HomeMy WebLinkAbout05-08-12 (2)
1505610101
RE ~ nn varda OFFI(:IAL USE ONLY
PA Department of Revenue Pe p ~ County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO BOX Z8o6D1 2 I~ 1 2 D 0 2 6 1
Harrichurrt. PA t9f2R-0601 RESIDENT DECEDENT
Y 1500 EX (ot-i0)
Date of Birth MMDDYYYY
/o ~~f/q26
Decedent's First Name MI
NN/1 Zk A/
(If Appliwblej Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST 8E FILED IN DUPLICATE WITH THE
5 ~ s~ REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
l~ 1. Original Return O 2. Supplemental Retum
O 4. Limited Estate
O 4a. Future Interest Compromise (date of
death after 12-12-82)
O 3. Remainder Return (date of death
prior to 12-13-82)
O 5. Federal Estate Tax Retum Required
O 6. Decedent Died Testate O 7, Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Bozes
(Attach Copy of Will) (Attach Copy of Trust)
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9713(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telepf~i ne Number -~-.~ _t
EMI R' k ~ K" @ {(~ li/~IAak ~ E'rCS ~,.. .II.~ ...d.., ~ . + ,- ~..~°~...2,..... ,,~§
.., ~A;
First line of address
,_.i~z
'.~J r-7 r7 -z~ -
~>tj'at
Jr- ^' __
.n ro
q .,._
r,. `
DATE FILED
~... -~,.
- %
Correspondent's email address; /fIR1t~/S .r7. q4 /O/I CAfB~~O/vJ~d'. COA~f
Under penalties of perjury, I declare that I have examined this refum, including accompanying schedules and statements, and to the best of my knowledge and belief,
it Is We, correct and wmplete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
/00 W8J7 V/NG ff Jni/flpytl9J T`N~ ~R %90//
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610101 1505610101 J
J
REV-t500 EX
Decedent's Name:
1. Real Estate (Schedule A) .......................................... ... 1.
2. Stocks and Bonds (Schedule B) .................................... ... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3.
4. Mortgages and Notes Receivable (Schedule D) ........................ ... 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).... ... 5.
6. Jointly Owned Property (Schedule F) p Separate Billing Requested .... ... 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) p Separate Biting Requested...... .. 7.
8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8.
9. Funeral Expenses and Administrative Costs (Schedule N) ................. .. 9.
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ .. 10.
11. Total Deductions (total Lines 9 and 10) ............................... .. 11.
12. Net Yalue of Estate (Line 8 minus Line 11) ............................ .. 12.
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ..................... ... t3.
14. Net Value Subject to Tax (Line 12 minus Line 13) ................... ..... 14.
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0~ 15.
16. Amount of Line 14 taxable
at lineal rate X .0 y~ 16.
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of line 14 taxable
at collateral rate X .15 18.
19. TAX DUE ......................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
1505610105
Decedent's Social Security Number
O
Side 2
1SU561~1O5 150561~1~5 J
REV-1500 EX Page 3 Flle Numbar 2~ _ ~Z ' d02G~
Decedent's Comolete Address: O
DECEDENTS NAME
STREET ADDRESS - -- ----_--~-~ --~ - ~- -
-- I00 _ !,v_UiNt~ JT~ - -- - ~----
CITY ------ ----- - ---~ STATE --~~ZIP -.
sN~~e~~r/~uN.J I /'A ~7DN
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. CreditsJPayments
A. Prior Payments _.-._
6. Discount
3. Interest
4. IT Line 2 is greater than Line 1 + Line 3, enter the difference. This is fhe OVERPAYIIIENT.
Fill in oval on Page 2, Llne 20 to request a refund.
Total Credits (A + B )
(t) 292.87
(3)
D, O O
(4)
5. If Line 1 + Line 3 Ls greater than Line 2, enter the difference. This is the TAX DUE. (5) ;[ 7 8'.l ,3
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did tlecedent make a transfer and: Yes rNo~
a, retain the use or income of the property transferted :.................................................................................... ...... ^ LJ
b. retain the right to designate who shall use the property transferted 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 Dec. 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 properly, which ~-,/
contains a beneficiary designation? .................................................................................................................. ...... ^ L'7
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July i, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent [72 P.S. §9116 (a) (1,1} (i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (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 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 [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 t~eneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1i].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent (72 P.S. §9t16(a)(1.3)]. Asibling 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-1503 EX+ (fi-99)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCNEpULE B
STOCKS & BONDS
ESTATE OF FILE NUMBER
RNA/kTCkA/ N MyCRJ 2/ - / Z - D Z /e /
All property ~olntly-owned wtth right of survivorship must be disclosed on Schedule F.
