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Home My WebLink About03-0348REV-1500 EX COMI,;,ONW EALTH OF PENNSY', VANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 (LAST, FIRST, AND MIDDLE INITIAL) Z ZELAZNY, ELIZABETH A UJ I DATE OF BIRTH (MM-DD-YEAR) t'"t DATE OF DEATH (MM-DD-YEAR) ~'~ 12/23/1919 O 07/04/2002 III , SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) INHERITANCE TAX RETURN F,_E RESIDENT DECEDENT SOCIAL SECURITY NUMBER 204-07-3?90 THIS RETURN MUST BE FILED IN DUPUCATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER 204-0?-3790 LU OO n" ..J 13. [] 1. Original Return [] 2. Supplemental Return [] 3. Remai,~e,- Return (date of death prior to 12-13-82) [] 4. Limited Estate [] 4a. Futura Interest Compromise (da~e of death a~ter 12-12-82) [] 5. Federal Estate Tax Return Required [] 6. Decedent Died Testate (Attach copy of Will)[] 7. Decedent Mointained a Living Trust (A, ac~ copy of Trust) ...8. Total Number of Safe Deposit Boxes [] 9. Litigation Proceeds Received [] 10. Spousal Poverty Credit (date of d~h betwe~12-31-91and l-l-95) [] 11. Election to tax under sec, 9113(A)(Att~s~o) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: z I COMPLETE MAILING ADDRESS ILl ~ LOUIS ZELAZNY JR 15 CHARISMA DRIVE z O n FIRM NAME (If Applicabie) CAMP HILL PA 17011 ,,, n, n, TELEPHONE NUMBER O o (717) 737-1131 ~ ,,i 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. QosdyHe~d Corporation, Partnership or Sale-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) (Schedule E) 6. Jointly Owned Propaty (Schedule F) (6) [] Separate Billing Requested 7, Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1 - 7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mo~gage Liabilities, & Uens (Schedule I) (10) 11. Total Deductions (total Unes 9 & 10) 12. Ne{ Value of Estate (Une 8 minus Une 11) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Ne{ Value Subject to Tax (Une 12 minus Line 13) 234.70 12,584.42 OFFICIAL USE ONLY (8) 12,819.12 1, 691.93 (11) 1,691.93 11,127.19 (12) (13) (14) 11,127.19 SEE INSTRUCTIONS FOR APPUCABLE RATES 15. Amount of Une 14 taxable atthe spousal tax rate, or transfem under Sec. 9116 (a)(1.2) 16. Amount of Une 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate O.O0, x.0 O, (15) 11,127.19 x.o 45, (16) 0.00 x.12 ¢7) 0.0 0 x .15 (18) (19) 19. Tax Due 20. [] [CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT] > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < 0.00 500.?2 0.00 0.00 50O.?2 STF PA42021F.1 Decedent's Complete Address: ISTREET ADDRESS 124 WOODS DRIVE, LOT 8 'lc~ MECHANICSBURG ISTATE PA I ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Pdor Payments C. Discount (1) Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (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. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF VI/ILLS, AGENT 500.72 0.00 500.72 500.72 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS Yes No 1. Did decedent make a transfer and: 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 secudty 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 SCHEBULE G AND FILE IT AS PART OF THE RETURN, Under penalties of perjury, I dedare that l have, examine, tl},,is r,et~,m, indudin,,g. - .,:~;~-?..a..n~ ~e.S=ra2h~env~n~ed~ote°, the best of my knowledge and bdief, it is true, correct and Declaration of preparer other than the persona representauve is based on all ..urn ~uu. u, w.,~, F,,.~. ...... ,, _,,v.. DATE SIGNATURE OF~.