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HomeMy WebLinkAbout01-29-09BUREAU OF INDIVIDUAL TAXES PO BOX 280601 WIRRISBURG PA 17128-0601 REV-1541 IX AFP (OB-OB) ~'~'r~ ~~~~~. ~~ ~r°r I?~ 09 PENNSYLVANIA INHERITANCE T INFORMATION NOTICE AND TAXPAYER RESPONSE - .,r ~~I r ~1 ~ EDWARD M BURTSAVAGE 327 SOMERSET DR SHIREMANSTOWN PA 17011-6539 FILE N0. 2108- f a16 s ACN 08155449 DATE 11-24-2008 EST. OF HELEN M BURTSAVAGE SSN 168-18-3207 DATE OF DEATH 11-01-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST a CERTIF. PSECU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account. If you feel the 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. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0168183207-C51 Date 01-25-1999 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 39, 043.69 payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to Tax $ 19, 521 .85 NOTE:. If tax payments are made within three months of the decedent's data of death, Tax Rate ~( . 045 deduct a 5 percent discount on the tax due. Potential Tax Due $ 878.48 Any Inheritance Tax due will become delinquent nine months after the date of death. P~r TAXPAYER RESPONSE 1 A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of 0 N E Wills and an official assessment will be issued by the PA Department of Revenue. BLOCK ~ 8. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheri 0 N L Y ~-,/to be filed by the estate representative. tance Tax return C. ~~Q The above inforaa ion is incorrect and/or debts and deductions were paid. Complete PART ~2 a`d/~ PART 3~ below. ~+. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION OF TAX ON JOI^NT/TRUST ACCOUNTS LINE 1 . Date Established 1 d/ -oes - / 999 2. Account Balance 2 s 34, o~~, q 3. Percent Taxable 3 X SIB Ob 4. Amount Subject to Tax 4 $ ~ p',rpZ ~ s 8$ 5. Debts and Deductions 5 - p / / , O a 6. Amount Taxable 6 $ ~ /, 7 / O . 83 7. Tax Rate 7 X • O ~f.5 8. Tax Due S ~` ~ _~, ~ . 99 PART 0 DEBTS AND DE ~~ s ~ ` ~~ ~ ~ ~ CTIONS CLAIMED -~., _ 300.6 4 DATE PAID PAYEE DESCRIPTION AMOUNT PAID !!- ~- d g r c Barr e/ R¢sf v P ~gr, v os FuNef•a efres~ ~a.e~v s - 6 / L F / O.Oo . -! - ~8 oti- a.vera .t e d~ a . F N2i',¢ sere ce 3 .o !!-° ~ - 08 v e.~ a of [ 6~~ a o~ a e~ ee ter t v~ a ~C.v ch k e s- o ~ o 0 OTA L CEnt o o . coo er on Line 5 of Tax Computation) ~ 0 Under penalties of perjury, I declare that the facts I complete to the best of my knowledge and belief have reported above are true, e correct and . ~j HOME C /7 ) 76~- 8 Q "'~ _ ° ~ TAXPAYER SIGNATURE WORK ( ) l v~GYj TELEPHONE NIIMBFR neT 1111IIIIliNI~II o ao Cracker Barrel Store #550 Mechanicsburg; PA 726542 ROBIN ~ 1 T8L 343J1 6 O O 9 GST 10 NOVGS'G8 2:44PM ------ - - - - ---------------------- 1 ICED TEA UNS4VEET 1.89 1 FF RST BEEF 8.79 ].RASPBERRY TEA 1.99 1 FF RST 6EEF' 8.79 1 RASPBERRY TEA 1.99 1 FF CFC 8.99 1 RASPBERRY TEA 1.99 1 CHICKEN & RICE 7.99 1 COFFEE 1.59 1 CHICKEN & RICE 7.99 1 COFFEE 1.59 1 CHICKEN & RICE 7.99 1 RASPBERRY LEMON 1.99 ~ 1 COUNTRY CHEF SAL 7.99 ~ PEPPERCORN ~ . 1 RASPBERRY LEMON 1.99 1 FF RST BEEF $.79 1 RASPBERRY LEMON 1.99 1 FF RST BEEF 8:79 1 RASPBERRY LEMOk 1.99 1 FF COHAM 3 VEG = %9 Subtota i i us . ~tu Tip 20.39 Tax _;~`` 6.21 Total ; 7 30 .00 ,.~ ~ ~ ~$ MAN AUTH CHECK --1140463 CLOSED NOV05 ' 3 30PM-- 1f~~~°8 __, : Thank You Please Came Back Pos~ w~~~~~.Crac~erBarrel.com ~'~ eve ~fi i Ie~FIQ~Sf<~rN~~VT'S Office of Ga~rholic Ce~ineteries Diocese of Harrisburg PO Box 365'! Harrisburg, Pennsylvania X7'105 Phone (717) 657-4804 Invoice No. I-2-1416 / vu.~avo~c.^ Name EDWARD BURTSAVAGE JR Address 317 PINEWOOD DR City SHIREMANSTOW State PA ZIP 17011 ~Pliane Date 11 /20!2008 Order No. I-2-1416 Rep Gate of Heaven Terms 90 DAYS Date Description TOTAL 11/05/08 Interment for Helen M. Burtsavage $500.00 SubTotal $900.00 $0.00 T OTAL $900.'00 / ~ ~ 6 `~" 9.~ l ~f~Z`'~0 ~~~ Cy ~ Please return one copy of this invoice along with your paymenf. If not paid within 90 days from the date of this invoice, a finance charge of 6% will be added. PENNSYLVANIA INHERITANCE TAX a INFORMATION NOTICE ~ BUREAU OF It'7IVIDUAL TAXES AN D Po Box zso6 t TAXPAYER RESPONSE HARRISBURG 1 17128-0681 REV-1543 E% AFP (pp-pe) FILE N0. 21 ACN 08155450 DATE 11-24-2008 /~1r~ ~~~'<<. f ~ ~~~~ ~~' ~~T. OF HELEN M BURTSAVAGE SSN 168-18-3207 L~- - DATE OF DEATH 11-01-2008 f~f'`(~I~f .F`, )' `(~~ COUNTY CUMBERLAND v~J''b~. ~ ~ " ~ `~~/ REMIT PAYMENT AND FORMS T0: :'. 1., v ED4'ARD M BURTSAVAGE REGISTER OF WILLS 32;' SOMERSET DR CUMBERLAND CO COURT HOUSE SHIREMANSTOWN PA 17011-6539 CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. PSECU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate. that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel t~~e 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. Please call (717) 787-8327 with questions. COMPL'._TE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0168183207-C53 Date 04-25-1999 T Accoun` Balance Percen~ Taxable Established $ 42,483.91 X 50.000 o ensure proper credit to the account, two copies of this notice must accompany payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Amount Subject to Tax $ 21,241.96 NOTE: If tax payments are made within three months of the decedent's date of death, TeX Ra`e X .045 deduct a 5 percent discount on the tax due. Potential Tax DUe $ 955.89 Any. Inheritance Tax due will became delinquent nine aon'ths after the date of death. PART TAXPAYER RESPONSE 1 FAILURE TC} RESPO,~ND IL RESULT~IN AN.OF"fICI~ L~TI~C,~A55ESSMENT A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of 0 N E Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K ~ B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax retur n Y to bo filed by the estate representative. C. The above i e nforms ion is incorrect and/ debts and deductions were paid Complete PA RT '2 . and/ PART 3~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETU:2N - COMPUTATION OF TAX ON JOIN T/TRUST ACCOUNTS LINE 1. Da `.e Established 1 tr «~ O~ 'o7 S"' /999 2. Account Balance 2 $ I/'vl. ~8 30 9/ 3. Percent Taxable 3 X Jre a OQA 4. Amount Subject to Tax 4 $ 3 ~ ~ , c~ T~• ~ ~ ,, 5. De,ts and Deductions 5_ - ~, O 6 6 • / O 6. Amount Taxable 6_ $ o'~O , j 7 Ss 8 6 7. Tax Rate 7 X • ~ Ll. S" 8. Tar. Due a $ 9 Q '7 . g / C PART _..........