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HomeMy WebLinkAbout04-0445Telept: ...... {717) 097-7050 ANDREW C. SHEELY ATTORNEY AT LAW 127 South Market Street P.O. Box 95 Mecb~nics[,urg, Pennsyl¢~'!~a 17055 F~,x: (717) °07-7005 Register of Wills Cumberland County Courthouse Carlisle, PA 17013 RE: Estate of Mildred L. Romberger Date of Death: December 30, 2003 Dear Register of Wills Agent: Enclosed for filing please find several Pennsylvania Inheritance Tax Returns. In addition, enclosed please find a check in the amount of $156.97 payable on behalf of Pennsylvania Inheritance Tax and a check in the amount of $15.00 which constitutes the filing fee. Thank you for your assistance with this matter. ACS/bmk Enclosures c: Patricia Fike 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 NO. REV-1162 EX(11-96) CD 003904 SHEELY ANDREW C ESQ PO BOX 95 MECHANICSBURG, PA 17055 ........ foJd ESTATE INFORMATION: SSN: 178-16-6764 FILE NUMBER: 2104-0445 DECEDENT NAME: ROMBERGER MILDRED L DATE OF PAYMENT: 05/05/2004 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 12/30/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $156.97 REMARKS: PATRICIA E FIKE CHECK# 1204 SEAL TOTAL AMOUNT PAID: $156.97 INITIALS: AC RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS REV-'~SCO EX (6-00) COMMONWEALTH OF PENNSYLVANIA , DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 I-- Z LU INHERITANCE TAX RETURN RESIDENT DECEDENT I COUNTY CODE YB&R NUMAR DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Romberger, Mildred L. DATE OF DEATH (MM-DD-YEAR) 12/30/03 LLJ (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER uJ 0 DATE OF BIRTH (MM-DB-YEAR SOCIAL SECURITY NUMBER 178-16-6764 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS r~l. Original Return [~] 2. Supplemental Return li~4. Limited Estate [] 4a. Future ',nterest Compromise (dat. or death after '12-12-82) D6. Decedent Died Testate (Attach copy of Will} [] 7. Decedent Maintained a Living Trust fAt,ach copy of Trbst) [] 9. Litigation Proceeds Received [] 10. Spousal Poverty Credit (~ata or dea:h bet'.ve~, 12-31-91 and 1-1-95) NAME Andrew C. Sheely FIRM NAME (If Applicable) Andrew C. Sheely, Attorney at Law TELEPHONE NUMBER (717) 697-7050 E~]3. Remainder Return (date of death pdor to 12-13~82) El5. Federal Estate Tax Relurn Required 8. Total Number of Safe Deposit Boxes []11. Election [o tax under Sec. 9113(A)(Ar, ach Sch O) COMPLETE MAILING ADDRESS Andrew C. Sheely, Attorney at Law P.O. Box 95 127 South Market Street Mechanicsburg, PA 17055 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash. Bank Deposits & Miscellaneous Personal Property (5) 3,567.37 (Schedule E) 6. Jointly Owned Properly (Schedule F) (6) 11,531.05 E~ Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) (8) 9. Funeral Expenses &Administrative Costs (Schedule H) (9) 11,488.98 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 121.14 11. Total Deductions (total Lines 9 & 10) (11) 12. Net Value of Estate (Line 8 minus Line 11) (12) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line 12 rninus Line 13) (14) 15,098.42 11,610.12 3,488.30 3,488.30 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers underSec. 9t16 (a)(1.2) x .0 __ (15) 16. Amounl of Line14 taxable at lineal rate 3,488.30 x .0 45 (16) 156.97 17. Amount of Line 14 taxable at sibling rate x .12 (17) 18. Amount of Line 14 taxable at collateral rate x .15 (18) t9. Tax Due (19) 156.97 ~i~:'"'"' ~?~,~i''''~'':'~':?'':'~ ~,~ii;~: '~'i~'~'~'-'~ ..... ..... ~': ........... ", i'~ ' Decedent's Complete Address: I STREET ADDFtESS Road #89 4905 East Trindle ClTYMechanicsburg, I STATEpA 7055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 156.97 156.97 Total Credits ( A + B + C ) (2) 3. InterestJPenalb/if applicable D. Interest E. Penalty Total InterestJPena[ty ( D + E } (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5Al B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; .......................................................................................... [] [] b. retain the right to designate who shall use the property transferred or its income; ............................................ [] [] c. retain a reversionary interest; or .......................................................................................................................... [] [] d. receive the promise for life of either payments, benefits or care? ...................................................................... [] [] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. [] [] 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. [] [] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ [] [] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and ~[,~,ients, and to '(ne best of my knowledge and belief, it is true, correct and complete, Declaration of preparer other than the personal representative is based on all information of ~hich preparer has any knowledge. .~C.~.ATURE OF PERSON ~ESPONSIBLE FOR FILING RETURN DATE ADDRESS 39 Konhaus Road, Mechanicsburg, PA 17055 ssTURE OF PREPARER-D.T~ER TbI¢C~REPRESENTATIVEUATE ........ 127 South Market Street P.O. Box 95, Mechan csburg PA 1~i~55 ................ For dates of death on or after July 1, 1994 and before January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. §9116 (al (1.1) For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. §9116 (al (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. §91 The tax rate imposed on tile net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX,' (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MILDRED SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY L. ROMBERGER 2 1 - 0 F,~L.-.E NUMBER Include t~e proceeds of litigation and the date the proceeds were received by the estate, All property jointly, owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER VALUE AT DATE DESCRIPTION OF DEATH Highmark Premium Refund Country Meadows Resident Refund Personal Property None Decedent was a resident of the Country Manor Adult Care facility, nursing unit at the time of death. TOTAL (Aisc enter on line 5, Recapitulation) $ 246.23 3,321.14 0.00 $3,567.37 (If more space is needed, insert addilio~al sheets of ti~e same size) ~~~-VOUCHER --~RO S AMOUNT 1"~;~ ..... -- INVOICE NO. :'REMIUM REFUND 200q-01-0800.627975 2~6.2~- 0. O0 246.22 ] i'~NDL[' ,CHECK NO. pay DATE [ V£NDOR NO. '1 VENDOR NAM,~ ...... TOTAL AMOUNT I , ! :30q,$86.63 20Oq,-O,',.],'l~', MILROHoool,] NILROMOOOI-OO! .... 2q&.2~ 0000190 MILDRED q905 E TRINDLE RD NECHANICSBURG, PA 17055 COUN'm¥ MEADOWS RES I DENT REFUND. INVOIOE DATE _2/I&/2005 REMrn'ANOE ,~VICE . 08.~ INVOKE NUk,.-,.~_,~· RO,~__BERGER 5.52 i =-!~ Cotmtry MeadoWs. ~, pENNSYLVANIA 17033 01/08/2004 084669 c~ ~°' 521 t45.* 8466~ $5, .... ~ DOLLARS THOUSAND THREE THREE _ ._ . ~,~?;,,~ '. ~~';ZL~. REV-1509 EX + [1.9'/) ~ COMI~NWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MILDRED L. SCHEDULE F JOINTLY-OWNED PROPERTY ROMBERGER FILE NUMBER 2 1- 0 &- If an asset was made joint within one year of the decedents date of death, It must be reported on Sc~duie G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Patricla E. Fike Daughter 3§ Konhaus Road Mechanicsburg, PA 17050 JOINTLY*OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and ba~k account number or similar identifying number Attach DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT dee~ for jointly-held mai es*ate. VALUE OF ASSET INTEREST DECEDENT'S INTERES* 1. A, 04/12/!16 Waypolnt Bank-checking account 1800011884 Principal Balance $ 1,263.28 Accrued Interest $ 0.02 Date of Death Value $ 1,263.30 50% :$631.65 Mildred L. Romberger/Patflcta E. Fike, Jr. Ten. 03/15/g ? Waypoint Bank-certificate of deposit 1654307101 Principal Balance $11,573.69 Accrued Interest $ 26.75 Date of Death Value $11,600.44 50% $ 5,800.22 Mildred L. Romberger/Patricla E. Fike, Jr. Ten. 1 !