VALUE AT DATE
ITEM DESCRIPTION OF DEATH
NUMBER
t. ~irs>< Cvm~1e.~[w~wc>N ~.~m.+ciAL Co,c~,rnne.J ~fcf~ ~/ 3 y 9P. yr
2~
~L ~ 3GN S~la/rS S.7I .~. T~KG
2 /house >taons Ciq/t/.~%ra .T~r. 500. co
TOTAL (Also enter on line 2, Recapdulation) I S ~„3~ 918',y5~
(If. more. space isneaded, ir~art~aalsh9ete of the same size)
AN.~509D~~Itw!
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TA% RETURN
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
A,vJ~A- ~t~ !/ in-yC/~d 2/ -/Z - oz6 /
Include the pnxeetls of litigatbn and the date the proceeds were received by the estate. All property Jointly-owned with the dgM o(survivotship must be dieebsed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
,. /99S S'A~rvu/ sra~/ z379~
2 i^h-n~crr~cro Avrd ~u.~cyr Ise-/3,~E ~/9 s/
3. Vfl-NGA~a~ /n~Ne y r~n,r':,c.~. f ~~n Ft8-y
TC?TAL (Also entecon line 5, Reicapitulatlon) I S Oi ~ ~ 7
space
16Vd5W IX.I1,B1)
SCHEDULE F
GOMMONWEALTHOF PENNSYLVANIA JOINTLY-OWNED PROPERTY
INHERITANCE TA% RETURN
RESI NT DECE ENT
ESTATE OF FILE NUMBER
kuNh ,Tt~-.v N myr~t.r Z./-/2-~OZG/
Ran asset was made jolts wNh(n one yoar of Rre decedeM's dab of deaTh, h moat ha repoMd on Schedub G.
SURVIVINGJOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
A. NI h-~CK N tat ,So./
i"Y /ao wrrd vcve• ,n- ,S~.itE,~.~AAt7.~wl /i4 /~eA!
B.
C.
JOINTLY-0WNED PROPERTY:
ITEM
NUMBER LETTER
FOR JOIM
TENANT DATE
MADE
JOINT DESCRIPTION OF PROPERTY
Include name otfiriancial insfiMion end bank acmun(number orsifMar Wenti/yxg nem6er. Arun
dead hM jointly-held feel eeteie.
DATE OF DEATH
VALUE OF ASSET %OF
DECA'S
INTEREST DATE OF DEATH
VALl1E OF
DECEDENT'S IMEREST
~. A. y/,~oo9 Mr~nbaa.- FiRrf F~./ia/ Goo: f ~/w.a^~
'e 77513/
/ A
z a cA/rex,N(~ 332 !. rG 5d 7. ! GGo-. 2B
3 '~ Sn v,Nrrs si ~. 28 sn7
ZG3.bi~
Mn+tr M~~a~ l 8 7 ~, 8;r Se7e 9 3~ . 9 /o
enter on line 6, R 3 8
more space is needed, it'L1gkTdL~heeis of the same size)
REV-7511 EX+(10-06)
scNS~u~E x
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCETAX RETURN ADMINISTRATNE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBEA
ANNA ~t~,rt k nLyLrcS Zl -/2- 02~/
Debts of decedent must be reported on Schedule 1
ITEM
NUMBEfl -0ESCRIPTION AMOUNT
A. FUNERAL EXPENSES: // p~8:;
i. /t'{RL~GZLt ~v.rtR.aL He,~tr[: 0 i~
Gr,/Gb~frcN ~c-s-d,S"f,~L
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Canmissions
Name of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid: NQn/f lJNI i D _
2~ Attorney Fees //oN~ PAiO
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address _
Ciry State Zip _
Relationship of Claimant to Decedent .