~.. ._. n~ .DEBTS AND DED TIONS CLAIMED DATE PAI7 PAYEE DESCRIPTION eMnuur PATn .Z D / d3 O ~ W ~s 7' Lowell s ~ ~ ~M s R/f~'N TAP ~/-~-5 M! 6 •+/ c Aa+ by /A Hr -sir v 'c ~ s Irv op 65'02 ^ o 3, o mane ~ yr iaX l.O mpULaL10nT $ Q ~ / ~ Under renalties of perjury, I declare that the facts I have reported above are true, correct and comple~e =t'othe best of my knowledge and belief. HOME ( 7j~ ) ~6 "7~~~ ~-°_ -" ~ ~ WORK C ) / ~q O TAMPA V'- 7 cTrtie TIIRG TFI FPNf1NF NIIMRFR ATF DEBTS (Medical) Estate of Helen M. Burtsavage Debts (Medical) Date Paid payee 1 1/20/2009 West Shore EMS 2 12/23/2008 Lower Allen Township EMS File Number 2108-1265 Description Ambulance Services Ambulance Services Amt Paid $ 1,052.40 $ 13.70 $ 1,066.10 WEST SHORE EMS -ALS 205 GRANDVIEW AVE u_ SUITE 211 CAMP HILL, PA 17011 = Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ~~ 1'S Q~ r:~ICUCr~cv ntrvlcal sr.rz~ icE PATIENT NAME: HELEN BURTSAVAGE PATIENT NUMBER CALL NUMBER: DATE OF CALL: TIME OF CALL: CALLER: FROM: TO: 76805 3115810A 11 /01 /2008 REJ NONE INSURANCE: MEDICARE B 168183207A ADVANTRA CLAIMS DEPT 80168823001 PEBTF 168183207 3115810A HELEN BURTSAVAGE 317 PINEWOOD DR SHIREMANSTOWN, PA 17011 REASON(S) FOR TRANSPORT INVOICE 317 PINEWOOD DR HOLY SPIRIT HOSPITAL CARDIAC ARREST DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT PARAMEDIC INTERCEPT A0999 1 0 ATROPINE 1 MG A0394 . 1 0 837.76 837.76 COMBINATION DEFIB/PACER PADS A0392 . 5.39 5.39 DOPAMINE 400MG A0394 1.0 62 84 62.84 EKG ELECTRODES (4PK) A0396 1.0 33.96 33.96 EPI 1 MG 1:10000 PFS A0394 1.0 1 0 5.19 5.19 ET TUBE HOLDER A0422 . 1 0 7.06 7.06 ETC02 (ADULT) FILTERLINE SET A0422 . 1 0 8.66 8.66 GLUCOSE BLOOD A0394 . 1 0 25.80 25.80 PERIPHERAL IV A0394 . 1 0 7,Og 7.08 STATMASTER IV FLOW CONTROL A0394 . 1 0 38.59 38.59 STYLET A0422 . 1 0 13.47 13.47 . 6.60 6.60 Total Charges 1052.40 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT ~ ~ ,/zo~aq ~{~ ~S!/ Total Credits 0.00 PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -- RETURNED CHECK FEE - $31.00 $1052.40 DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT AMOUNT DUE 1052.40 'ATIENT NAME: BURTSAVAGE, HELEN CALL NUMBER 3115810A AMOUNT $ 'ATIENT NUMBER: 76805 01/08/2009 BILLING DATE: ENCLOSED w ..~_:.._ r__ ~._~_ ~.u..~~ w~ ~~~~~ ~~w~we arnouni was aenied by your insurance carrier. Balance is your responsibility -please remit. ~ VISA as _ AND MASTER CARD WEST SHORE EMS -ALS 205 GRANDVIEW AVE CAMP HILL, PA 17011 ED PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE N0. 21 PD Box zaocol ...TAXPAYER RESPONSE ACN 08155451 HARRISBURG PA 17128-0601 REV-1543 E% AFP (OB-OB) - DATE 11 - 24 - 2 0 0 8 r ~'? TYPE OF ACCOUNT .J~qF HELEN M BURTSAVAGE ~ SAVINGS ~,~ __ SSN 168-18-3207 ~ CHECKING OF;'F~-~ ~ ~ DATE OF DEATH 11-01-2008 ~ TRUST L'~w~~ ' ' (i-~OUNTY CUMBERLAND ~ CERTIF. ~ r~`~ l - ~, R,E~IT PAYMENT AND FORMS T0: EDWARD M BURTSAVAGE R'`En6ISTER OF WILLS 327 SOMERSET DR CUMBERLAND CO COURT HOUSE SHIREMANSTOWN PA 17011-6539 CARLISLE, PA 17013 PSECU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the 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. Please call (717) 787-8327 with questions. COMPLETE PART 1 BELOW ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0168183207-C54 Date 06-13-1998 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 36,841.06 payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to Tax $ 18,42U.53 NOTE: If tax payments are made within three months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Potential Tax Due $ $28.92 Any Inheritance Tax due will become delinquent nine months after the date of death. PART TAXPAYER RESPONSE - AILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT ~~,,/~~~~ ~,, ~~/ ~ 7e c~C..~_ A. 7~(~ Tha above information and tax due is correct. •~~l Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of C 0 N E ~ Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. ~ 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 estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3~ below. rnrti ~~ +nuicacing a airrerent tax rate, please state relationship t:o decedent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Established 1 2. Account Balance 2 $ 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 $ 5. Debts and Deductions 5 6. Amount Taxable 6 $ 7. Tax Rate 7 X 8. Tax Due g $ PAD OFFICIAL USE ONLY ~ AAF PA DEPARTMENT OF REVENUE I 2 3 4 5 6 7 8 TART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE nFSr_arprrnu ...,....._ ____ Under penalties of perjury, I declare that the facts I have reported a°b7ove are true, correct and complete to /the best Iof my~knowledge and belief. HOME C / ~7 ) O l'-" l ~O q - ~'G~WTt'4f ~~ ~~~' ~ WORK ( ) ~ oZ °7t7v/ TAXPAYER SIGNATURE TELEPHONE NUMBER AT 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 when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 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 fully taxable. 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 a 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 estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 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 REY-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 who died after l2/12/82, accounts the decedent put in joint names within one year of death are fully taxable. 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 was 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 percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one year prior to the decedent's death: 1 DIVIDED BV TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 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 = 16.7 percent (TAXABLE TO EACH SURVIVOR) B. The percentage 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 MULTIPLIED BY 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 near of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable (Line 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 subject to tax (Line 4). 7. Enter the appropriate tax rate (Line 7) as determined below. ^The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger t death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent. The lineal class of heirs includes grandparents, Parents, children and other 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 are legally 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 the 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 8 1/2" x 11" sheet of paper. Proof of oavment may be requested by the PA Department of Revenue. TAXPAYER ASSISTANCE IF YOU NEED FURTHER INFORMATION OR ASSISTANCE, CONTACT ANY REGISTER DF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE OR THE BUREAU DF INDIVIDUAL TAXES, AT 0717) 787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/DR SPEAKING NEEDS ONLY: 1-80~-447-3U2U. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent a PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE N0. 21 PO BOX 280601 HARRISBURG PA 17128-8601 TAXPAYER RESPONSE ACN 08155452 REV-1543 EX I1FR (OB-08) .. DATE 11 - 24 - 2 U 0 8 DaF L ~ :_ r~; ~~T ~A EDWARD M BURTSAVAGE 327 SOMERSET DR SHIREMANSTOWN PA 17011-6539 EST. OF HELEN M BURTSAVAGE SSN 168-18-3207 DATE OF DEATH 11-01-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. PSECU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the 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. Please call (717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0168183207 -C55 Date 07- 22 -1998 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 44 ,90 7 17 payment to the Register of Wills. Make check . payable to "Register of Wills A t" Percent Taxable , gen . X 5 0. 