/30; ~0 Waypoint Bank-certEicate of deposit 7100005330 Principal Balance $10,184.68 Accrued Interest $ 13.67 Date of Death Value $10,198.35 50% $ 5,O09.18 Mildred g Romberger/Patricia E. Fike, Jt. Ten. TOTAL (Also enter on line 6, Recapitulation) $ $11,531.05 (If more space is needed, inserl additiona~ sheets of the same size) LOOK FOR US. WE?LL GET YOU THERE, 1/16/2004 ANDREW C SHEELY 127 S MARKET ST PO BOX 95 MECHANICSBURG PA 17055 The information which you requested on the account(s) of MILDRED L ROMBERGER (Social Security Number 178-16-6764) is/are as follows: Account Number 1800011884 1854307101 7100005330 Class of Account CHECKING CERTIFICATE CERTIFICATE Date Opened 041296 031597 i 13000 Principal Balance 1263.28 11573.69 10184.68 Accrued Interest .02 26.75 13.67 Balm]ce at Date of 1263.30 11600.44 10198.35 Death Account Ownership JTO Name of Joint PATRICIA E Owner, if any FIKE Date Ownership 041296 Was Established JTO JTO PATRICIA E PATRICIA E FIKE FIKE 031597 113000 Account Number Class of Account Date Opened Principal Balance Accrued hlterest Balance at Date of Death Account Ownership Name of Joint Owner, if any Date Ownership Was Established Additional [nfonnation Requested SENIOR SERVICES REP. RO. Box 1711. HARRISBURIS, PENNSYLVANIA 1710S-1711 Toff Free I-EIEE-WAYPOlN? (I-EI6G-9;~g-7E;46). IN YOR~ AREA 717/815-4S00 · www. weajpolntbank, com REV-1511 EX+ (t2-99)~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEOENT ESTATE OF MILDRED V,o ROMBERGER SCHEDULE H FUNERAl. EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21-04- Debts of decedent must be reported on Schedule I, ITEM NUMBER DESCRIPTION AMOUNT FUNERAL EXPENSES: 5. 6. 7. MYERS FUNERAL HOME GINGRICH MEMORIALS TRINDLE NPRING LUTNRAN CHURCH - FUNERAL LUNCHEON ADMINISTRATIVE COSTS: Personal Representative's Commissions Patric~a E. Fike, Executrix Name of Personal Representative(s) Social Security Numbsr(s)/EIN Number of Personal Representative(s) Street Address 39 Kon~aus Rd. City ~..:&c,,c.~,ic=_u:--'- ,. = State ~,... Zip Year(s) Commission Paid: Attorney Fees ANDREW C. SHEELY, ESQUIRE, PER AGREEMENT Family Exemption: (If decedent's address is not the same as claimant's, attach, explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent Probate Fees Accountant'sFees FILINO FEES FOR XNNERXTANCE TAX RETURNS Tax Return Pmparer's Fees Reserves to conclude administration o£ Estate $9,041.48 1,780.00 100.00 $ 412.50 15.00 $ 150.00 TOTAL (Aisc enter on line 9, Recapitulation) $ 11, ~,8a. 98 (If more space is needed, insed additional sheets of the same size) (717) 766-3421 Myers Funeral Home, Inc. Boyd L. Myers Jr., Supel~isor 37 East Main Street Mechanicsburg, Pennsylvania 17055 A standm'd of excellence in Central Pemasylvmaia since 1910 Fax (717) 795-7291 Saturday, January 4, 2003 Mrs. Patricia E. Fike 39 Kohnhaus Road Mechanicsburg, Pa. 17050 Dear Mrs. Fike, Thank you for selecting our funeral home to provfde services for your family during your bereavement. I hope that you found our services to be of the highest standards and that they met your needs and those of your family and friends. The following is a summary of the service charges as previously explained and provided in written form and herein indicated as PAID-iN-FULL. Mildt'ed L. Romber~er SUNINIARY OF EXPENSES TOTAL OF SERVICE RENDERED $'10,997.24 LESS: Credits granted 1,955.76 LESS: Total Payments 9,041,48 CURRENT BALANCE $0.00 Credits Granted: $215.76 Early pay discount $1,740.0 Package Price Discount ncems that remain unanswered, please call me. ~,.L.,.,,c<!o,,.,9 1~ft t-7~o Phone (H) ~lC.r..,, ,.T. 3T'G (W) 't Location. .Se.e.'~,eY~ C Ce:{- CenterOver · . ,, Graves Lot# Appmx. Date of Completion . ~. '~ ! O vJ e e.