10. 11. Total Deductions (total Lines 9 & 10) .................................................................... .. 11. 12• Net Value of Estate (Line 8 minus Line 11) ........................................................... .. 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................................................ . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ............................................... .. 14. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .00 0 0 0 15. 16. Amount of Line 14 taxable at lineal rate X .045 1 5 8 2 9 8 9 8 16. 17. Amount of Line 14 taxable at sibling rate X .12 0 0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 18. 19. Tax Due .................................................................................................................... . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 1505607220 Decedent's Social Security Number 216 46 9161 180,094.57 468,25 9,222.21 189, 785. 03 28, 574. 44 911. 61 29, 486, 05 160, 298. 98 2, 000. 00 158, 298. 98 0,00 7,123.45 0.00 0.00 7,123,45 Side 2 1505607220 1505607220 Rev-1503 EX+ (6.98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS t,lAlE OF Fogtman, Esther I. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM CUSIP NUMBER NUMBER DESCRIPTION 1 792 shares of Exxon Mobile -stock Accrued dividend on Item 1 through date of death 2 600 shares of Lockheed Martin -stock Accrued dividend on Item 2 through date of death 3 281 shares of M8tT Bank Corp. -stock Accrued dividend on Item 3 through date of death 4 500 shares of Wachovia Corp. -stock 5 275 shares of Xerox Corp. -stock Accrued dividend on Item 5 through date of death FILE NUMBER 21-08-0622 UNIT VALUE VALUE AT DATE OF DEATH 89.24 70,678.08 277.20 107.95 64,770.00 252.00 92.4 25,964.40 196.70 27.98 13,990.00 14.38 3,954.50 11.69 TOTAL (Also enter on Line 2, Recapitulation) I 180 094 57 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Fogtman, Esther I. 21-08-0622 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schetlule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 AARP -refund of health insurance premium 168.25 2 US Treasury -stimulus rebate 300.00 TOTAL (Also enter on Line 5, Recapitulation) I 468.25 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1b09 EX+ (6-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Fogtman, Esther I. 21-08-0622 If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Patricia E. Fogtman B. C. 27 Wetherburn Rd. Daughter Enola, PA 17025 JOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET o /o OF DECD'S INTEREST DAVALOUE OF TH DECEDENT'S INTEREST 1 A 11/18/2000 PSECU Certificate of Deposit #50 10,103.20 50.000% 5,051.60 2 A 11/18/2000 PSECU Certificate of Deposit #51 5,051.59 50.000% 2,525.80 3 A 11/18/2000 PSECU Checking Account S04 597.00 50 000% 298 50 . . 4 A 11/18/2000 PSECU Money Market Account S07 2,681.38 50.000% 1,340.69 5 A 11/18/2000 PSECU Savings Account S01 11.24 50.000% 5.62 TOTAL (Also enter on Line 6, Recapitulation) I 9,222.21 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98) REV-1151 EX+t1y_99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Fogtman, Esther I. 21-08-0622 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION NUMBER AMOUNT A. FUNERAL EXPENSES: See continuation schedule(s) attached B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Patricia E. Fogtman Social Security Number(s) / EIN Number of Personal Representative(s): Street Address 27 Wetherburn Rd. city Enola state PA Z;p 17025 Year(s) Commission paid 2009 2. Attorney's Fees Hazen Elder Law 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Patricia Fogtman Street Address 27 Wetherburn Rd. City Enola State PA Zip 17025 Relationship of Claimant to Decedent daughter 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs See continuation schedule(s) attached 7,259.71 8,388.00 8,800.00 3,500.00 322.00 304.73 TOTAL (Also enter on line 9, Recapitulation) ~ 28,574.44 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Fogtman, Esther I. 21-08-0622 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Cumberland Monuments -Headstone 125.00 2 Oscar's Restaurant -funeral luncheon 170.71 3 Scarpelli Funeral Home 6,964.00 H-A Subtotal 7,259.71 Other Administrative Costs 4 Cumberland Law Journal -estate legal advertisement 75.00 5 Hazen Elder Law -Disbursements 9.19 6 Register of Wills -Filing fee for PA Inheritance Tax