000 Amount Subject to Tax $ 22 ,45 3. 59 NOTE: If tax payments are made within three TaX Rat months of the decedent's date of death, e X . 045 deduct a 5 percent discount on the tax due. Potential Tax Due $ 1 01 0 41 Any Inheritance Tax due will become delinquent , . nine months after the date of death PAR1 CHECK ONE BLOCK ONLY TAXPAYER RESPONSE Q_ =AILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT /S ~ 8 p A. The above information and tax due is correct. ~~JJ~~ Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or 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. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3^ below. PART it 1nalcating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Established 1 2. Account Balance 2 $ 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 $ 5. Debts and Deductions 5 - 6. Amount Taxable 6 $ 7. Tax Rate 7 X 8. Tax Due B $ PART DATE PAID DEBTS AND DEDUCTIONS CL PAYEE OFFICIAL USE ONLY ~ AAF PA DEPARTMENT OF REVENUE PAD 1 2 3 4 5 6 7 8 AIMED DESCRiPTTnN - - - - - i as wmpuiaLlOnJ $ Under penalties of perjury, I declare that the facts I have reported alb-ovey are true, correct and complete t/o t1h'e,~ be/~st o~f¢my-.k~nowledge and belief. HOME C I~ / ) 7p ~ -" ~~Q ~~"c.G[ /''I fi~.u/i.~Ls-evv`4~, W O R K C ) ~ v~, c~ ~ TAXPAYER SIGNATURE TELEPHONE NUMBER qT 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 when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 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 fully taxable. 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 a 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 estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 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 who died after 12/12/82, accounts the decedent put in joint names within one year of death are fully taxable. 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 53,000 exclusion was 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 percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A ]oint 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 = 16.7 percent (TAXABLE TO EACH SURVIVOR) The percentage taxable for assets created within one near 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 MULTIPLIED BY 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 Dercent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable (Line 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 subject to tax (Line 4). 7. Enter the appropriate tax rate (Line 7) as determined below. ^The tax rate imposed on the net value of transfers from a deceased child 21 nears of age v 9 t death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent. The lineal class of heirs includes grandparents, parents, children and other lineal descendents. "Children" includes natural children whether or not then 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 are legally 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 the 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 8 1/2" x 11" sheet of paper. Proof of oavment may be requested by the PA Department of Revenue. TAXPAYER ASSISTANCE IF YOU NEED FURTHER INFORMATION OR ASSISTANCE, CONTACT ANY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE OR THE BUREAU DF INDIVIDUAL TAXES, AT C717~ 787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/DR SPEAKING NEEDS ONLY: I-8~0-447-302. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/45 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent or oun er a PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D Po Box zsocol TAXPAYER RESPONSE HARRISBURG PA 17128-0601 REV-1543 E% AFP (OB-OB) FILE N0. 21 ACN 08155453 DATE 11-24-2008 EST. OF HELEN M BURTSAVAGE ~~ .-, _ ~ - SSN 168-18-3207 ~~{ F~ ~ r~,n; ~ iT DATE OF DEATH 11 - O 1- 20 08 ~' ~.; vtJt~f I C~ 4~'! y t -~, ~A COUNTY CUMBERLAND EDWARD M BURTSAVAGE 327 SOMERSET DR SHIREMANSTOWN PA 17011-6539 REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. PSECU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the 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. Please call (717) 7B7-8327 with questions. COMPLETE PART 1 BELOW ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0168183207-C56 Date 07-22-1998 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 44,907.17 Payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to Tax $ 22, 453.59 NOTE: If tax payments are made within three months of the decedent's date of death, Tax Rate X . 045 deduct a 5 percent discount on the tax due. Potential Tax Due $ 1 , 010.41 Any Inheritance Tax due will become delinquent nine months after the date of death. PART TAXPAYER RESPONSE _ Q-~v, g~ FAILURE TD RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT A. M The above information and tax due is correct. ~`' S /.mil` Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of C 0 N E ~ Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return D N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART ~ and/or PART ~ below. PART If indicating a different tax rate, please state OFFICIAL U5E ONLY relationship to decedent: ~ AAF PA DEPARTMENT OF REVENUE TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Date Established 1 1 2. Account Balance 2 $ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 - 5 6. Amount Taxable 6 $ 6 7. Tax Rate 7 X 7 8. Tax Due g $ 8 PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRTPTrnN ,, ..r`~~.,r .,. .., -~- - - ~ ui i ax (,o mpULaLlOnJ $ Under penalties of perjury, I declare that the facts I have reported above are true, correct and compl~l~~e,~t~e~ t~o the best of my knowledge and belief. HOME (7!7 ) 7U~ _ 7/ ~~'j -~i~?""""''Zr ~ WORK C ) ~ ~. ~ o2Go TAXPAYER SIGNATURE TELEPHONE NUMBER ATE 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 when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 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 fully taxable. 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 a 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 estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 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 who died after l2/12/82, accounts the decedent put in joint names within one near of death are fully taxable. 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 was 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 percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 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 = 16.7 percent (TAXABLE TO EACH SURVIVOR) 4 5 6 7 ^The tax rate imposed on the net value of transfers from a deceased child 21 Years 9 t death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent. The lineal class of heirs includes grandparents, parents, children and other 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 are legally 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 the 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 B 1/2" x 11" sheet of paper. Proof of o.,+ m ~ he requested by the PA Department of Revenue. TAXPAYER ASSISTANCE IF YOU NEED FURTHER INFORMATION OR ASSISTANCE, CONTACT ANY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE OR THE BUREAU OF INDIVIDUAL TAXES, AT (717? 