~ ~ LeVering Type of Memorial .2){o,~; size a-O x 0'to x I' ~ Base ~ X X Mlsc as,gn U3 Finish [.ocatl°n: [] Vase [] Corner Posts Agraamenl: A 60% da~ollt le squired I:~or to eammaneamant of WOrk. ~gree to pay a.tated baJanoe uperl are allan rega~le~a o~ ~ or t roul:31~ or shipments or any other g~ ecl reasons. This o~er o r eonla<~t oann al ~ eana~a~ ay ouatemor umeaa agreed Oy aoll~ ~0~L~laa. The an}cie haman mentioned shell remain the property of dames R. alnerla~ Memorials until pa{d In full anal ~.ay ma~va ~ ng~! to remove me same la n~ paid aa aloud. agree to aen~ul~ proofread edl names aaa da~& for ae,,uraayan,~ aoaept fu~ mapanalblll~-for any errors ar omla.la~e, TH~EW~LLBB AN ADOIT~3NAL :HAR<31E FOR ANY LBTrBRIN~ ADDED TO,I~Ie, MEMORIAL Alrr~FI alFiB~3TaO ON TNe-CltMBTEI=~. ~u~her agree to pay the betanoe atatecl tot the work pedomma under thts contract wa. In thl~y (30) days of moelpt ,'.f ~e line{ law:IDa and furlher agree nat ~qta real al'mil ao~ma at [ne rata of mia anal one-half Peroanl ('~ ~%) par manlh on the unpaid be. leR ~e owed 1o dames fl. C~ngl'loh Mm'nodals n~ paid vtll~n thirty (,90) a.ya al the Inve~3e dam, In aclolt~c Ihareto, I agill~ I~ ~ beaomaa nacessa~/tar James R. Glngdch to Inel~lute legal proceeding fo collect otrlYoOtleatfUrll~l'tlla(fuesame.fr°m me tar.my account bathg past due tlllrty (~lO)'dava, to pay ell eeun coats an¢l attorney's fees bleu n'~a 13¥ James R. Olng.~l Mamoda a ::)ealer' talesman WHITE'lO{flea. j'::¥~;..,..',~.: Foundation $ TOTAL $ DEPOSIT ¢~ $ ~;~O.- Balance Due ~ ' ,,,. .. . ~ .... .,..,~.,~...; .. 'r~pe~0f:Sak~ YELLOW/PrOduot~:,. ,|l (] (] 0 0 (] ~!(] 0 0 0 il| R~-1512 EX, (1.97} COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS :ILE NUMBER 21-04- Include unreimbursed medical expenses, ITEM NUMBER DESCRIPTION West Shore EMS TOTAL (Also enter on line 10, Recapitulation) $ AMOUNT $121.1A $121.14 (If more space is neede(~, insert additional sheets of the same size) PATRIClA E. FIKE 60'72381e 12 04 39 KONHAUS RD. 2313 180O004061 1PI Wa~jpolnt MEMO -- ~: ~ ~ ~ ~ ? ~ ~8 ?~: ~SO000hO~ ~,' PATIENT NAME: INSURANCE: Phone #: M!LDRED ROtCBERGER 203'~ ~4307D ZAL203 t Q430"~ '! 13059W I~LDRED ROWIBERGER 39 KONHAUS RD ffIECHANICS, IBtJRG. PA 170.30 PATIENT NUMBER: CALL NUMBER: DATE OF CALL: TIME OF CALL: CALLER: FROM: TO: REASON(8) FOR TRANSPORT 13827 WC',3 'I t 3059W 12/18/2003 09:40 AM HEAL:TH SOUTH SPECIAL SE HEALTH ~OUTH SPECIAL SEF:V~CES HOLY SPIRIT HOSPITAL Parkin ~r','s Dise axe DEIIGRIPTION OF I~&¥MEN'T RE(~BIPT PAYMENT DATE PLEASE PAY THIS AMOUNT ~ BUREAU OF ZNDZVZDUAL TAXES ZNHERTTANCE TAX DTVTSZON DEPT. 180601 HARRTSBURG, PA 17118-0601 CONNONNEALTH OF PENNSYLVANZA DEPARTNENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAZSENENT, ALLO#ANCE OR DZSALLONANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-lG47 EX AFP ANDREN C SHEELY ATTY 127 S NARKET ST PO BOX 95 NECHANICSBURG PA 17055 BATE ESTATE OF BATE OF DEATH FILE NUNBER cOuN~ ACN 07-05-200~ RONBERGER 12-$0-Z005 Z1 0~-0~5 CUNBERLAND 101 Amoun~ Remitted NILDRED L HAKE CHECK PAYABLE AND RENZT PAYNENT TO: REGISTER OF HILLS CUNBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE I~~ RETAIN LONER PORTION FOR YOUR RECORBS ~ REV-1547 EX AFP [01-03) NOTICE OF INHERITANCE TAX APPRAZSENENT, ALLONANCE OR DZSALLONANCE OF DEDUCTIONS AND ASSESSNENT OF TAX ESTATE OF ROHBERGER NILDRED L FZLE NO. 21 O4-O4q5 ACN 101 BATE 07-05-200q TAX RETURN NAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAZSED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) 2. Stocks end Bonds (Schedule B) (2) 3. Closely Held Stock/PartnershAp Interest (Schedule C) ($) ~. Mortgages/Notes Receivable (Schedule D) (~) 5. Cash/Bank Deposits~Misc. Personal Property (Schedule E) (5) 6. Jo/n~ly Owned Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. To(aZ Assets APPROVED DEDUCTZONS AND EXENPTZONS: 9. Funeral Expansas/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule Z) (10) 11. Total Deductions 12. Net Value of Tax Return .00 .00 .00 .00 3/567.37 11~531.05 .00 (8) 11,r, 88.98 121.1~ NOTE: To insure proper credit to your account, submit *he upper portion of this form with your tax payment. 15,098.A,Z (11) ll .610.12 (12) 3,~88.30 15. 