4. Probate Fees RE6~S9'FJG pF 4~at-J'
-Tvn`e,ee,-n,v~e Whir FrGwG- fC~
5. Accounhant's Fees
6, Tax Retum Preparer's Fees
7,
8'08' °°
~et h/ So
/.S A
TOTAL (Also enter on line 9, Recapitulation) I $ 9 ~ 3 Jr `3 ~
(II more space is needed, kMetE ^sheets of the same size)
REV-1513 EX+ (11-OB)
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVEON LINES 15 THROUGH 16 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS.
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
~ pennsylvania SCHEDULE
DEPARTMENT OF REVENUE BENEFICIARIES
INHERRANCE TAX RETURN
RESIDENT DECEDENT
ESTATE Of FILE NUMBER
Ar/Nr4 Tcr1 Al /! Mr r.<-.P 2 i - ~ 2 - 6 o ZG /
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Lint Trustce(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 2116 (a) (1.2).]
1. 1er/ ZS7
Mrs ~K N /n yr~s N PMIsa
/oo G/cs~ Vi,vc rr ,SA/it.,~wrnL..
/~MrcNTf~ 2s7.
~nA.ny /hytfS
7 Nor'~'f. ya.~d'f E N-eir Pa / 93C 9
GrNAr WkiD Di1vGMTB.t- ZS%
3L'j GFFY4'K ,e0 Gay Caav SQ, 29GyS
/~rcWaa~ ~. ~ eav JL. 15/0
/i35 C''IrM.uur~.rM st. Ar[n,rnF cA. 3o3L8 Son/
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL Of PART II -ENTER TOTAL NON-TAXABLE DISTRI9UT(ON5<QN LIN€ 13 OF REV-1500 COVER SHEET.
If more space is needed, lit 8iteets of the same sire.
REV-1572E%. (72-03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCNEDWE 1
aESrs o~ aECE~EIVr,
MORTGAGE LIABILITIES, & LIEtVS
ESTATE OF FILE NUMBER
fIA/A~.6 ~tMJ MYr~ 1J'IZ'OOZG/
BUREAU OF INDIVIDUAL TAXES
PO BOx 280601
WIRRI SBUR6 PA 1]128-0601
Pennsylvania
pfPMTMENT OF PEVENUE
PEV -154a EX XFP 105 -11)
PENNSYLVANIA INHERITANCE TAX
INFORNATION NOTICE FILE No. 21
AND ALN 12114343
TAXPAYER RESPONSE DATE oz-28-2D12
MARK H MYERS
100 W VINE ST
SHIREMANSTOWN PA 17011-6346
EST. OF ANNA J MYERS
SSN 186-24-9996
DATE OF DEATH 02-15-2012
COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
TYPE OF ACCOUNT
SAVINGS
® CHECKING
TRUST
CERTIF.
MEMBERS 1ST FCU prpvitletl the department with the information below. whf ch was used in calculating the inheritance tax tlue.
Records indi rate that at Lhe death of the abpve-nametl decedent. you were a Joint owner/bene£i ciary of this account. If you are the Spouse Of the
deceased and any amount other than zero is reflected below on the Potential Tax Due line, note na tax may be due, but you must
notify the department of your relationship to the deceased by checking Box C 1n PART 1 below and wri ttng "spouse" in PART 2.
I£ you believe the in£orma ti on is incorrect, please obtain written correctl on from the £i nand al institution. attach a copy to this farm and return
it to the abme atltlress. Please call 717 -7 R7-8327 with questions.
COMPLETE PART 1 BELON * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 275431-11 Date 11-25-2005 To ensure proper credit to the account, two
Established conies of this notice musk accompany
oavment tp the Register of Wills. Make Check
Account Balance r}` 3,321.56 payable to "R eg isier of Wills, AOent".
Percent Taxable X 50.000
NOTE: If Yax payments era made within three
Amount Sub]ect to Tex 5` 1,660.78 months of the decedent's date of death,
lax Rate X . 0 45 deduct a 5 percent discount on the tax due.
Am inheritance tax tlue will become delinauant
Potential Tax Due $ 74.74 nine months of tar the date of death.
PART TAXPAYER RESPONSE
A. ~ The above information and tax due is correct.
Remit pavnent to the ReBi sier of Wills with two copies of this notice to obtain
a discount or avoitl iota res t. or return this not ice to the Re sister pf Wills and
CHECK an official assessman4 will be issued by the PA Depa rknent of Revenue.