and Inventory 30.00 7 The Sentinel -estate legal advertisement 190.54 H-B~ Subtotal 304.73 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev1512 EXt (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Fogtman, Esther I. 21-08-0622 Include unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Griswold Caregivers -medical expense 794.25 2 Phillips Lifeline -medical expense 117.36 TOTAL (Also enter on Line 10, Recapitulation) I 911.61 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) REV•1513 EX+ (9-0O) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF Fogtman, Esther I. NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116(a)(1.2)] 1 Beverly D. Fogtman 11738 Melrose Ave. Greencastle, PA 17225 2 Patricia E. Fogtman 27 Wetherburn Rd. Enola, PA 17025 FILE NUMBER 21-08-0622 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE DECEDENT (Words) ($$$) Do Not List Trustee(s) Daughter-in-Law fifty percent of residuary estate Daughter fifty percent of residuary estate Total I Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet III NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 Centre Street United Methodist Church 2,000.00 _ TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 2,000 00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES FILE N0. 21 DEPT. 280601 AND HARRISBURG, PA 17128-8601 TAXPAYER RESPONSE ACN 08124318 REV-1543 EX11FP(09-00) DATE 06-04-2008 TYPE OF ACCOUNT EST. OF ESTHER I FOGTMAN ^ SAVINGS S.S. N0. 216-46-9161 ^ CHECKING DATE OF DEATH 05-13-2008 ^ TRUST COUNTY CUMBERLAND a CERTIF. REMIT PAYMENT AND FORMS T0: ** PATRICIA FOGTMAN REGISTER OF WILLS 27 WETHERBURN RD CUMBERLAND CO COURT HOUSE ENOLA PA 17025 CARLISLE, PA 17013 PSECU has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this forn and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. questions may be answered by calling C717) 787-8327. COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0216469161-C50 Date 02-1 2-2008 To insure proper credit to your account, two Established (2) copies of this notice must accompany your Account Balance 7, 103 .20 payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". Percent Taxable X 100 .00 Amount Subject to Tax 7, 103 .20 NOTE: If tax paynents are made within three C3) months of the decedent's date of death, Tax Rate X .045 you may deduct a 5Y. discount of the tax due. Potential Tax DUe 319 .64 Any inheritance tax due will becowe delinquent nine (9) months after the date of death. PART TAXPAYER RESPONSE A. ^ The above information and tax due is correct. 1. You may choose to remit payment to the Resister of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or you nay check box "A" and return this notice to the Register of ONE Wills and an official assessment will be issued by the PA Department of Revenue. BLOCK ~ g, The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return ONLY ~ to be filed by the decedent's representative. C. ^ The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ^ and/or PART ^ below. PART You indicate a different tax rate, please state your shi t d d ...... ~~•~ ~ ~-•• ..... ...... ~• 9~ ::,,~•~• ~ ::::~ ~~•~~~-•~~_~'~~~ €~~ °~ ~ :. ;;€~: € : € ~i~€~€ 2 o e c a e • ..............^.., ......; . . ;_ : .,aa ::::..:_ .. 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'ii:1:•1~v2 i ~i::itiliilTe:~~~ a ' i " i ' TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS ;rise:riSi~i:i:iS:i:i;iS:iS:Eti: :::: :: :::::.:~::::::::::: ....SAD:~~='~'~''~'; S;;~ ~ ;; ;; ;;Eiasi e: :;:iFiie:;ai r'Ec:iiiF:Eiii:::::::n'c:::=-i:~ ir:i:g'::i:iir. -i:r;'iyeee ? r ;e :::::~::~::~::::::;~::;~:;~:;:,,::::e~'::;::'•,;,:-::;:;:~:~:,:::,:::::::::::~':~::~::~::: ;,,,,,,,,,,,,,,,,,,;,,,,,,,,;,,,,,,,,,,,,,,,,,,,~~:,~,.,.,.:~:,:,:,~::,:,:.:,:~:::::~::::::::::::::::::::::~:::; ata E s t a b 13 s h e d 1 :::::av:;•~ ........-. r.cc:::::: .............zs:y,?; i ~c',S:;:i:; . ...:........ :::::.ra:c::;...• 4 :ax ,:ate ::_::c:::.:ef:,c :: ::::::::::.. . ...a''': '3zvi3'SS :;'??r;i^~ i:_^,.,ki4'cii i:i:~:::i4~i:~r,:ii!E:i:i!' -.•.... :_.,:~ .::::::.::............._:1;;;<<€;i=` ~E€~€€~€'sii:::~ ::::~ ;:,_.__..... 2. Account 3. Pe r c e n T a x a b l e X :::a::::::;:;c::.•.•::::::.a:,::::::::c:::: ::ri'7a:r.,p:z:,:,czi?,~, rei;:ii~'2FS~ i;egeen;:::;F;aei:;:::s: ~,;:p ~z:.:a:.,,,y_,:.. . _ ............. • ..... ~;,;:::::;,,.,~ ,,;: 4 . Am ount Subject to Tax 4 ::~::;:~::::::: ~ ::::::::::::::: ~ ~ ... . ................................. ~-•=~-~°--°- ::::::::::::::::::,;:;,::.::::::::,.,;,:::;:::,,:,:,,:...,..,...:,., ......................:.........:. . ................ ....... .::s:;;~::s; ::~::::::::::::,;::::::~ ~::::. ,:;: 5. Debts and Deductions - 5 s ~ €~ :: €€ p:'~: i ~";:~;€€~ iii ~I~ €~ €~ € ~ ;;;~ € Amount Taxable 6 :::::, - :;°e':'`sr:'2 - Tax Rate 7 X ':;_;~';:;;,~{';'v~;~':~:;:.;:::;:,~::;:;,;,•:::::::.•: ,,.. a... ,.;,..a.. ................... . .. :rrr: :r^rre: 8. _ Tax Due €~€~1 ~iii€E~;:::::€i€i~€°•.;,;~i~€;~;:;;::;:::a;:::z::::~:;:i::s::::t:=_ ~:~v:re<is:;'a;:v~::•r;';::::';';s a;:;:,:;:::~ ::::::::::::: :::: ...a.2dva:i. :=. ......... z r:...... PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIPTION eMniiNT porn Under penalties of perjury, I declare that the facts I have reported above are true, correct and c late to thebb~est of my knowledge and belief. HOME C ) K. WORK C ) r-n~ 7" o I TAXPAYER SIGNATUR TELEPHONE NUMBER DATE :uiw~ ~tn[er on Line 5 of Tax Computation) 8 GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance tax becomes delinquent nine months after the decedent's date of death. 3. A Joint account is taxable even though the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) which the decedent put in joint names within one year prior to death are fully taxable as transfers. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with your check for the amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept 280601, Harrisburg, PA 17128-0601 in the envelope provided. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent dying after 12/12/82: Accounts which the decedent put in joint names within one (1) year of death are taxable fully as transfers. However, there is an exclusion not to exceed 53,000 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk (~*) appears before your first name in the address portion of this notice, the 53,000 exclusion already has been deducted fron the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for joint assets established more than one Year Prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons. 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7Y. (TAXABLE FOR EACH SURVIVOR) B. The percent taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT X 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other Persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50% (TAXABLE FOR EACH SURVIVOR) 4. 5. 6. 7. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3% 6% 15% 15% 01/01/95 to 06/30/00 0% 6% 15% 15% 07/01/00 to present 0% 4.5%* .... ~ donna< 12% ad child tw enty-on 15% e Years of age or y ounger at xin@ Lax rate a~y„av~ w death to or for the use of a natural parent, an adoptive parent, or a stepparent of the chi is .. The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in cowmon with the decedent, whether by blood ar adoption. The "Collateral" class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: The amount subject to tax (line 4) is determined by multiplying the account balance (line 2) by the percent taxable (line 3). Enter the total of the debts and deductions listed in Part 3. The amount taxable Cline 6) is determined by subtracting the debts and deductions (line 5) from the amount subject to tax (line 4). Enter the appropriate tax rate (line 7) as determined below. A. You legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paver 8 1/2" x 11". Proof of ..~..~e..• .,~., tie raaua<ted by the PA Department of Revenue. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES FILE N0. 21 DEPT. 28D601 AND ACN 08124319 HARRISBURG, PA 171za-ocol TAXPAYER RESPONSE REY-1543 E:C AFP (09-00) DATE 06-04-2008 TYPE OF ACCOUNT EST. OF ESTHER I FOGTMAN ^ SAVINGS S.S. N0. 216-46-9161 ^ CHECKING DATE OF DEATH 05-13-2008 ^ TRUSr COUNTY CUMBERLAND 0 CERTIF. REMIT PAYMENT AND FORMS T0: PATRICIA FOGTMAN REGISTER OF WILLS 27 WETHERBURN RD CUMBERLAND CO COURT HOUSE ENOLA PA 17025 CARLISLE, PA 17013 PSECU has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this fora and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. puestions may be answered by calling (717) 787-8327. COMPLETE PART 1 BELOW * ~ * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0216469161-C51 Date 02-12-2008 7o insure proper credit to your account, two Established (2) copies of this notice must accompany your Account Balance 5, 051.59 payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". Percent Taxable X 100.00 Amount Subject t0 Tax 5, 051.59 NOTE: If tax payments are made within three (3) months of the decedent's date of death, Tax Rate X .045 you nay deduct a 5Y. discount of the tax due. Potential Tax Due 227.32 Any inheritance tax due will become delinquent nine (9) months after the date of death. PART TAXPAYER RESPONSE 1 .:.::::::::::.:::::r,:r:::::::::::::~:....:.:.:_.,.,.,.,.............._......................._......