1~. NOTE: Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) . O0 Ne* Value of Es*a~a Subject to Tax (1~) 3,~88. zf an assessment ~as issued previously, lines 1~, 15 and/or 16, 17, 18 and 19 reflect figures that lnclude the total of ALL returns assessed to date. (1;) .00 x O0 = .00 (la) 3,~88.30 x 0~5= 156.97 (17) . O0 x 1Z = . O0 (18) . O0 X 15 = . O0 (19)= 156.97 ANOUNT PA/D 156.97 TOTAL TAX CREDIT BALANCE OF TAX DUEI ZNTEREST AND PEN. TOTAL DUE ASSESSNENT OF TAX.' 1.6. Amount of Line lq at Spousal rate 16. Amount of Line II taxable et Lineal/Class A rate 17. Amount of Line lq at SibXing rata 18. Amount of Line 1~ taxable at Collateral/Class B rate 19. Principal Tax Due TAX CREDTTS: PAYHENT RECETpT DZSCOUNT (+) DATE NUMBER INTEREST/PEN PA/D (-) 05-05-Z00~ CD00390~ .00 ZF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. 156.97 .00 .00 .00 ( IF TOTAL DUE TS LESS THAN $1, NO PAYMENT TS REQUTRED. I IF TOTAL DUE IS REFLECTED AS A "CREDZT" (CR), YOU HAY BE A REFUND. SEE REVERSE S/DE OF THZS FORM FOR ZNSTRUCTZONS.) RESERVATION: Estates of decedents dying on or before December 1Z, 1982 -- if any future interest in the estate is transferred in possession or enjoyment to Class B (collateral) beneficiaries of the decadent after the expiration of any estate for life or for years, the Commonaealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lamful Class B (collateral) rate on any such future interest. PURPOSE OF NOTICE: PAYHEHT: REFUND (CR): OBJECTIONS: ADHIN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: To fulfill the requirements of Section Il40 of the Inheritance and Estate Tax Act, Act Z$ of ZOO0. (TI P.$. Section 9140). Detach the top portion of this Notice and submit aith your payment to the Register of Hills printed on the reverse side. --Hake check or money order payable to: REGISTER OF NILLS, AGENT A refund of a tax credit, mhich ams not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-IS15). Applications are available at the Office of the Register of Hills, any of the Z3 Revenue District Offices, or by calling the special Z4-hour ansaering service for forms ordering: 1-800-562-2050; services for taxpayers aith special hearing and / or speaking needs: 1-800-447-5020 (TT Any party in interest not satisfied aith the appraisement, alloaance, or disalloaance of deductions, or assessment of tax (including discount or interest) as sheen on this Notice must object eithin sixty (60) days of receipt of this Notice by: --erittan protest to the PA Department of Revenue, Board of Appeals, Dept. ZBIOZ1, Harrisburg, PA 171za-loz1, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. Factual errors discovered on this assessment should be addressed in mriting to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Pest Assessment Reviem Unit, Dept. 280601, Harrisburg, PA 171Z8-0601 Phone (717) 767-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-IS01) for an explanation of administratively correctable errors. If any tax due is paid aithin three (S) calendar months after the decedant's death, a five percent (SI) discount of the tax paid is alloeed. The 15Z tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same time period as you mould appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning eith first day of delinquency, or nine (9) months and one (l) day from the date of death, to the date of payment. Taxes which became delinquent before January 1, 198Z bear interest at the rate of six (BI) percent par annum calculated at a daily rate of .000164. All taxes ahich became delinquent on and after January 1, 198Z will bear interest at a rata which mill vary fram calendar year to calendar year eith that rate announced by the PA Department of Revenue. The applicable interest rates for 198Z through ZOO4 are: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor ~ lOX .000548 ~)'~'~-1991 XXZ .000301 2001 9Z .000247 1983 16Z .000438 199Z 9Z .000Z47 ZOOZ 6Z .000164 1984 llZ .000501 1993-1994 7Z .O0019Z ZO0~ 5X .000137 1985 132 .000356 1995-1996 9Z .000247 2004 42 .000110 1986 lOX .000274 1999 7Z .00019Z 1987 lOX .000274 ZOO0 7Z .00019Z --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUHBER OF DAYS DELINQUENT X DAllY INTEREST FACTOR --Any Hotice issued after the tax becomes delinquent mill reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date sheen on the Notice, additional interest must be calculated.