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HomeMy WebLinkAbout03-14-11PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES } ._ ~,-~}~ AND FILE N0. 21-~ ~ - ?) ~~ Po Box 280601 ~ ~~~AlXpAYER RESPONSE ACN 11107581 HARRISBURG PA 17128-0601 r. (~ ! C DATE 02-08-2011 REV-1543 E% ~FP (0§, OB) ' ,J ..k~ ~ ~ ~_~~ ~ ~ ~'l ~. ~ ~ TYPE OF ACCOUNT EST. OF BRADLY J JOHNSON ~ SAVINGS CLtR~ Or ssN 160-48-8824 ~ CHECKING DATE OF DEATH 01-15-2011 ©TRUST Q~r~t'{~`,f1~ ~ ~~`~~T COUNTY CUMBERLAND ~ CERTIF. Cl1P~p~E`?L,~~A1J CQ., PA REMIT PAYMENT AND FORMS T0: BOYD J JOHNSON III REGISTER OF WILLS 109 SANDBANK RD 1 COURTHOUSE SQUARE SHIPPENSBURG PA 17257 CARLISLE PA 17013 FARMERS ~ MERCHANTS TRUST CO 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 9oint 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 withqueetions. _. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 34-96546 Date 07-26-2010 To ensure proper credit to the account, two Established copies of this notice ^ust accompany Account Balance $ 37,080.63 payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Percent Taxable X 100.00 j ~ 37, 080.63 NOTE: If tax payments are made within three Amount Sub ect to Tax months of the decedent's date of death, Tax Rate ~( , lj deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due ~ i 5,562.09 nine months after the date of death. PART TAXPAYER RESPONSE 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 Tax return 0 N L Y to be filed by the estate representative. C. ~ The above infona ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax r te, ple a st e ~ ~ i ~~,~;. ~ ~~+~ ~~~ relationship to decedent: ,~~~L~ ~~ ~^~'`"~ I ' ? ~ G~.1 ,.~~ ~. TAX RETURN - COMPUTATION OF TAX ON JOINT/TR U ST ACCOUNTS ~-*"" ~~"`~"~' ~~' "^~ LINE // ~ a 1. Date Established 1 ~ Co " ~~ t 0 }~%' ~ ~ ~~.'~'` ~F; ~ ~ ~ 2. Account Balance 2 ~ 7 ~ Q ~1 ,..++-~~ ~ . Y " ,.~,~ +~' ~a <~ dA 4 3. Percent Taxable 3 X Q . ~~ ~.x , `'~, ~ ~-'~ ;~~`~~ :~~~~~ 4. Amount Subject to Tax 4 $ Q 4 `w;>r - 5. Debts and Deductions 5 - r0 t. s :'~'`~~_`~.. ^" ~ '; ~;~ 6. Amount Taxable 6 ~ ~O ~ ~ ~ '''~ 'Yf`F~`~'' ''<~ 7. Tax Rate 7 X ~ ~_ ~ 7 '~`' ~ ' ~_ ~~~k ; 8. Tax Due 8 $ ~ 7~i ~ ~ - - ~ ""y. „x}-Yn~? t ~ ~.~ t a ,iw~+x~Qc?t+t :~§; - s PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above> are true, correct and i~~l~ o he est of my knowledge and belief. HOME C~l ! ) ~~~-~ ~ ~-~Q~~~ / ~ WORK C ) TAYPAVCQ tCTGWATIIDC :u:w~ Fencer onuane s oT iax computation) # w~ ,;r HETRICK CREMATION SERVICES Funeral Expense Agreement OF CENTRAL PENNSYLVANIA, INC. 'Plus is an explanation of charges as well as a sad 3125 Walnut Street, Harrisburg, PA 17109 ment presented in accordance with the regulations ~ (717) 671-1289 Fax (717) 545-2325 State Board of Funeral Directors. Mark D. Fasnacht, Supervisor STATEMENT OF FUNERAL GOODS AND ERVICES SELECTED ~' Charges are only for those items that you Selected or are required. If we are required by .law or by a cemetery or crematory to use an}/ will explain the reasons in writing below. If you selected. a funeral which may require embalming, such as a funeral with a viewing have to pay for embalming. You do not have to pay for embalming you did not approve, if you selected arrangements such as direcf' or immediate burial. If we charge for embalming we will explain why below. Legal, cemetery, crematory or other re irements compelling the purchase of any items listed below: Reason for Embalming:. /~` Funeral Services for < ;rG~ I~ ~ ~f~hNS~-~Da~e of~Deat~~ ~ ~ ~` ~ Date of Service ,~~ GOODS AND SERVICES SELECTED TYPE OF SERVICE AUTHORIZED TO BE PROVIDED Prayer Cards : ^ Traditional Full Service ^ Viewing day of Service ... , .......... ..... Crucifix ................. ........... $ '~ ~ i ^ Graveside service only ^ 1Vo Viewing Temporary Grave Marker . ~ ~ ~ ~ $ ' ^ Cremation ^ Immediate Dis sition Po Memorial Board Rental . ............ $ ^ Public Viewing ^ P ^ Anatomical Gift Casket Rental . ....... .................. $ rivate Family Viewing ^ Memorial. Service Cl thin .......... r ` ^ Evening Viewing ^ SFipping Service o g.. Fla C $ ^ Receiving Service g ase ................... ............ Other $ i' A. Package Arrangement $ Total of Merchandise Selected (C) .............. _ i ~<p~~~~ `r ~ m~-~i Wt $ ~ ~.,~©c~ D. Special Charges B. Charge for Services Selected• Forwarding Remains to 1. PROFESSIONAL SERVICES Basic Services Fee ................... $ Y Embalming ...... .... ..... $ ~_ Cremation ....... ... .... ... $ Other Preparation of Body Transfer of Remains to Funeral Home ... Sub-Total of Professional Services (Bl) .. .. $ 2. ADDITIONAL SERVICES AND FACILITIES Visitation .......... ............ .... $ Funeral Service ........................ $ Memorial Service ...................... $ Graveside Service ........... .... .. $ Sub-Total of Additional Services and Facilities (B2) ........ ....... $ 3. AUTOMOTIVE EQUlI'MENT Funeral Coach ........................ $ Lead /Clergy Car ..... .. ........... $ Flower Car ............................ $ Family Car ............................ $ Other than loca120 mile Transportation .. $ Sub-Total of Automotive Equipment (B3) ... $ Total of Professional Services, Additional Services and Facilities, and Automotive Equipment (B) .. $ /_.~(~ C. CHARGE FOR MERCHANDISE SELECTED Casket Description ~ ~ $ j .Nl~~ Other Receptacle Description $ Outer Burial Container Description $ Urn Description P~~~ ~/C._. $ Wit; ~~ Acknowledgement Cards .........::....... $ Memorial Folders ......................... $ Register Book ............................. $ Receiving Remains from $ $ Immediate Burial $ ..... Equipment Rental ..................... .... Direct Cremation .. .................... $ Total of Special Charges (D) ..... ............ $ E. Cash Advances Opening of Grave ................ .. $ .... Cemetery Equipment .......... .... $ _. .... Clergy/Mass Offering ..................... $ Flowers " $ r Certified Copies of DE±ath Certificate ... . cs~ $ ~£ _ . . Newspaper Notice .................... $ .... Cemetery Lot and Deed .................... $ Pallbearers ................................ $ Airfare ................................... $ Vault Service Charge ....................... $ Honor Guard .......... ................ $ Organist.. ...... .... ............. _~ $ Other C '~l1 r~ l~c"(~ -1--~`~r n^ i -i $ :-,;~ ~ ~~ For your convenience, we will advance the cost of the foregoing items; however, any'; error made by any supplier of services shall be the sole responsibility of that supplier and our funeral home is relieved of liability therefore by acting as your agent. Hetrick Cremation Services is entitled to take and retain any discounts offered on the purchase of a cash advance item. Total of Cash.Advances(E) .................... $ ~7f A. PACKAGE ARRANGEMENTS ............. $ ~ ~ :' C) B. ADDITIONAL SERVICES /FACILITIES .... $ C. MERCHANDISE .......................... $ D. SPECIAL CHARGES ......... ........... $ Total of Funeral Home Charges ............ ... $ ~~`~°' E. CASH ADVANCES.. ~ '` Total of Funeral Home Charges and _. Cash Ar~vanroa T ~.•' !s°~ i' i 1.•IGII,IJ, UGIIIC11 ,u.a, •..uu.~a..i v, uv..v.., ... .... ~~..._ _. _. _.~ ..... result of, based upon or connected with this authorization, including the failure to properly identify the decedent or the human remains transmitted to Cr~una#pry, the processing, shipping and final disposition of the decedent's cremated remains, the failure to take possession of or make proper arrangements for ~f~i~'1~'mal disposition of the cremated remains, any damage due to harmful or explodable implants, claims brought by any other person(s) claiming the right to cotitn~ the disposition of the decedent or the decedent's cremated remains, or any otheraction performed by Crematory, its officers, agents, or employees, pursuatlt,Xoi,this authorization, excepting only acts of willful negligence. ~rti• ._ __. >,,,,F. ~4 I (We), the undersigned, have read the chaptet on 'Th ~ 3 (W) ~- = ~'~ - -. Initials of.AA- : ~r/` ` e Cremation Process"f and 1 e understand what is nvoh}ed in the cremation process. +, ' rh Initials of AAA SIGNATURE OF AUTHORIZING AGENT(S) ~~ THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. By executing this Cremation Authorization Form, as Authorizing Agent(s), the undersigned warrant that all representations and statements contained on this~form are true and correct, that these statements were made to induce. Crematory to cremate the human remains of the decedent, and that the undersigned have ', and understand the provision contained one tlhis form. Executed at ~ ^"~: this ~` ~ day of C;%~4 , ~~~,~ Name ~ ~~ ~ ~'~'1 ~~ignature _ _ Relationship to Decedent f ! - ~ ~~ Phone No. ( .~/ ~` ) :~~-~~ .~ ~7 ~ Address ~~ ~ Q''~ ~ {~ '~- Name Signature ~ ~.~7",~~" 1 ,. .;~~ ~"--- Relationship to Decedent Phone No. ( ~'1 Address Signature of Funeral Director as Witness to Signature(s) of Authorizing Agent(s) "I Name and Address of Funeral Home ~ HITFJ Funeral Home Copy CANA / ory Cop PINWFamily Copy DATE TIME CREMATION REP. F.H. REP xeglstertsoox.. ............. ........ w ........................... $ `r'` ~. Cash'Advances CASH ADVANCES MUST BE REIMBURSED PRIOR TO SERVICE DAY "" I~ AGREEMENT: I agree that I have inspected the goods and services selected above and found them to be accurate and according to the azrangements I have selected. I acknowledge ' pk ~ ; I of a copy of this Statement of Goods and Services Selected. It is understood that the total charges shown above may be estimated and reflect only that agreed upon at the time of ; agreement. Any additional items of service or merdlaridise ordered or required after the time of this arrangement shall be considered part of this agreement and the cost will be re .j ed on your Final Statement which we provide. ~ TERMS: This is a cash transaction due in full in 30 days, and in all events bernmes past due and delinquent after the 30 days date. A penalty of 15% per annum (1.25% monthly) be,, i ~ charged for unanticipated late payment effective on the 31st day. ty y rovided b the manufacturer. The funeral'. WARRANTIES: The only warranty of the merchandise sold in connection with this agreement is the express written warran (if an ), p y for makes no warranty (expressed or implied) with respect to any funeral merchandise. ' i, . AUTHORIZATION: I or We authorize and ratify prior consent to the funeral director to take possession of the body, give care to and carry out the arrangements hereto specifi ' 1sn ~ agreed to. I or We represent