ONE
BLOCK B. ~ Tha above asset has been or will be reportetl and tax paid with the Pennsylvania inheritance tax return
ONLY files by the estate representative.
C. ~ The above infona ]on is incorrect and/or debts and deductions ware paid.
Couple to PART ~2 and/or PART ~ below.
PART If indicating a differ¢nt tax rate, please state t irNy` ' ~1 ~ s~~ri•
r~~
' P t
~ ~ u
~
relationship to decedent: ~
~
~ ~~ ~
#
~~~ ' ~~'
TAX RE TURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS ~~ ,4 ~ ~~~~~ ~~
LINE 1. Date Established 1
2. Account Balance 2 $
3. Percent l"axable 3 X
4. Amount Subdect to Tax 4 S
5. D¢bts and D¢ductSons 5
6. Amount TaXa61¢ 6 ^t
7. Tax Rate 7 X
R. Tax Due B
PART DEBTS AND DEDUCTIONS CLAIMED
0
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
2 y teri 7f/t a ct M N N ~
Z 10 2m]1 pJ E'M ~ 2 ~
f secs tJ:y w a W%ll ZV 33
3 ZI 1a,'~ Y r: /G
TOTAL (Enter on Line 5 of Tax Computation] 8
Under penalties of perjury. I declare that the facts I report¢d shove are true, correct and
complete to the best of my knowledge and bell ¢f. HOME C )
WORK ( )
rervAYER SIGNATURE TELEPHONE NUMBER DATE
GENERAL INFORMATION
1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with avoli cable interest basetl on informaki on
subnitfed by the financial inskituti on.
2. Inheritance tax becomes dalingu¢nt nine months after the tlecadent's dat¢ of death.
3. A joint account is taxable even when tho decetlent•s nane was added as a makkar of convenience.
4. Accounts (ln cludinp Those held between hushantl and wife) The decedent put in joi nk names within one year Drior to
death era fully taxable.
5. Accounts established jointly between husband and wife more than one year Drior Yo death are not taxable.
6. Accounts held by a decedenk •'in trust for'' another or others era fully taxable.
REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE
1. BLOCK A - If the inf arnation antl calcul akion in iha notice are to rrect antl de tlu ckions are not being elained, place an "X'•
in Block A of Part 1 of the "T axpaver Ra spouse" section. Sian two copies and subnit then with a check for the anoun4 of
Tax ko the rapi star of wills of the county indi catetl. The PA Departmenk of Revenue will issue an official assessment
(Form REV •1548 IX) upon receipt of the return fron the register of wills.
2. BLOCK B - If the asset sDecif ied on this notice has been or will be reported and tax paitl with the Pennsylvania inheritance
tax return Filed by the estate's represents kive, place an '•X" in Block B of Part 1 of the "Taxpny er Response" section. Sion two
copies end return to the register of wills of the county indicated.
3. BLOCK C - If the notice inf ornati on is incorrect and/or tleduction5 are being cl ainetl. check Block C and complete Parts 2 and 3
according to the instructions below. Sian two copies antl subnit then with Your check for the amount of tax payable to the register
of wills of the county indicated. Tha PA Devartn ant of Revenue w311 issue an official asse ssnont (Porn REV-1548 IX) upon receipk
of the return fron the register of will s.
TAX RETURN - PART 2 - TAX CALCULATION
LINE
1. Enter the date The account originally was establishatl or titled in the Hann er existing at tlake of death.
NOTE: For a decedent who dietl after l2/12/82. accounts the detetlent out in joint Hanes within one Year of death are
fully taxable. However, there is an Bxtlusi on not to exceed !3,000 per trans! arse, regartlle ss of the value of
the account or the number of accounts hal tl.
If a double asterisk (ae) appears before Your first nane in the address portion of this noti te, the x3.000 exclusion
was detlueied from the account bal ante as rep ortetl by the financial institution.