787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEFDS ONLY: 1-80-447-3~2~. B. The percentage 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 MULTIPLIED BY 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 percent (TAXABLE FOR EACH SURVIVOR) 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 (Line 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. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 of a e percent or younger a PENNSYLVANIA INHERITANCE INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D Po BDx zao6al HARRISBURG PA I n zs-o6ol TAXPAY E R R E S P O N S E REV-i5G3 EX IIFp. (09-OB7 FILE N0. 21 ACN 08155454 DATE 11-24-2008 1 , ~ ~~ 1~.~ ZU ~RPf .~~~~ ;;~i.1PtT EDWARD M BURTS'~AGE 327 SOMERSET DR SHIREMANSTOWN PA 17011-6539 TAXPAYER RESPONSE AILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX AS5E5SMENT EST. OF HELEN M BURTSAVAGE SSN 168-18-3207 DATE OF DEATH 11-01-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 PSECU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the 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. Please call (717) 787-8327 with questions. COMPLETE PART 1 BELOW ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0168183207-C57 Date 10-29-1998 Established Account Balance $ 43, 231.97 Percent Taxable X 50.000 Amount Subject to Tax $ 21,615.99 Tax Rate X .045 Potential Tax Due $ 972.72 ~~ PART 1^ CHECK ONE BLOCK ONLY A TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. ---~ ~~ yc, oe ~ ~~; ~,~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or 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. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3~ below. p2 T ^ •r inaicacing a different relationship to decedent: tax rate, please state OFFICIAL USE ONLY ~ AAF PA DEPARTMENT OF REVENUE TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Date Established 1 1 2. Account Balance 2 $ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 - 5 6. Amount Taxable 6 $ 6 7. Tax Rate 7 X 7 8. Tax Due B $ 8 PART DATE PAID DEBTS AND DEDUCTIONS CLAIMED PAYEE DESCRIPTION AMnIIAIT owrn Under penalties of perjury, I declare that the facts I have reported ab~ojv/e>are true, correct and cosmpl~ete to the best of my knowledge and belief. HOME C /L /~ 76!`7~~Z} `~~~ ~~ ~~ WORK C ~ I ~ ~ ~Go~ TAXPAYER SIGNATURE TELEPHONE NUMBER DAT To ensure proper credit to the account, two copies of this notice must accompany payment to the Register of Wills. Make check payable to "Register of Wills, Agent". NOTE: If tax payments are made within three months of the decedent's date of death, deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent nine months after the date of death. TAX - ~ amine ~ ur iax l.OmpULaLlOn) $ 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 when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 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 fully taxable. 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 a 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 estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 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 who died after l2/12/82, accounts the decedent put in joint names within one year of death are fully taxable. 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 83,000 exclusion was 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 percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 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 = 16.7 percent (TAXABLE TO EACN SURVIVOR) B. The percentage 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 MULTIPLIED BY 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 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable (Line 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 subject to tax (Line 4). 7. Enter the appropriate tax rate (Line 7) as determined below. ^The tax rate imposed on the net value of transfers from a deceased child 21 years of age or young t death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent. The lineal class of heirs includes grandparents, parents, children and other 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 are legally 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 the 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 8 1/2" x 11" sheet of paper. Proof of oavment may be requested by the PA Department of Revenue. TAXPAYER ASSISTANCE FF YDU NEED FURTHER INFORMATION OR ASSISTANCE, CONTACT ANY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE OR THE BUREAU DF INDIVIDUAL TAKES, AT (7173 787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30000 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent er a PENNSYLVANIA INHERITANCE TAX PSECU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account. If you feel the 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. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE N0. 21 Po Box zaocol TAXPAYER RESPONSE ACN 08155455 HARRISBURG PA 17128-0601 DATE 11-24-2008 REV-1543 EX I4fP (08-OB) TYPE OF ACCOUNT Cr'~~} ~,~ ",' ~~~~~ ~'~~;.~ ~~. T. OF HELEN M BURTSAVAGE ^ savlNGs N 168-18-3207 ^ CHECKING ,,,, _.._. , ,.,w DATE OF DEATH 11-01-2008 ^ TRUST ~~~ ~~~°' `-'~./ ~~~ ROUNT AYMENT AND ~FDRMSLADND ~ CERTIF. EDWARD M BURTSAVAGE mil)"~f. ' ~~ --•-~•, FA REGISTER OF WILLS 327 SOMERSET DR CUMBERLAND CO COURT HOUSE SHIREMANSTOWN PA 17011-6539 CARLISLE, PA 17013 Account No. 0168183207-C59 Date 03-14-1999 To ensure proper credit to the account, two Established copies of this notice must accompany PART 0 Account Balance $ 16,251. 47 Payment to the Register of Wills. Make check payable to "Register of Wills Agent" Percent Taxable X 50. 000 , . Amount Subject to Tax $ 8, 125.74 NOTE: If tax payments are made within three months of the decedent's date of death Tax Rate X .045 , deduct a 5 percent discount on the tax due. Potential Tax Due $ 365. 66 Any Inheritance Tax due will become delinquent ne months after the date of death . CHECK ONE BLOCK ONLY TAXPAYER RESPONSE ,-~ =A IaaaaL..~~...U~l~~RE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT ~;~, ~`~~~y`),7i ~ 38 A. The above information and tax due is correct. ~- s 7d ~"`^G Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or 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. ^ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return to be filed by the estate representative. C. ^ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3^ below. pp RT If indicating a different tax rate, please state ,L ^ relationship to decedent: DFFICIAL U5E ONLY ^ AAF PA DEPARTMENT OF REVENUE TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Date Established 1 1 2. Account Balance 2 $ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 - 5 6. Amount Taxable 6 $ 6 7. Tax Rate 7 X ~ 8. Tax Due g $ 8 PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION eMniiur Dorn Under penalties of perjury, I declare that the facts I have reported ab^-o7v/e°~are true, corretc~t and complete to the bes/t~ of my knowledge and belief. HOME C /L / ) ~f -7l V6 ~~~ Zl'I i~ ~~y~.q.