_............ ..... :':5: :: ;; -.: "e_4rf...... .;~ ..............:...:::::....~ .....,._..::re....,;v.;.:.,.:.:. :., re.i ~a:•.:•yv;5::::::::e:;r:.:::a::::::::::a:::: wm,,'~++~~;; ~~ff ~~ww ??:~n;::ee~~ ,. a.. e. -: .: .. ,.. . a::a::.:ae=: fq:::::;e:;e:::3:.:;:::.c:::::: ~:::::::::a::::~ ~:a::::na:::::::::::c::::::::::r•~:r.._~ :::::::::::::::::..::.a.,.;...,.,.,.,.:.,.,.,..... -~"'71ii;~llii,:iii:;i[;iRi'i: ,gym :~. :. .Er..: ::.`:' }E~ ~iE~ ..................................,_.,.:_.__.. ,..:::.:.,.::,,._. ..... ~~~~fi:: i.. :.... ~i~+~; ',~,,`, ~f2~,,_• .................................._..........a.....,a.o 4:e',,.. ..e ...._v, .u... ... _.~,e4._. .....a,.:n:::::::r..............._..........................E,.,......._................ ~~ ~T:iiEii3liea:F:,[ieii~ei^:e .,., .. ^:errv~,.,e~~+,~~e. ~i .. _.... - _...._ ......................................_._..,.__..e...._........_.....,u v.:.:.:.:.:.:.:.:.:e!rn:P r-area§aa-::::: A. ^ The above information and tax due is correct. 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or you may check box •'A" and return this notice to the Register of ONE Wills and an official assessment will be issued by the PA Department of Revenue. BLOCK ~ B. The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return ONLY ~to be filed by the decedent's representative. C. ^ The above information is incorrect and/or debts and deductions were paid by you. You oust complete PART 2^ and/or PART 3^ below. PART you indicate a different tax rate, please state your ~i r e l a t i o n s h i t o - _-€*~~~~'_ lrs'ieE;Q~i~ee ~_; • ee~~' p decedent: •--~- ~ ~ _~, ...a ....................................-. ....-..... ..., ,,L4 r4,;d,5'e:;E e:&S:EEE«:~ ;E;E?;!:::.........4$SiP~~ :c'j:,: ......_...._ ..................y ........... ~:::::::::oF~r. ;:a::aa:::: ... ....,... ::e:§e,e:::eS4a .............. C 0 MP U TAT .:....:..::::::::::::::::~::aa:::::~:::::: ~::::::::,a:. -!,,5.:.:.::2:S:eee e4~'~':'e'iia'i5=7e'I=E4E're5 444: ~,• TAX RETURN €;~.,.........__...,., .,.x~,,,.,.. ION OF TAX ON JOINT/T :::~ ........................................_._....,._..._. .. t4:::::::r:::::a=,~,:~'e:ei;E~::r:::E,',4:~,:,~,,-. RUST ACCOUNTS :::: a... ....,..,~,.,...., ., . 4,a~'.ee.'~e;Pe[e~€~€€€€ NE 1. Date Established 1 ........`"''-''_._.._........~......, - 4eise:si=pe,e=„'4,e=°=E4'=e;~Eei€~Elie ..a ..... . . :. :::: ...... ........e.,,,.:.::E. ............................ .......... ....,:ree44 a f::r ;:aic:E;:;,;c;;S E;E;i; 2. _ c c o u n t Balance 2 ..........::::::::r =:::a::,::,:::::-a::aa::::_:::~ :;:::e;ai,.=.:::::ai: i~:a:,- ~ ~:::::::: ~•a ~ eE, r, , ,......, ., ,~:::-::.: ,.;_.,.,~ ::::::::aa,_ ............. :............:...... .... ...... ....... i:,,:: ~,Ei ::.:..::.:.:.r............. nt Taxable _._.• ...... .,..._....... ,4 .,~~:::, ...__... ......:~~.:~:.. ,::~:~:~.:.:,:..,:~ :~:~:~ : P, _ ._-.....:r :r:. .:::. r;~.,,,.r: rrr: ....rrr-:e::::r.:::::::~::~ ................rvr,:zee:3:r:iSSi;Si;Sq;p::.:.~:;:.:.4:~:c:::~:.:: r:a.,:,,,a,r.:;44'E9.z:::ar.::::::::::::::: t o .................. .......... . 4. Amoun - - - t Sub ec = ,::~: Ec . ...:...........r.,.. .;,:,;:::eE~ e; er::;:;.;~ eq.^~e' e:;i:2i::.::::::._::'~ is ................: ,'":?~,a4:,~,a::y -,,,•.E;Steies=::~ ?__;~ E E~ t;t;~ :~aEt:E~ tsE:'; E:a~ E;Eis':~ ~Et :,,- .:.:::::::::::.: ......_........ 4 R: .....,r•, ,,E,:::- :~::45`:i:P, eyc;;';e;e;?:EE ~ F3EE~ E;!;S~:cF~ ei:::Fz°=EEF~!i:i4E; e s and Deductions 5 - .............:.... ~~a4t:;:;eiE:::4e=.,:~eiEi:~ :.::r-:::...:~:~:~::.,.,.,.,,_.,,:r,,.,,,,,.,.,.;.,... ..,..,_._..... r: .......................,....,,,::::::::::;:::...,pi~::;€€'`.ii.?eea':;4e,=.isi~a€`ege=€E€eE€~s e¢es:eee~€€€e-':ie~.`=.€€€?<'s~ieiie? 6 . Amount Taxable 6 :::::::: ~a:;:::::r ., ::..................... r 4:,...,4.,,,,.,,,.,, :-::;:::,;. :............... ................... :: a......, ..,, •,:,:;.,:..,.,.,.,.,.,...,.;.,.,.,r .................. ..._.:.rvrr...4::a , r .: r, : , ...................aax::r.; :r ,.:.::~ 4... 