2. Enter the total balance ofi the accounk including interest accrued to the date of death.
3. The pe rcenkape of the account that is taxable to each survivor is de to rained as fall ow s:
A. The Dartentape taxable of ioint assets estab Lishetl more khan one Year Drior to the decetl¢nt's tleath:
1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE
JOINT OWNERS SURVIVING JOINT OWNERS
Exaaple: A joint asset reBiskered in the nane of the decedent and two other persons:
1 DIVIDED BY 3 CJOINT dJNERS) DIYI DEO BY 2 (BURY IVDRS) _ .167 X 100 = 16.7 percent (TAXABLE TO EACH SURVSYOR)
B. The percentage taxable for assets created within one year of the decedent's tlaaM or accounts owned by the detetlent but heltl
in truck far another indivitlual(s) (t rvst beneficiaries):
1 OIYIOED BY TOTAL NUMBER OF SURVIVING JOINT NULTIPLIEO BY 100 = PERCENT TAXABLE
DWN ERS OR TRUST BENEFICIARIES
Exempla: Joint account regi ste ratl in the nane of the decedent antl two other yeraons and established within one year Of death by
the tlecetlent.
1 DIVIDED BY 2 CSURVIVORS) _ .50 X 100 50 percent (TAXABLE FOR EACH SURVIVOR)
4. The anount subject to tax (Line 4) is tleta rninetl by nulkiplyine the account balance (Line 2) by the percent taxable (Line 3).
5. Enter iha total of the debts antl da tluctions listed in Part 3.
6. The amount taxable (Line 6) is tleta rained by subtracting the debts antl tleductions (Line 5) from The anount subject to tax (Line 4).
7. Enter the appropriate tax rate (13ne 7) as tlate rn in ed 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 per<enY 4.5 percent ~ 12 percent 15 percent
sTha tax rate smpos¢0 on the net value of transfers from a deceasatl child 2 Years of spa or younger at
death to or for the use of a neLUral parent, an adoptive Darent or a stepparent of the child is D percent.
The lineal class of heirs inclutles grantlparent s, Darent s, chi! tlran antl other lineal tlescandents. '•Chiltlren" includes natural chiltl ran
whether or not they have been advptad by others, atloptetl children and step chiltlran. ^Llneal descentlents" inclutles all chi! tlren of the
natural parents and their tlascenden ts, whether or Hat then pave been adopted by others; adopted descendents and their descentlents;
and step-tlascendanis. "Siblingz" era tlafinad as intlividuals who have at least one Darent in common with the tlecetlent, whether by blood
or adoption. The Collateral class of heirs includes all other beneficiaries.
CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED
Allowable tlebts antl datlucki ons are determined as follows:
A. You are legally responsible for paynenk, or the estate subject to administration by a personal representative is insufficient
to Day 4he de tluctible items.
B. You actually paitl She debts after the tleath of the detetlent and can furnish proof of payment.
C. Debts being cl ainetl oust be itemized fully in Part 3. If adtli tional space is neatletl, use B 1/2" z 11" sheet of paper. Proof of
paynenY nay be re sue steel by the PA Department of Revenue.
BUREAU OF INDIVIDUAL TAXES
PO BOX 280601
NARRSSBURG PA 17128-0601
Pennsylvania
DEPARTMENT OF REVENNE
XEV -1563 EX X.LP (05-11)
PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE FILE N0. 21
AND ACN 12114342
TAXPAYER RESPONSE DATE oz-2B-zDl2
MARK H MYERS
100 W VINE ST
SHIREMANSTOWN PA 17011-6346
EST. OF ANNA J MYERS
SSN 186-24-9996
DATE OF DEATH 02-15-2012
COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
TYPE OF ACCOUNT
® SAVINGS
CHECKING
TRUST
CERTIF.
HEMBERS 1ST FCU Drpvide0 the deDa rtment with the information below. which was used in calculating the inheritance tax due.
Records indicate that at the death of the above-name0 decetlent, you were a Joint owner/beneficiary pf this account. If y0U are the SpOUBe Of the
deceased and any amount other than zero 1s reflected below on the Potential Tax Bue line, note no tax may be due, but you must
notify the department of your relationship to the deceased by checking Boz C in PART 1 below and writing "spouse" in PART 2.
if you believe the information is incorrect. Dlease obtain wrf tten correction from Lhe financial institution. attach a copy to this form and return
it to the above address. Please ca11717-787 -8327,.with pees tt on s.
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account Ho. 275431-00 Date 11-25-20D5 To ensure vrover credit to the account, two
EStabllsAetl covies of this notice oust acconvanv
Davnent tD the Register of Wills. Make check
Account Balance 527 28
payable to "Register of Wills, Agent".