~. WORK C ) 1 ~~ o2oa9' TAXPAYER SIGNATURE TELEPHONE NUMBER A E ~.~~_. a,n une ~ yr iax computation) S 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 ]oint account is taxable even when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in point names within one year prior to death are fully taxable. 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 fully taxable. 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 a 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 estate's representative, place an "X" in Block B of Part 1 of the "T ax paver Response" section. Sign one copy and return to the register of wills of the county indicated. 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 - TP.X 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 who died afterl2/12/82, accounts the decedent put in ioint names within one year of death are fully taxable. 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 was 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 percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of ,joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED 8Y TOTAL NUMBER OF MULTIPLIED BY 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 = 16.7 percent (TAXABLE TO EACH SURVIVOR) The percentage 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 MULTIPLIED BY 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 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount sub]ect to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable (Line 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 subJect to tax (Line 4). 7. Enter the appropriate tax rate (Line 7) as determined below. ^The tax rate imposed on the net value of transfers from a deceased child 21 nears of age or younger at death to or for the use of a natural parent, an adoptive parent or a stevparent of the child is 0 percent. The lineal class of heirs includes grandparents, parents, children and other 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. Vou are legally responsible for payment, or the estate subject to administration by a personal rev resentative is insufficient to pay the deductible items. B. You actually paid the debts after the 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 8 1/2" x 11" sheet of paper. Proof of payment may be requested by the PA Department of Revenue. TAXPAYER ASSISTANCE IF YOU NEED FURTHER INFORMATION OR ASSISTANCE, CONTACT ANY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE OR THE BUREAU OF INDIVIDUAL TAXES, AT (717) 787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING ANB/OR SPEAKING NEEDS ONLY: 1-800-447-3020. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/45 to 06/30/OG 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent PENNSYLVANIA INHERITANCE T INFORMATION NOTICE BUREAU DF INDIVIDUAL TAXES AN D PO BOX 280601 HARRISBURG PA 171za-B6o1 TAXPAYER .R E S P O N S E REY-1543 E% AFP [oe-oe, FILE N0. 21 ACN 08155456 DATE 11-24-2008 EDWARD M BURTSAVAGE 327 SOMERSET DR SHIREMANSTOWN PA 17011-6539 r::; ,.nJ ~;.. ~ C~'.J;'~;-s' `''£S~'~ tQF HELEN M BURTSAVAGE SSN~ ~' zG 168-18-3207 ia~«~~;,D~9~'E OF DEATH 11 - 01-2008 O~Cf-~/Jh,~'c, ~,~U~N~^~TY CUMBERLAND C~~i~,"'r- ~N'1fr~~AYMENT AND FORMS T0: R~'6~IS~R OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. PSECU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a ioint owner/beneficiary of this account. If you feel the 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. Please call (717) 787-8327 with questions. COMPLETE PART 1 BELOW ~ SEE REVERSE SIDE FOR FILING AND PAYNENT INSTRUCTIONS Account No. 01681832 07-IRA Date Established 04- 14 -1997 To ensure proper credit to the account, two copies of this notice must accompany AccOUnt Balance $ 23, 21 2. 9U payment to the Register of Wills. Make check payable to "Register of Wills A t" Percent Taxable X 5 0. 000 , gen . Amount Subject to TeX $ 11,60 6. 45 NOTE: If tax payments are made within three months of the decedent's date f d th TaX Rate X . 045 o ea , deduct a 5 percent discount on the tax due. Potential Tax Due $ 52 2. 29 Any Inheritance Tax due will become delinquent th nine mon s after the date of death. PART TAXPAYER RESPONSE ~ ~ 9'~, i8 FAILURE TD RESPOND WILL RESULT IN AN OFFICIAL TAX ASSE55MENT L .s-~ A. The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of 0 N E Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K ~ B. ~ 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 estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3L1 below. PART If indicating a different tax rate, please state OFFICIAL USE ONLY ~ AAF relationship to decedent: PA DEPARTMENT OF REVENUE TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Date Established 1 1 2. Account Balance 2 $ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 +fi 4 5. Debts and Deductions 5 - 5 6. Amount Taxable 6 $ 6 7. Tax Rate 7 X 7 8. Tax Due g $ ~~% 8 PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRrPTrnN ....,,,.,r .,. _.. - -- u, i ax l,O mpULaLlOn) $ Under penalties of perjury, I declare that the facts I have reported a+-b~ov+e~ are trtue, correct and complet~e- ~tJo the bes-ty^of myQknowle~dge~ and belief. HOME C `I L ) 7(,~~ ?~ ~p `~`~ ~`! /C~i~t~l/~-<-r~.~' WORK C ) ~ ~~ ,~00~ TAXPAYER SIGNATURE TELEPHONE NUMBER DAT GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with avplicable 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 when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 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 fully taxable. 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 a 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 CForm REY-1548 EX) upon receipt of the return from the register of wills. 2. BLDCK 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 estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 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 adecedent who died after 12/12/82, accounts the decedent put in Joint names within one year of death are fully taxable. 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 was 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 percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of Joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 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 = 16.7 percent (TAXABLE TO EACH SURVIVOR) The percentage 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 MULTIPLIED BY 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 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable (Line 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 (Line 5) from the amount subject to tax Cline 4). 