4, ,a.r:a. ;5 „'4='; ~955!;era::::::::::.::,., Tax Rate X ~!~E ,=,4=„ ,rr: ti~~!lE~ ie~ ::.:.: iie~e=i ,,:4" „4iyie :::::.:::::ice. .. ............................................r . r...... ..............__........................,., .......,4^: eee ii e e ise:e~u4,y'e,~txie~,,.,v.,...........e _ _ 'i:;'2?.isiSsE;E;=;::Ei:ii;S:i:;?;:,:i'.,:i'::i^~S:'i+ 8 . Tax Due g _ ,.,,,4r,,4:: r:.::,:::-:;::,e:,;:i:; PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION aMniiNT porn ~v~,tL ienier on L1ne 5 of Tax Computation) @ Under penalties of perjury, I declare that the facts I have reported above are true, correct and com ete to the best o/~f my knowledge and belief. HOME C ) ~CJ~ I WORK C ) ~ a~ Q~ TAXPAYER SIGNATURE TELEPHONE NUMBER DA7•E GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance tax becomes delinquent nine months after the decedent's date of death. 3. A ioint account is taxable even though the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) which the decedent put in joint names within one year prior to death are fully taxable as transfers. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with your check far the amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REY-1548 EX) upon receipt of the return from the Register of Wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept 280601, Harrisburg, PA 17128-0601 in the envelope provided. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the nanner existing at date of death. NOTE: For a decedent dying after 12/12/82: Accounts which the decedent put in ioint names within one C1) year of death are taxable fully as transfers. However, there is an exclusion not to exceed 83,000 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk (~~) appears before your first name in the address portion of this notice, the 53,000 exclusion already has been deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons. 1 DIVIDED BV 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7Y. (TAXABLE FOR EACH SURVIVOR) B. The percent taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT X 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50Y. (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax Cline 4) is determined by multiplying the account balance Cline 2) by the percent taxable Cline 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (line 6) is determined by subtracting the debts and deductions (line 5) from the amount subiect to tax (line 4). 7. Enter the appropriate tax rate (line 7) as determined below. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3% 6% 15% 15% 01/01/95 to 06/30/00 0% 6% 15% 15% 07/01/00 to present 0% 4.5%~ ~___ ., a.,..a~~ 12% e.: ~ti;in twenty-on 15% e years of age or y ounger at +ine aas ra a i,xv.,~=~ death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is Y.. The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The "Collateral" class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You legally are responsible for payment, or the estate sub]ect to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paper 8 1/2" x 11". Proof of navment may be requested by the PA Department of Revenue. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES FILE N0. 21 DEPT. 280601 AND ACN 08124084 HARRISBURG, PA 17128-0601 TAXPAYER RESPONSE DATE 05-27-2008 REV-1543 EX I4FP (09-001 TYPE OF ACCOUNT EST. OF ESTHER I FOGTMAN ®SAVINGS S.S. N0. 216-46-9161 ~ CHECKING DATE OF DEATH 05-13-2008 ~ TRUST COUNTY CUMBERLAND ~ CERTIF. REMIT PAYMENT AND FORMS T0: PATRICIA FOGTMAN REGISTER OF WILLS 27 WETHERBURN RD CUMBERLAND CO COURT HOUSE ENOLA PA 17025 CARLISLE, PA 17013 PSECU has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a point owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questions may be answered by calling (717) 787-8327. COMPLETE PART 1 BELOW * * * SEE REY`ERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0216469161-$7 Date 07-16-2001 To insure proper credit to your account, two Established C2) copies of this notice must accompany your Account Balance 2, 681.37 payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax 1 , 340.69 (3) months of the decedent's date of death, Tax Rate X .045 you may deduct a 5Y. discount of the tax due. 60.33 Any inheritance tax due will become delinquent Potential Tax Due nine (9) months after the date of death. PART TAXPAYER RESPONSE 1 :~:::::::::~,::,:,~ ::.::::::::::.:~,:,.,.:.,.,.:.,.,.,.,.,.,.,...................................................................................... _.............................. . ;:;.:CAI'. 