ourselves as the person(s) having the legal right to arrange for the final disposition of the above named decedent, and do hereby grant authority to the x director to supply the services and merchandise'as listed above. I or We guazantee the payment of this tract according to the above terms, and also ag/ree tO Day attorney, dL~ legal judgement imposed upon the collection of the rnst of this service agree. went. ~~ b ~ 7 ~„~ (~h ~ S'~ N ,~[ / ~ Oral Permission to Embalm the above named decedent O Was granted ,{$'C~yas refused by ~ Name / FINAL ACCEPT CE: or We list effective - ~ ,~,I Rel Accepted By .` rove the above ~leceio list effeckive // f /~ on ~ l /,.Sl ~f at approx. ~ (am) (pm)hone O in pt and terms, and acknowledge that the general price list effective ~/ f /~rj;"casket were made availab p prig r to selection of services. _ ~fi Date _ Statement To: _ f~~~r.~ Tifle U ti N ~ ~ ~ ~ ~ W W CnWn:V ~ ~ 1~ Z ~ r- ~ Q ~ .. OJ ,~ o am m ~ ~ ~ ~~ -.~ ~ Z U ~ m WJ~~ N ,k (1:Q~f\ 'k Q vim.. r-*cn ]C !n ~ ~ ~ ~ m ~ ~ U N(Yw _ ~C1~0 Q 2 ~ # .. F- _ _ a ~ U 0 W 2 W U ~ ~ ¢ U 0 ~ (d ~ ~ ~ W F- Cd D7 0~'1 2 i=- Z Q CD In F- ~ ~ }mow ~ ~~~ W ~ p Z Q ~ ~ ~ ~ 0_ U ~ W ~ W ~¢ J •• O ~ ~ W H ~ .-~ Q ~ O ~ Z . -+ tJ] ~ ~ ~ Q Q Q ~ U ~w a ~~ > > > O I F- p~ +¢ ~ r ~ '"" IH ti I U7 ~ Z t ~ I ~ ~ Z J = I ~ X ~ } o ' ~ ~ ~ U U Z Z W = Q O ~- W ~ ~ t!J Q ~ = U N I (We), the ur cordance with and BITNER CREMATORY, LLC ` 2100 LING~ESTOWN ROAD HARRISBURG, PA 17110 PHONE: (T 17) 652-77~~~ • FAX: (717) 545-2325 AUTHORIZATION FOR CREMATION AND DISPOSITION (Please print or type) (the "authorizing Agent(s)"), hereby authorize and request Bitner Crematory, LLC, hereafter known as "Cremato its r`~le~ and regns, n applic~ a state/provi ial or local laws or regulations, to cremate the human re ~G~' /'~~ ~~ ~*)~ ~he "deced'e~nY') and to arrange for the final disposition of the cremated as set forth on this form. I (We) have identified the human remains that were delivered to the funeral home as the decedent, and have authorized the funeral home to decedent to the Crematory for cremation. Otherwise, I (We) have elected to waive the:right to identify the human remains at the funeral home. I (We) have read th~_attached document eptitled "Crematory Policies, PF`ocedurejs agd F~equirements," and hereby authorize Crematory to F _ _ :. cremation of the decedent ih accordance with tktat document.{Reverse fide of this d4cumeht:) f~ ~ '' ' Initials of AA ;; r' -;f (Acknowledgement of prior 3 pa IDENTIFICATION Date of Death Time of Death AM/PM Place of Death: City, Borough, Twp. County. Sex ~_ Race_ ~ Age Was death caused by an infectious or contagious disease? If yes, please explain Yes ^ ~~~ ', 'i; ~. ',i ~~ ~~ ;. ~,. i , L' {: PACEMAKERS, PROSTHESES, SILICON AND RADIOACTIVE IMPLANTS ~ Please initial one of the next two. q~gr~ h,~s. The decedent's rer~m'~s d not c tain a pacemaker, radioactive implant or any other device that could be harmful to the crematory. They are safe to crepnate.. ; Initials of AA ~ ' The following list contains all existing devices (ncluding all mechanical, radioactive implants and prosthetic devices) which are implanted in or attached to the decedent, that should be removed prior to cremation. I have instructed the fungal home to remove or arrange for the removal of these devices and to property dispose of them prior to transporting the decesertCto" Crematory. Initials of AA `~_,~_ I hereby authorize Crematory to properly dispose of or`recycle any surgical steel remaining after