~ERSON..EE, SP.O~ISIBLE FOR FILING RETURN XDD S 'r - ¢-' 15 CHARISMA DRIVE, CAMP HILL PA SIGNATUR[~?F P~REPARER OTL-IER T~AN REPRESENTATIVE 17011 DATE ADDRESS 621A WEST ELM AVENUE, HANOVER PA 17331 04/04/03 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 (a) (1.1) (i)]. or dates of death on or after January 1, 1995, the tax rate im posed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. §9116 (a) (1.1) (ii)]. F from tax and the statuto requirements for d~sclosure of assets and filing a tax retum The statute does not exempt a transfer to a surviving spouse , ry · . · 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 RS. §9116(a)(1)], The tax rate imposed on the 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. STF PA42021F.2 REV-1508 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE E CASH, BANKDEPOSITS,&MISC. PERSONALPROPERTY FILE NUMBER Include the proceeds of litigation and the date the proceeds were received bythe ~t~e All property jolntly.~wned with the right of survivorship must be disclosed on Schedule R VALUE AT DATE ITEM OF DEATH NUMBER DESCRIPTION 200.00 34.70 HOUSEHOLD GOODS REFUND CHECKS TOTAL (Also enter on line 5, Recapitulation) $ 234.70 (If mom space is needed, inse~ additional sheets of the same size) STFPA42021F,9 REV-1509 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ELIZABETH A. ZELAZNY SCHEDULE F JOINTLY-OWNED PROPERTY FILE NUMBER If an ~__~_~e~__ was mede joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME A. LOUIS ZELAZNY, JR. ADDRESS 15 CHARISMA DRIVE CAMP HILL, PA 17011 RELATIONSHIP TO DECEDENT SON JOINTLY-OWNED PHUP~-hH Y: %OF DATE OF DEATH LETTER DATE DESCRIPTION OF PROPI::R I Y DATE OF DEATH DECD'S VALUE OF ITEM FOR JOINT MADE ndude name of financial institu~on and bank accost nJznber or similar iden~fying rtmba'. VALUE OF ASSET iNTEREST DECEDENTS INTEREST NUMBER TENANT JOINT Attach deed for joinlly-hetd real estate. 1. A. MEMBERS 1ST FEDERAL CREDIT UNION 5000 lOUISE DRIVE, PO BOX 40 ~ECHANICSBURG PA 17055 1982 CHECKING ACCOUNT 12680-11 1,604.60 50 802.30 1985 SAVINGS ACCOUNT 12680-05 21,079.31 50 10,539.66 1985 SAVINGS ACCOUNT 12680-00 270.68 50 135.34 1985 SAVINGS ACCOUNT 12680-02 151.11 50 75.56 2. A PNC BANK, PO BOX 609 PITTSBURGH, PA 15230 1985 CHECKING 50-7008-7132 2,063.11 50 1,031.56 TOTAL (Also enter on line 6, Recapitulation)$ 12,5 8 4.4 2 (If more space is needed, insert addition~ STF PA42021 F.IO REV-1511 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ELIZABETH A. ZELAZNY SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER Debts of de;~t must be reported on Sch.~u!e I. ITEM NUMBER 1, 2. 3. 8. 9. 10. 11. 12. DESCRIPTION :UNERAL EXPENSES: HOLLINGER FUNERAL HOME FUNERAL FLOWERS FUNERAL FOOD ~,DMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Sodal Security Number(s) / EIN Number of Pe'senal Representative(s) Stre~ Addrsss city State Year(s) Commission Paid: Attorney Fees Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Zip Street Address City Relationship of Claimant to Decedent State Zip Probate Fees Accountant's Fees Tax Return Preparer's Fees CAPITAL AREA SURGICAL ASSOCIATES LOT RENT CABLE ELECTRIC ADVERTISING BANK CHARGE TOTAL (Also enter on line g, Recapitulation) AMOUNT 905.00 119.74 89.33 27 13 295 00 19 61 131 41 100 71 4 00 1,691.93 (If more space is needed, insert additional sheets of the same size) STF PA42021 F.12 REV-1513 EX + (9-00) I I ' I SCHEDULE J I COMMONWEALTH OF PENNSYLVANIA / BENEFICIARIES / / ................ __ FILE NUMBER ESTATE OF ELIZABETH A. ZELAZNY II. 1. NUMBER I. RELATIONSHIP TO DECEDENT Do Not Ust Trustee(s) NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] LOUIS ZELAZNY, JR. 15 CHARISMA DRIVE CAMP HILL PA 17011 SON ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOW N ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET AMOUNT OR SHARE OF ESTATE 100% ~ ON REV-1500 COVER SHEET (If more space is needed, insert additional sheets of the same size) S'IF PA42021 F.14 ~bscibed and swon~ to bcfem ma Martin Ripso~ Notary Pablic COmJnis:~k,n ~;~p::(~ ,)~1~' ~7, 2004 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 002476 ZELAZNY LOUIS JR 15 CHARISMA DRIVE CAMP HILL, PA 17011 ESTATE INFORMATION: SSN: 204-07-3790 FILE NUMBER: 2103-0348 DECEDENT NAME: ZELAZNY ELIZABETH A DATE OF PAYMENT: 04/22/2003 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 07/04/2002 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $5OO.72 TOTAL AMOUNT PAID: $500.72 REMARKS: LOUISZELAZNY POSTMARK DATE ? SEAL CHECK//3459 INITIALS: DO RECEIVED BY: DONNA M. OTTO DEPUTY REGISTER OF WILLS REGISTER OF WILLS BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA I7128-060I LOUIS ZELAZNY JR 15 CHARISMA DR CAMP HILL CUT ALONG THIS LINE PA 17011 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT~ ALLOWANCE OR DISALLOWANCE! OF DEDUCTIONS AND ASSESSMENT OF TAX DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 06-16-2005 Z ZN , 21 03-0348 L~I~E RLAND Amount/' g ,.'~ Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17015 RETAIN LOWER PORTION FOR YOUR RECORDS -~ Mr. Louis Zelazny 15 Charism Dr. Cmnp Hill, PA 17011 co. 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 002714 ZELAZNY LOUIS JR 15 CHARISMA DRIVE CAMP HILL, PA 17011 ........ fold ESTATE INFORMATION: SSN: 204-07-3790 FILE NUMBER: 2103-0348 DECEDENT NAME: ZELAZNY ELIZABETH A DATE OF PAYMENT: 06/20/2003 POSTMARK DATE: 06/19/2003 COUNTY: CUMBERLAND DATE OF DEATH: 07/04/2002 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $1.23 REMARKS' LOUIS ZELAZNY TOTAL AMOUNT PAID: $1.23 SEAL CHECK# 3482 INITIALS' AC RECEIVED BY.' DONNA M. OTTO DEPUTY REGISTER OF WILLS REGISTER OF WILLS Lewis Zelazny 15 Charisma Camp Hill, PA 17011-1010 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 LOUIS ZELAZNY JR 15 CHARISHA DR CAHP HILL COMMONNEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOT[CE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLONANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ~S~-~" :- - ~ DATE 06-16-2005 ~" " "' ESTATE OF ZELAZNY DATE OF DEATH 07-04-2002 FILE NUHBER 21 05-0548 ,]U;'I 20 ,~l: :40 COUNTY CUMBERLAND ACN 101 Amount Remitted REV-1547 EX AFP ¢01-05) ELIZABETH A MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF MILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17015 CUT ALONG THIS LINE ~ RETAIN LONER PORTION FOR YOUR RECORDS ~ REV-lS47 EX AFP ¢01-03) NOTICE OF INHERITANCE TAX APPRAISEHENT, ALLONANCE OR ESTATE OF ZELAZNY DISALLONANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ELIZABETH A FILE NO. 21 03-0548 ACN 101 DATE 06-16-2003 TAX RETURN NAS: (X} ACCEPTED AS FILED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE CHANGED APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A} (1} 2. Stocks and Bonds (Schedule B} C2} $. Closely Held Stock/Partnership Interest (Schedule 4. Mortgages/Notes Receivable (Schedule D} 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E} (5} 6. Jointly Owned Property (Schedule F} 7. Transfers (Schedule G} 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H} (9) 10. Debts/Hortgage Liabilities/Liens (Schedule I} (10} 11. Total Deductions 12. Net Value of Tax Return 15. 1~. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J} Net Value of Estate Sub3ect to Tax 234.70 12r584.42 o00 · 00 NOTE: To insure Proper · 00 credit to Your account, .00 submit the upper Port/on .00 of this form w/th your tax payment. (8) 12,819.12 1,691.93 .00 (11) . ] .ggl (12) 11,127.19 (15) .00 (1~) 11,127.19 NOTE: reflect f~gures that ~nc[ude the term! of ~LL returns assessed to date. ASSESSMENT OF TAX: If an assessment was issued previous/y, lines 14, 15 and/or 16, 17, 18 and 19 w111 TAX CREDITS: PAYMENT [ DATE 04-22-2003 BALANCE OF UNPAID INTEREST/PENALTY AS OF 04-23-2003 IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. . O0 x O0 = . O0 11,127.19 x 045 = 500.72 .00 x 12 = .00 . O0 x 15 = . O0 TOTAL TAX CREDIT / 500.72 BALANCE OF TAX DUE .00 INTEREST AND PEN. 1.23 TOTAL DUE 1.23 RECEIPT NUMBER CD002476 DISCOUNT C+) INTEREST/PEN PAID C-) .00 500.72 AMOUNT PAID 500.72 C IF TOTAL DUE IS LESS THAN ~1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR}, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.