1i:~~:T €:~: ... :::::~:;:~:: ~~~€ ~~ ~:: ~:: ~~::::::.:::~::.. ::::::::. ~:;:; ::~ :::: :: :: ::: :: ... ~.: ; _:: :.:.:.....:...:....................._.:.:.~.€.~~.. ~:?!~.1'~:.1.'.`~:~k._1.i€°€~C°~~'°~. ~1~.'t`:~:=:~~...~A~,....~~:I.~'~:I .,,:fi~:~::A~*~~~N:E~1.:.:.:.,. ..... ._._.. ...:. ... ,:.: ,::: .......,a ...... a...._. _..,5 .......:.:.........................._...,....._..........................:.:::::: A. ~ The above information and tax due is correct. 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or you ^ay check box "A" and return this notice to the Register of ONE Wills and an official assessment will be issued by the PA Department of Revenue. BLOCK ~ B. ~~J~/ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return ONLY Tto be filed by the decedent's representative. C. ~ The above information is incorrect and/or debts and deductions were paid by you. You must comvlete PART ~ and/or PART ~ below. PART y dicate a different tax rate, please state your ~!{ ::::::::::::::::::::::i,i:iiilaiEiiE v :::::::::::::::cc:., ............ ~ ~ ~ ~~io,' .'-.°~ '1Giii `=A~iiiie7i[+,7F ~'i?- ' i?~~:e:~ti'i? iiiii:e ES :: 2 r e l a t i o n s h i p t o decedent : .........:.....................::::,'y:_,,; ::~ ::e:,:::::,;,~,,.~ :::.::::~:::::~ ::::::::::::::,;,:,.:;;;;::::::~:~.: ~'u'i':~ €:; 4tv:~€'sis ....................................... e.....::...,._ := i3e'ivv,:a,:E:::::rc::c:::::::::~' ~Sd:i§~:asr:a-:,:c: h4k°:~ i:Eirr.,= 46:' TAX RET - €€~:_:.~::~:~;~~;;:;;€€~€€~s::;.._ ...................................:.4,:::~::::~~~,:,,- - U RN COMPUTATION O F TAX ON JOINT/TRUST ACCOUNTS ~::~?A~:~::::..::, :::~:::::,:,, ,4= :::::::::::::::::::::::::: :: .:::~ ~:~;:;:;:;:;:;,::;,,,;,_ ~,::,;:;:::;:;::,,~~,::::: ..... LINE 1 . Date E s t a b 11 s h e d 1 :::::::::~ ~ ::..: : :::::::::::::::: ~:::_;~.~:~:_:.::,.,.,,,,,.,,.,,..,.,.,.,.,......:~ ::~::::::::-:::::v::- r-, ~._ . , .,,,......,,..,....:.. ,., .. .................... :................... _ :.... 2. Acco ..................:..~::::::::::~~:::::::-:::.::-. unt Balance 2 ....................:_...... ....~.. ...................:...::~:~ ::~ ~ ;:s:: ~::::tPP - ~irk;f~lE;I's~~~~~?.=':€~i~€=€€~si~s'°:ii~ ~f==i'i~i~itii~~ii€~ <€ii~i ........ : r ..:...:............. .................: 3. Percent Taxable ....._ ............ .........__...............~.:,,:::,,,, ~,:.x. ~•:....... .._a_ ...... :: 3 X ......._.......... . .......... .. ...., ...........,,:......._. t Subject to Tax 4 _ ~i€€ 5. Debts - and Deduc i t ons 5 - ~i'li _ Ely;; _ 6. Amoun t Tax =is: able 6 ::a ::::::::::::::::::&pP:iS~ iii EE: ~ i::iiei:SEc:i .s.`~ , , . ..... , ............. ................... ...........................ee-,::cc:::diiieiiie is:::. •,=E'~:~:.`•.pieis'r'r'ii3ijijP°-ri:ii^i::g:i}ie:e_::::::::^:: 7 . Tax Rate 7 X ' ................. :::::::.::::::::::~ :::::,:, , ::::::.: .:::::::::::::.:...:°°'=ate'°=~,~::::::,~ :::::~::::::::,''=s~'-_;;::::t:t:~ ::~ ::~:,:,',','::v ,'r~:v[v: ~E=a€';~, ~ ; ~ a:=.~~:_ v:~ ,',a' ax Due ::: ~:::::::_:, . ,','~:~~::::;;°::•:•:•,.,.,.,._~;~ ::::::::.:.:.:_;::•:.. :.;,E,E,E,r ~~;:,. ;:;:E:PE,Er,E ................... :::. ........................................,..:::.::.......:.: ~.....:...:.:..:.:... ~::::::::::::::::::::.:.,s:,.._: ,: a::::.,:,!a:!,:,:::,...,.... PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and comp to the be s t of l~to my knowledge and belief. HOME C ) / ~ t ? / / ~~V 'TJ 1L(,A-(~: WORK C ) _ . (~ TAXPAYER SIGNATURE TELEPHONE NUMBER DATE EuEAL ctnter on Line 5 of Tax Computation) 6 GENERAL INFORMATION I. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even though the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) which the decedent put in Joint names within one year prior to death are fully taxable as transfers. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part 1 of the "T ax paver Response" section. Sign two copies and submit them with your check for the amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept 280601, Harrisburg, PA 17128-0601 in the envelope Provided. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent dying after 12/12/82: Accounts which the decedent out in ioint names within one (1) year of death are taxable fully as transfers. However, there is an exclusion not to exceed 53,000 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk C~^) appears before your first name in the address portion of this notice, the S3,OOD exclusion already has been deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for ioint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X lOD = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons. 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7Y. (TAXABLE FOR EACH SURVIVOR) The percent taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT X 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50Y. (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax Cline 4) is determined by multiplying the account balance Cline 2) by the percent taxable Cline 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable Cline 6) is determined by subtracting the debts and deductions Cline 5) from the amount subiect to tax (line 4). 7. Enter the appropriate tax rate Cline 7) as determined below. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3% 6% 15% 15% 01/01/95 to 06/30/00 0% 6% 15% 15% 07/01/00 to present 0% 4.5%* ~___.._ 12% _a ,.ti:i,: F...e..rv -nn 15% n voars of aae or v ounger at ~:ne cax ra ~e in~v~~o., death to or far the use of a natural parent, an adoptive parent, or a stepparent of the child is OY.. The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adapted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not then have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The "Collateral" class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can furnish proof of Dayment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paper B 1/2" x 11". Proof of oavment ^av be requested by the PA Department of Revenue. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES FILE N0. 21 DEPT. 280601 AND ACN 08124083 HARRISBURG, Pa 1712e-o6o1 TAXP AY E R R E S P O N S E REY-ISGi EX aFP (99-90) DATE 05-27-2008 TYPE OF ACCOUNT EST. OF ESTHER I FOGTMAN ^ SAVINGS S.S. N0. 216-46-9161 ® CHECKING DATE OF DEATH 05-13-2008 ^ rRUSr COUNTY CUMBERLAND ^ CERTIF. REMIT PAYMENT AND FORMS T0: PATRICIA FOGTMAN REGISTER OF WILLS 27 WETHERBURN RD CUMBERLAND CO COURT HOUSE ENOLA PA 17025 CARLISLE, PA 17013 PSECU has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a ioint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. puestions may be answered by calling C717) 787-8327. COMPLETE PART 1 BELOW * * ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0216469161-S4 Date 11-18-2000 To insure proper credit to your account, two Established (2) copies of this notice must accompany your Account Balance 592.00 payment to the Register of Wills. Make check " payable to: Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to Ta 00 NOTE: If tax payments are made within three x 296 . (3) months of the decedent's date of death, Tax Rate X .045 you may deduct a 5Y. discount of the tax due. Potential Tax Due 3 2 AnY inheritance tax due will become delinquent 1 3 . nine C9) months after the date of death. PART TAXPAYER RESPONSE ....... :~l~fi~ ~:IN::~; ........ :::: ..... ..................:......_.... . . . . . . : . . . . . . ..................... .... ............... ................:.~_..:.......:1~.._:____~...: _:~. A. ^ The above information and tax due is correct. 1. You may choose to resit payment to the Register of Wills with two copies of this notice to obtain CHECK 0 N E a discount or avoid interest, or you nay check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. [ B L 0 C K ~ g, The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y ~ to be filed by the decedent's representative. C. ^ The above information is incorrect and/or debts and deductions were paid by you. You must complete PART 2^ and/or PART ~ below. I f Yo v i n d i c a t e a d i f f e r e n t t a x rate , l e a s e s tat a ::-::~::::::,:::::~ :~~:...,,,...,.;..._ :.....:.:.:.......................:.......:........:::::: : ::::::~ ::::s~::::::~: ~.:.:.:: s: PART P Your s:j~:::~~€s:~~ =:~[€~;::... 0 ::::......:...:..:.._....,....,......:::........................_................._..........:_.