cremation. Initials of AA ALL PACEMAKERS AND RADIOACTIVE IMPLANTS MUST BE REMOVED PR/OR TO DELIVERING THE DECEDENT TO THE CREMATORY. TIME OF CREMATION Crematory is authorized to perform the cremation upon receipt of the human remains, as its discretion, and according to its own time schedule, as work permits, without obtaining any further authorization or instructions. rmr~ ~ rwrv.a, ~ w~~ ..... _ - ....t .._ _ ~. r - _..._, . - - -~ ,,, After the cremation has-taken-pfa`cs;~fie cr'~maTed't`Bmairis~5ave been p' ess~~arrc~Yl~e`p~pdessedcreitlatfurd'r8maiffs place~in~he d6~lr~hed recepfaCle; Crematory will arrange for the disposition of the cremated remains as fot5ows; and the Authorizing Agent(s) hereby authorizes Crematory to release, deliver, transport, or ship the cremated remains as specified. Check one of the following:. 1. ~er the cremated remains to By (date and time) 2. Release the cremated remains to the funeral home to be picked up within 10 days. 3. Deliver the cremated remains to the U.S. Postal Service for shipment by Registered, Return Receipt mail to: _ (or other specific i (If option three is selected, then 1(We) agn:e to assume all liability that may arise from such shipment, and to indemnify and hold Crematory harmless from any and all claims that may arise from such shipment.) ~ ' ' Initials of AA~,___~ :_ AUTHORITY OF AUTHORIZING AGENT I (We), the undersigned, hereby certify that I am the closest living ~t~ t J~t and that I am related to the decedent as his/her or that otherwise serve (served) in the capacity of to the dec that I have charge of the remains of the decedent and as such possess full legal authority and power, according to thaws of the state/province of , to execute the authorization form and to arrange for the cremation and disposition of the cremated remains of the decedent. In addition, I am aware of no objection to this cremation by any spouse, child, parent or sibling. LIMITATION QF LIABILITY As the Authorizing Agent(s), I (We) hereby agree to indemnify, defend and hold harmless Crematory, its officers, agents and employees, of and from any and ail claims, demands, causes of action, and suns of every kind, nature and description, in law or equity, including legal fees, costs and expenses of litigation, arising as a result of, based upon or connected with this authorization, including the failure to properly identify the decedent or the human remains transmitted to Crematory, the processing, shipping and final disposition of the decedent's cremated remains, the failure to take possession of or make proper arrangements for the final disposition of the cremated remains, any damage due to harmful or explodable implants, claims brought by any other person(s) claiming the right to control the disposition of the decedent or the decedent's cremated remains, or any other action performed by Crematory, its officers, agents, or employees, pursuant to this authorization, excepting only acts of willful negligence. >, ,_. __ r , ~ , >r:...~ ~, ~ .. ., .. '. Initials of_AA ~~~ ~, ,. .... __ a I (We), the undersigned, have read the chapter on "The Cremation Process'~and i (We) und~rsfand what is involved in the cretnatiori process. p. , Initials of AAA` SIGNATURE OF AUTHORIZING AGENT(S) ~r _ ~~ ,~: ~~ ~; ;'. n.~ 51!. 1Fi ~~ ~:'~ ~~~ ~ r'! ~°` '~: ~' .{ r `~ , =aa N ¢ a L C 01 ~ f6 7 ~ a ~ g v ! `~./ L ~ ff~~ vJ ~ ~ C~. ~ b ~ ~ S ~ ~ tit ~~ i * } ~ ~ ~ _. ~ ~ ~'~~ dd ~~0~ '~f~~~+~Ic~d~~~1f1~ 1d~10~ S,i`~HdJO F. 1 ~' k'.,~ '~ I ~ ~ ~! 1 I I~ J •~