7. Enter the appropriate tax rate (Line 7) as determined below. The tax rate imposed on the net value of transfers from a deceased child 21 nears 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 0 percent. The lineal class of heirs includes grandparents, parents, children and other 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 are legally 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 the 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 8 1/2" x 11" sheet of paper. Proof of oavment may be requested by the PA Department of Revenue. TAXPAYER ASSISTANCE IF YOU NEED FURTHER INFORMATION OR ASSISTANCE, CONTACT ANY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE OR THE BUREAU OF INDIVIDUAL TAXES, AT 0717) 787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-8~~-447-3020. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent Rtb-548 EX (12-03) ~ Iw11JC1'fITA ~~~~ ~~ v acv= o9/os6~g ^.....~ ^ ~ ~ ~ ~ `~ \1 1 AI r V G 1 /'~/~ ~/ V ~ ~r ~ HIV ~ Hlr (, V U N I COUNTY FILE NUMBER ~~ og -~a6~ ADVA NCE PAYMENT WORKSN E ET INHERITANCE TAX RECEIPT NUMBER DECEDENT'S NAME (LAST) s u R TSB ~~ ~ (FIRST) (MIDDLE INITIAL) ~~~ti ,~ DECEDENT DECEDENT'S SOCIAL SECURITY NUMBER DATE OF DEATH INFORMATION (~'~' !8'^ ~ci~47 ~~'-~ p?OOg ADDRESS OF DECEDENT 317 P CITY STATE ZIP r~ew©~, ~- SLID!-e,,~~giv,s~caw,t, !%~ 17 01 NAME OF FINANCIAL INSTITUTION ~ ~ ~ ~ 4' ~ FINANCIAL ' w INSTITUTION ADDRESS so219 S ~ ~ sa .v P CITY STATE ZIP ~ ~ rr ~ d ~ /Yne~1 ~~`~s~"~''~ ~~ ~ 7 ©~O INFORMATION TELEPHONE NUMBER ~ l7 ~ 697-1s/s TYPE OF ACCOUNT ^ SAVINGS CHECKING ^ TRUST ^ CERTIFICATE OF DEPOSIT ^ OTHER ACCOUNT ACCOUNT BALANCE (INCLUDE INTEREST TO DATE OF DEATH) ~ ~ ` ACCOUNT NUMBER INFORMATION ` ~ () ~ 39. 9~p ~ O ,~ ~85- ACCOUNT ITLE AS APPEARS ON SIGNATURE CARD OR CD ORIGIN DAT ESTABLISHED ~e.v ~? ~uf1'~sav e c~ ~dw ~' f ~ / © 8~~~9~ F ~.rq ur s~uq e M NAQME (Last) (yFirst) ~(AMiddle Initial) ~ - SURVIVING '4DDRESS ~ b~ 317 ~%v~2wo PERCENT TAXABLE JOINT OWNER dc INFORMATION CITY -/ S'fi ~ re~•r~4•vs7~o w.v STATE ZIP CODE /~~ ~7 0l~ RELATIONSHIP TO DECEDENT S TELEPHONE NUMBER TAX RATE ®,~ c ?~7 ~ 76/- 7180 NAME (Last) (First) (Middle Initial) ~~' SURVIVING ADDRESS _ ~RCENTT LE JOINT OWNER ?~~ CITY STAT ` INFORMATION E ZIP CODE ^- -:!~ ~~~-'j ~.> _^ ~n RELATIONSHIP TO DECEDENT TELEPHONE NUMBER ;; ('~ TE "~7 C ' NAME (Last) (First) (Middle Initial) N SURVIVING ADDRESS O PERCENT TAXABLE JOINT OWNER INFORMATION CITY STATE ZIP CODE RELATIONSHIP TO DECEDENT TELEPHONE NUMBER TAX RATE ~ ~ ~ • ~ uate hala Payee Description Amount Paid Note: Please attach to receipt Total $ ~ Page 1 of 2 BELINDA LAWRENCE - Re: prod -Date of Death Request /~/~ ~ ~- g A N K From: DATE OF DEATH REQUESTS To: LAWRENCE, BELINDA Date: 11/25/2008 12:53 PM Subject: Re: prod -Date of Death Request To: Belinda 11/25/08 Please print a copy for your files. Please find below the date of death balance for: Helen M Burtsavage, social security # 168-18-3207. Ck --1. Account # 950203485 Balance $10 238.92 + accrued interest $0.09 = $10 239.01 total oP~ C - 2. Account # 18788165, Balance $2,333.44 + accrued interest $0.04 = $2,333.48 total e.D - 3. Account # 31003916014043, Balance $32,563.45 + accrued interest $23.88 = $32,587.33 total C D - 4. Account # 31003914526230, Balance $6,359.81 + accrued interest $8.62 = $6,368.43 total Records Management /DOD Unit M&T Bank- "Understanding what's important." »> <BLAWRENCE@mtb.com> 11/21/2008 12:11 PM »> Account Information Date of death: 11/01/2008 Account Number: 31003916014043 Product Type: Deposit Account ~ D Account Number: 950203485 Product Type: Deposit Account c K Account Number: 31003914526230 Product Type: Deposit Account ~ p Account Number: 18788165 Product Type: Deposit Account C!~ ~ ~ 50 -___ _ __ ~, ~ s ~ . ~ X , o ~s ---a3 a o 3~ ,qS _ Additional Information Decedent was Helen M. Burtsavage social security 168183207 Request Details Deliver to: Requestor Delivery Options: E-mail '/YQQ file://C:\Documents and Settings\EBRNPIE\Local Settings\Temp\XPgrpwise\492BF566R... 12/4/2008 PENNSYLVANIA INHERITANCE TA. INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D Po Box zao6al TAXPAYER RESPONSE HARRISBURG PA 17128-0601 REV-1543 EX AFP (OB-OB7 FILE N0. 21 08-1265 ACN 09103194 DATE 01-19-2009 ~b1ST. OF HELEN M BURTSAVAGE SSN 168-18-3207 CL~Cf{ ~~ DATE OF DEATH 11- O 1- 2 0 0 8 I'~F~_'L~~~~~~ (;(,~~ I~~' COUNTY CUMBERLAND C11~'^~ ~~ .'~~',~~~ j~ ~' ~~ REMIT PAYMENT AND FORMS T0: EDWARD M BURTSAVAGE JR REGISTER OF WILLS 327 SOMERSET DR CUMBERLAND CO COURT HOUSE SHIREMANSTOWN PA 17011 CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS ® CHECKING TRUST CERTIF. M 8 T BANK provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account. If you feel the 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. Please call (717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 18788165 Date 03-28-1974 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 2, 333.48 payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to Tax $ 1,166.74 NOTE: If tax payments are made within three months of the decedent's date of death, TaX Rate X . 045 deduct a 5 percent discount on the tax due. Potential TaX Due $ 52.50 Any Inheritance Tax due will become delinquent nine months after the date of death. PART TAXPAYER RESPONSE D ~ ~'' 8'~ FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT n C S ~ oGC,¢c A. The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, ar check box "A" and return this notice to the Register of 0 N E .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 D N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART ~ and/or PART ~ below. PART If indicating a different tax rate, please state OFFICIAL USE ONLY relationship t.o decedent: ~ AAF PA DEPARTMENT OF REVENUE TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Date Established i 1 2. Account Balance Z $ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 - 5 6. Amount Taxable 6 $ 6 7. Tax Rate 7 X ~ 8. Tax Due 8 $ 8 PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTinN ~...,7~.~r .,.r„ ~~~~n n or i ax computation) g Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best/~of,, my~~knowledge and'b'elief. HOME ( ~`7 ) 76~~"71~U C a,~~ ~~ ~"`~~~~t~ ~ WORK C ) I ~q ~~ TAXPAYER SIGNATURE TELEPHONE NUMBER ATE 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 when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 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 fully taxable. 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 a 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 estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 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 who died after 12/12/82, accounts the decedent put in joint names within one year of death are fully taxable. 