} 15. Amount of L/ne 1~ at SPousal rate C15}. 16. Amount of L/ne 14 taxable at Lineal/Class A rate C16} 17. Amount of L/ne 14 at Sibling rate C17}.. 18. Amount of L/ne 14 taxable at Collateral/Class B rate C18} 19. Pr/nc/pal Tax Due RESERVATION= Estates of decedents dying on or before December 12, 1982 -- if any future interest in the estate is transferred in possession or enjoyment to Class B Ccollateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class B Ccollateral) rate on any such future interest. PURPOSE OF NOTICE: To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act 25 of 2000. (72 P.S. Section 9140). PAYMENT= Detach the top portion of this Notice and submit with your payment to the Register of Mills printed on the reverse side. --Make check or money order payable to: RBG~ST~'~ OF RXLLS; AGENT REFUND (CR)= A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an 0'Application for Refund of Pennsylvania inheritance and Estate Tax" (REV-ISIS). Applications are available at the Office of the Register of Mills, any of the 25 Revenue District Offices, or bY calling the special 24-hour answering service for forms ordering= 1-800-562-2050; services for taxpayers with special hearing and / or speaking needs= 1-800-447-$020 (TT only). OBJECTXONS= Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment of tax Cincluding discount or interest) as sho~n on this Notice must object within sixty C&O) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. ADMIN- ISTRATIVE CORRECTIONS= Factual errors discovered on this assessment should be addressed in writing to= PA Department of Revenue, Bureau of Individual Taxes, ATTN= Post Assessment Review Unit, DePt. 280601, Harrisburg, PA 17128-0601 Phone C717) 787-6505. See page 5 of the booklet °'Instructions for Inheritance Tax Return for a Resident Decedent" (REV-1501) for an explanation of administratively correctable errors. DISCOUNT= If any tax due is paid within three CS) calendar months after the decedent's death, a five percent (SX) discount of the tax paid is allo~ed. PENALTY~ The 15X tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before Januar~ 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalt~ is appealable in the same manner and in the the same time period as you would appeal tho tax and interest that has been assessed as indicated on this notice. INTEREST= Interest is charged beginning u/th first day of delinquencY, or nine (9) months and one C1) day from the date of death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of six (6~) percent per annum calculated at a daily rate of .000164. All taxes which became delinquent on and after danuar~ 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2005 are= Interest Daily Interest Daily Interest Daily Year Rate Factor Yeast Rate Factor Yea~ Rate Factor 1982 20~ .000548 1987 9X .000247 1999 7X .000192 1983 16X .000438 1988-1991 11X .000501 2000 8X .000219 1984 11X .000501 1992 9X .000247 2001 9X .000247 2002 6X .000164 1985 15X .000~56 199~-1994 7X .000192 1986 lOX .000274 1995-1998 9X .000247 2003 5~ .000137 --Interest is calculated as follows= /NTERBST = BALANCE OF TAX UNPAXD X NUMBER OF DAYS DBLXNQUENT X DAXLY XNTBRBST FACTOR --ANY Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date sho~n on the Notice, additional interest must be calculated. BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX D/VTSION DEPT. 280601 HARRISBURG, PA 17128-06D! LOUIS ZELAZNY JR 15 CHARISHA DR CAHP HILL CONHONWEALTH OF PENNSYLVANIA DEPARTNENT OF REVENUE INHERITANCE TAX STATEHENT OF ACCOUNT DATE ESTATE OF DATE OF DEATH COUNTY ACN 07-14-2003 ZELAZNY 07-04-2002 21 05-0348 CUNBERLAND 101 Amoun~ RemJ.'l:'~ed KEY-lin7 EX AFP (~1-~$) ELIZABETH A HAKE CHECK PAYABLE AND RENZT PAYNENT TO: REGISTER OF WILLS CUHBERLAND CO COURT HOUSE CARLISLE, PA 17015 NOTE: To insure proper crmdi~ ~o your mccoun~, submi~ ~hm upper portion of ~h~s form wi~h your ~ax payment. CUT ALONG TH'rS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS -.~ REV-1607 EX AFP (01-03) ~ INHERITANCE TAX STATEHENT OF ACCOUNT ~ ESTATE OF ZELAZNY ELIZABETH A FILE NO. 21 05-0348 ACN 101 DATE 07-14-2005 THIS STATEHENT TS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACH IN THE NAHED ESTATE. SHONN BELO# IS A SUHNARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYNENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 06-16-2005 PRINCIPAL TAX DUE: PAYMENTS (TAX CREDITS): PAYMENT DATE 04-22-200~ 06-19-Z00~ 500.72 RECEIPT NUHBER CDOOZ476 CD002714 DISCOUNT (+) !INTEREST/PEN PAID (-) .00 I .Z$- AHOUNT PAID 500.72 1.23 IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE ZS LESS THAN $1~ NO PAYHENT IS REQUIRED. TOTAL TAX CREDIT 500.72 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 IF TOTAL DUE ZS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. ) PAYMENT: Detach the top portion of this Notice and submit eith your payment made payable to the nome and address printed on the reverse side. -- If RESIDENT DECEDENT make check or money order payable to: REGISTER OF NILLS, AGENT. -- If NON-RESIDENT DECEDENT make check or money order payable to: COMMON#EALTH OF PENNSYLVANIA. REFUND (CR): A refund of a tax credit, ehich mas not requested on the Tax Return, amy be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1315). Applications ere available at the Office of the Register of gills, any of the Z3 Revenue District Offices or free the Department's lq-hour enamoring service for fores ordering: 1-800-362-20S0; services for taxpayers with special hearing and / or speaking needs: 1-SO0-~qT-3D20 (TT only). REPLY TO: Questions regarding errors contained on this notice should be addressed to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 17128-060l, phone (7[7) 787-6S05. DISCOUNT: If any tax duo is paid within three (3) calendar months after the docedent's death, a five percent (5X) discount of the tax paid is allowed. PENALTY: The 1SI tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January lB, 1996, the first day after the end of the tax amnesty period. INTEREST: Interest is charged beginning with first day of delinquency, or nine (9) months and Dna (1) day from the date of death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of six (6Z) percent per annum calculated at a daily rate of .00016~. All taxes which became delinquent on and after January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by fha PA Department of Revenue. The applicable interest rates for 1982 through 2003 are: Interest Daily Interest Daily Interest Daily Rate Factor Year Rate Factor Year Rate Factor 1982 lOX .000S~8 1987 92 .O00Z~7 1999 7Z .000192 1983 lei .000638 1988-1991 llZ .000301 2000 8Z .000219 1986 llZ .000301 1992 9X .0002~7 200! 9Z .O00Zq7 1985 X3Z .000356 1993-199~ 7Z .000192 2002 62 .00016~ 1986 lOX .00027~ 1995-1998 92 .O00Z~7 2003 5Z .000137 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPATD X NUtIBER OF DAYS DELINI;IUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days beyond the data of tho assessment. If payment is made after the interest computation date shoen on the Notice, additional interest must bo caIcuIated.