~~~._ :+ relationship to decedent: "~'```'`'`~""""''~'~"""`' TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 X 4 5 6 7 X 8 ART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMf)I1NT PATT1 Under penalties of perjury, I declare that the facts I have reported above are true, correct and co lets to the best of my knowledge and belief. HOME C ) WORK C ) _ .v TAXPAYER SIGNATURE TELEPHONE NUMBER DATE (VIAL icncer on ~lne 5 or pax Computation) $ GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance tax becomes delinquent nine months after the decedent's date of death. 3. A ioint account is taxable even though the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) which the decedent put in point names within one year prior to death are fully taxable as transfers. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are taxable fully• REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with your check far the amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept 280601, Harrisburg, PA 17128-0601 in the envelope provided. 3. BLOCK C - If the notice information is incorrect and/or deductions are being clained, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the Wanner existing at date of death. NOTE: For a decedent dying after 12/12/82: Accounts which the decedent put in point names within one (1) year of death are taxable fully as transfers. However, there is an exclusion not to exceed 03,000 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk (*^) appears before your first name in the address portion of this notice, the 83,D00 exclusion already has been deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for ioint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A point asset registered in the name of the decedent and two other persons. 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7Y. (TAXABLE FOR EACH SURVIVOR) B. The percent taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT X 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50Y. (TAXABLE FOR EACH SURVIVOR) 4. The amount sub]ect to tax (line 4) is determined by multiplying the account balance Cline 2) by the percent taxable (line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. Tha amount taxable (line 6) is determined by subtracting the debts and deductions (line 5) from the amount subject to tax Cline 4). 7. Enter the appropriate tax rate Cline 7) as determined below. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3% 6% 15% 15% 01/01/95 to 06/30/00 0% 6% 15% 15% 07/01/00 to present 0% 4.5%+ .. _. 12% -..w ,.ti;id t~o.,t.,-nn 15% o vaars of aoe or v ounger at ^ine cox race imyuaeu ..~, . e ..~. ...~ ~ _. _. _.._. _. - -- --- - -- death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is OY.. The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one varent in common with the decedent, whether by blood or adoption. The "Collateral" class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. 8. You actually paid the debts after death of the decedent and can furnish proof of payment. C. Debts being clained must be itemized fully in Part 3. If additional space is needed, use plain paper 8 1/2" x 11". Proof of „a.,ment nay he requested by the PA Department of Revenue. PSEC~ ,/ MARCI S. MILLER C/O HAZEN ELDER LAW 20000 LINGLESTOWN RD STE 202 HARRISBURG, PA 17110 Dear MS. MILLER: June 26, 2008 Account # 0216XXXXXX The following is the status of ESTHER I. FOGTMAN's account with PSECU as of the date of death. Joint Owner's Name PATRICIA FOGTMAN, JOINT TENANT W/ROS SINCE OPEN DATE OF 11.18.2000 Date of Death 05.13.2008 Date of Birth 12.07.1916 Share Description Open date Balance Accrued Dividend S O1 Regular Shares 11.18.2000 $ 11.24 $0.00 S 04 Checking 11.18.2000 596.89 0.11 S 07 Money Market 07.16.2001 2,678.90 2.48 C50 3 Month Certificate 02.12.2008 10,103.20 0.00 C50 3 Month Certificate 02.12.2008 5,051.59 0.00 The dividend earned from January 1, 2008 through the date of death was $387.12. The decedent had no loans with us. We do not have safe deposit boxes for our members. . If you have any questions, please call 234-8484 in Harrisburg or our toll-free number, (800) 237-7328. At the menu prompt, enter 6 and then extension 2227. Sincerely, r~ ,~ Meaci Fa' ax Member Service Representative Finance Support Unit ~~-----•..,...o....---~----.. Pennsylvania State Employees Credit Union Main Address: 1 Credit Union Place, Harrisburg, PA 171 10-2990 717.234.8484 800.237.7328 Mailing Address: PO. Box 67013, Harrisburg, PA 17106-7013 717.777.2100 (TDD) 800.472.1967 (TDD) ~~` _ _ _ _.. _n.. _.e _. _. -.. _ _ - This credit union is federally insured by the National Credit Union Administration. Equal Opportunity Lender www.pSeCU.tOnl