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 was 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 percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 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 = 16.7 percent (TAXABLE TO EACH SURVIVOR) B. The percentage 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 MULTIPLIED BY 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 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable (Line 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 subject to tax (Line 4). 7. Enter the appropriate tax rate (Line 7) as determined below. ^The tax rate imposed on the net value of transfers from a deceased child 21 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 0 vercent. The lineal class of heirs includes grandparents, parents, children and other 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 incommon 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 are legally 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 the 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 B 1/2" x 11" sheet of paper. Proof of payment may be requested by the PA Department of Revenue. TAXPAYER ASSISTANCE IF YDU NEED FURTHER INFORMATION OR ASSISTANCE, CONTACT ANY REGISTER DF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE OR THE BUREAU OF INDIVIDUAL TAXES, AT (717) 787-8327. SERVICES FDR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-80~-447-320. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent PENNSYLVANIA INHERITANCE TAX M $ T BANK provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the 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 Fennsvlva~lia. Please caii (717) 707-x327 with questions. COMPLETE PART 1 BELOW ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 31003916014043 Date 01-20-2006 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 32, 587.33 payment to the Register of Wills. Make check payable to "Register of Wills, Agent". INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE N0. 21 08-1265 PD Box zaB6B1 TAXPAYER RESPONSE ACN 09103193 HARRISBURG PA 17128-0601 REV-1543 EX AFP (~B-OBJ _ DATE 01-19 - 20 0 9 TYPE OF ACCOUNT ~4~~ ~ r`,l~ Gg P~ I~~g~, OF HELEN M BURTSAVAGE ~ SAVINGS SSN 168-18-3207 ~ CHECKING CI t.F;{ (~ DATE OF DEATH 11 - O 1 - 2008 ~ TRUST ORr'i~~;~v" ~ ~f~; !ft-( COUNTY CUMBERLAND ~ CERTIF. ~Ar .C; CU7V.i!r ._r`,~`~'y; i~,'JL. (.EMIT PAYMENT AND FORMS T0: EDWARD M BURTSAVAGE JR REGISTER OF WILLS 327 SOMERSET DR CUMBERLAND CO COURT HOUSE SHIREMANSTOWN PA 17011 CARLISLE, PA 17013 Percent Taxable X 50. 000 Amount Subject to Tax Tax Rate ~{` X 16,293. . 67 045 NOTE: If tax payments are made within three months of the decedent's date of death, deduct a 5 percent discount on the tax due. Potential TaX Due $ 733. 22 Any Inheritance Tax due will become delinquent nine months after the date of death. PART 1^ CHECK ONE BLOCK ONLY TAXPAYER RESPONSE _ FAILURE TO RESPOND WILL l~ESULT IN AN OFFICIAL TAX A55E5SMENT ~~a/~~~~Sy/~6~~ A. The above information and tax due is correct. ~ s -' `~ - -" Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or 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. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3LJ below. PART it inaicating a different tax rate, please state relationship to decedent: OFFICIAL USE ONLY Q AAF TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PA DEPARTMENT OF REVENUE PAD LINE 1. Date Established 1 I 2. Account Balance 2 $ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 - 5 6. Amount Taxable 6 $ 6 7. Tax Rate 7 X ~ 8. Tax Due g $ $ PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMllll\IT owTn - ~ ine ~ yr lax l.OmpULatlOn) $ Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best --o~,fe--my knowledge and belief. HOME C 7~7 ) ~(~l "7~8Q p ~~-ol ~ ~yLGs-sv'°~% ~, WO R K C ) r ,~ 9 © 7 TAXPAYER SIGNATURE TELEPHONE NUMBER ATE 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 when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in point names within one year prior to death are fully taxable. 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 fully taxable. 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 a 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 estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 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 who died afterl2/12/82, accounts the decedent put in point names within one year of death are fully taxable. 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 was 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 percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of point assets established more than one year prior to the decedent's death: 1 DIVIDED BV TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 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 = 16.7 percent (TAXABLE TO EACH SURVIVOR) B. The percentage 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 MULTIPLIED BY 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 percent (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 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 sub.7ect to tax (Line 4). 7. Enter the appropriate tax rate (Line 7) as determined below. ^The tax rate imposed on the net value of transfers from a deceased child 21 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 0 percent. The lineal class of heirs includes grandparents, parents, children and other 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 are legally 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 the 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 B 1/2" x 11" sheet of paper. Proof of payment may be requested by the PA Department of Revenue. TAXPAYER ASSISTANCE IF YOU NEED FURTHER INFORMATION DR ASSISTANCE, CONTACT ANY REGISTER DF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE OR THE BUREAU DF INDIVIDUAL TAXES, AT C717~ 787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-80-447-302. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent PENNSYLVANIA INHERITANCE T INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D PD Box zaocol TAXPAYER RESPONSE HARRISBURG PA 17128-0601 REV-1543 EX AFP (OB-08) FILE N0. 21 08-1265 ACN 09103192 DATE 01-19-2009 EtrF„~, `i''~r~~ t'~ p~~~ ~~: ~~T. OF HELEN M BURTSAVAGE ~~ 168-18-3207 ~-~ DATE OF DEATH 11-01-2008 LCr,'l~, ~ „_ ~' ~ COUNTY CUMBERLAND /^. T ((~~t ~ee ` ~' ~ ~ ~ G'~~1P litJfJl ,~,- 4,- ,•, ,- I! REMIT PAYMENT AND FORMS T0: EDWARD M BURTSAVAGE JR --'-'-~ ~A REGISTER OF WILLS 327 SOMERSET DR CUMBERLAND CO COURT HOUSE SHIREMANSTOWN PA 17011 CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. M 8 T BANK provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account. If you feel the 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. Flease call C717) 787-8327 with questions. COMPLETE PART 1 BELOW ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 31003914526230 Date 07-12-1996 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 6, 368.43 payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Percent Taxable X 50.000 PART 0 CHECK ONE BLOCK ONLY TAXPAYER RESPONSE «6,~ ~3 FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT ~ ~~ ~- . A. The above information and tax due is correct. ~ Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or 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. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART t.__I below. p T it inoicating a different tax rate, please state 2 relationship to decedent: OFFICIAL USE ONLY AAF PA DEPARTMENT OF REVENUE TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LING 1. Date Established 1 1 2. Account Balance 2 $ Z 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 - 5 6. Amount Taxable 6 $ 6 7. Tax Rate 7 X ~ 8. Tax Due g $ $ PART 0 DATE PAID DEBTS AND DEDUCTIONS CLAIMED PAYEE DESCRIPTION AMfIIIAIT oArn Under penalties of perjury, I declare that the facts I have reported above are true, cor/rect and co''mpQQle..te to the best of my knowledge and belief. HOME C f 7 ) 76l 7! ~~ ~-e~4 WORK C ) ~ ~,~ p~ TAXPAYER SIGNATURE TELEPHONE NUMBER qT Amount Subject to Tax $ 3, 184.22 NOTE: If tax payments are made within three months of the decedent's date of death, TeX Rate X .045 deduct a 5 percent discount on the tax due. Potential Tax Due $ 143.29 Any Inheritance Tax due will become delinquent s after the date of death. .+~ « „per un amine n or lax Computation) S 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 when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 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 fully taxable. 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 a 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 estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 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 who died after 12/12/82, accounts the decedent put in joint names within one year of death are fully taxable. 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 was 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 percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BV TOTAL NUMBER OF MULTIPLIED BY 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 = 16.7 percent (TAXABLE TO EACH SURVIVOR) B. The percentage 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 MULTIPLIED BY 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 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable (Line 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 subject to tax (Line 4). 7. Enter the appropriate tax rate (Line 7) as determined below. The tax rate imposed on the net value of transfers from a deceased child 21 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 0 percent. The lineal class of heirs includes grandparents, parents, children and other 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 are legally responsible for payment, or the estate subject to administration by a personal representative is insufficient to pav the deductible items. B. You actually paid the debts after the 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 8 1/2" x 11" sheet of paper. Proof of payment may be requested by the PA Department of Revenue. TAXPAYER ASSISTANCE IF YOU NEED FURTHER INFORMATION OR ASSISTANCE, CONTACT ANY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE OR THE BUREAU DF INDIVIDUAL TAXES, AT (717? 787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL NEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent PENNSYLVANIA INHERITANCE TAX SOVEREIGN BK provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the 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. Please call C717) 787-8327 wikh,:~sgstions.. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0571111807 Date 05-01-1995 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 1, 113.14 payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to Tax $ 556.57 NOTE: If tax paynents are made within three Tax Rate months of the decedent's date of death, X . 1 5 deduct a 5 percent discount on the tax due. Potential Tax Due $ 83.49 Any Inheritance Tax due will become delinquent - nine months after the date of death. PART TAXPAYER RESPONSE ~ ._ . INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE ND. 21 08-1265 Po Box zeocol TAXPAYER RESPONSE ACN HARRISBURG PA nlza-osol 09103175 REV-ieaa Ex ~P ,aB_ae, DATE 01-19-2009 L~~~ ~~~~ ~ TYPE OF ACCOUNT ~..,d~~ L~ ~~ ~57~(~OF HELEN M BURTSAVAGE ^ SAVINGS $$N 1-68-18-3207 ® CHECKING C~~~~~ (}~' DATE OF DEATH 11-01-2008 ~ TRUST ~PH~`tl~~ ~' '~{' LINTY CUMBERLAND CERTIF. ~ Rg~IT PAYMENT AND FORMS T0: LINDA J MCCARR v REGISTER OF WILLS 5 E MAIN ST CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055 CARLISLE, PA 17013 A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of 0 N E 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 0 N L Y to be filed by the estate representative. Tax return C. The above information is incorrect omplete PART 121 and/or PART 3^ below. PART If indicating a different t rate, please state a relationship to decedent: ~~ygl-'f'Cf 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 PART DATE PAID OF TAX ON JOINT/TRUST ACCOUNTS z $ 1, f/3./~ 3 X .5~0 4 -'~ S 6e.7 7 5 6 _ $ ~.S eJr7 ~ X . o''t5 B S a s. os ~ l~tls-1 ' ND DEDU IONS C s-~ ~~s~ _ a3 ~o PAYEE llFS(~R TPTTfIN ~- '- '- - ~ ax ~.ompuiailOn) ~` Under penalties of perjury, I declare that the facts I have reported above are true, correct and co~m~pl~~e~te~ too the best of my knowledge and belief. ~'e""^'svy~ ~ ~ HOME C 7/] ) ~6! -~ ~Ij TAXPAYER SIGNATURE ~ WORKroun-~r -u unrn / a~' ~A09 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT BURTSAVAGE EDWARD M JR 327 SOMERSET DR SHIREMANSTOWN, PA 17011 ACN ASSESSMENT CONTROL NUMBER -------- fold ESTATE INFORMATION: ssN: Asa-i$-a2o~ FILE NUMBER: 2108-1265 DECEDENT NAME: BURTSAVAGE HELEN M DATE OF PAYMENT: 01/29/2009 POSTMARK DATE: 01 /29/2009 couNTY: CUMBERLAND DATE OF DEATH: 1 1 /01 /2008 AMOUNT 08155449 ~ 5500.64 08155450 ~ 5862.51 08155451 ~ 5787.47 08155452 ~ 5959.89 08155453 ~ 5959.89 08155454 ~ 5924.08 08155455 ~ 5347.38 08155456 ~ 5496.18 09105688 ~ 5218.86 TOTAL AMOUNT PAID: REMARKS: SEAL CHECK# 6514 56,056.90 INITIALS: JN RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REV-1162 EX(11-96) N0. CD 010829 REGISTER OF WILLS COMMONWEALTH Of PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: REV-1162 EX111-961 PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT BURTSAVAGE EDWARD M JR 327 SOMERSET DR SHIREMANSTOWN, PA 17011 -- fold ESTATE INFORMATION: ssly: ass-is-a2o~ FILE NUMBER: 2108-1265 DECEDENT NAME: BURTSAVAGE HELEN M DATE OF PAYMENT: 01/29/2009 POSTMARK DATE: 01 /29/2009 couNTY: CUMBERLAND DATE OF DEATH: 1 1 /01 /2008 ACN ASSESSMENT CONTROL NUMBER AMOUNT 09103194 ~ $49.88 09103193 ~ 5696.56 09103192 ~ 5136.13 09103175 I 523.80 TOTAL AMOUNT PAID: REMARKS: CHECK# 6514 SEAL 5906.37 INITIALS: JN RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS NO. CD 010830 REGISTER OF WILLS