Percent Taxable X SD.OOD
NOTE: If tax vayments are made within three
Amount Subiect to Tax $ 263.64
months of khe decedent's date at death,
Tax Rate X , p 4 5 tleduct a 5 Darcent discount on khe tax due.
Any inheritance tax due will becone tlalinmu ent
Potential Tax Due ~ 11.86
nine nonths after the tla[e of death.
PART TAXPAYER RESPONSE
0
A. ^ The above information and kex due is correct.
Remik vaynent to the Re9i star of Wills with two copies of this notice Yo obtain
a discount or avoid interest, or return this notice to the Register of Wills and
r CHECK an official assessment will be issued by the PA Department of Revenue.
I ONE ~
L BL DCK B. ~ The above asset has bean or will be reDOrted and taz void wi kh the Pennsylvania inheritance tax rata rn
ONLY tiled by the estate rep resen [ati ve.
C. ~ The above informs eon is incorrect and/or debts and deductions were paid.
Lonvlete PART ~2 and/or PART ~ below.
PART If intlicating a different tax rate, please state
relationship LO tle<etle nt:
TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS
LINE 1. Data Established 1
2. Account Balance 2 $
3. Perc ¢nt Taxabl¢ 3 X
4. Amount Subject to Tax 4 S
5. Debts and Deductions 5
6. Amount Taxable 6
7. Tax Rate 7 X
e. Tax Due 8
PART
C
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
Under penalties of perjury, I declare that the facts I reported above are true, correct antl
complete to th¢ best of my knowledge and belief. HOME C )
WORK ( )
Te3cpAYER SIGNATURE TELEPHONE NUMBER DATE
GENERAL INFORMATION
1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with apoli cable interest based on infornatipn
submitted by the financial institution.
2. Inheritance tax becomes tle linguent nine months after the tlecatlent's date of death.
3. A joint account is taxablo even when th¢ tlecadont's nave was atldetl as a natter of convenience.
4. Accounts (in cludinB chose heltl between husband antl wife) The decetlent out in joint names within one year prior to
death are fully taxable.
5. Accounts established jointly between husbantl and wife oo re than one year prior io death are not Taxable.
6. Accounts held by a decedent "in trust fo r^ another or others are fu11v taxable.
REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE
1. BLOCK A - If the inf ornation antl calculation in the notice are correct and deductions are not boinp claiaed, place an "X^
in Block A of Part 1 of the "Taxpayer Response" section. Sian two copies antl submit then with a the ck for the anount of
taz to the reBisker of wills of the tountY indicated. The PA Departnenk of Revenue will issue an official assessment
(Porn REV-1548 IX) upon races of of the return fron the register of wills.
2. BLOCK B - If the asset specif ietl on This notice has been or will be reported and tax paid with khe Pennsylvania inheritance
tax return filed by the estate's representative, place an '•X'• in Block B of Part 1 of the "Taxp av ¢r Respon se^ section. Sign two
copies and re ku rn to the rapist ar of wills of the County in tlicated.
3. BLOCK C - If tho notice infornati on is incorrect and/or tlatluc tions are ba ing claiaed, cheek Block C and conDl ate Parts 2 and 3
aceortlinB to the in sf ruct ions below. Sign two copies antl submit then with vour check for She anount of tax payable fo the register
of wills of the county indicated, The PA Departnant of Revenue will issue an official asse ssne nt (Porn REV-1548 IX) upon receipt
of the return fron the register of wills.
TAX RETURN - PART 2 - TAX CALCULATION
LINE
1. Enter the tlate the account originally was establishetl or ti tlatl in the Wanner existing at tlate of tleath.
NOTE: for a tlecetlent who died after 12/12/82. accounts the decedent put in joins names within one Year of tleath are
fully Taxable. However, there is an ¢xclusion not to exceed 63,000 per transferee, raga rtlle ss of the value of
the account or the number of accounts held.
If a double alto risk (s.) appears before Your first nave in the atldress Dort ion of this notice, the 83.000 exclusion
was tleducted fron the account balance as reportetl by the financial institution.
2. Enter the total balance of the account including interest accrued to khe date of death.
3. The percentage of the account that is taxable ko each survivor is deters fined as Poll ors:
A. The percentage taxable of joint assets establishetl pore than one year prior to the tlecetlent's tleath:
1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 199 = PERCENT TAXABLE
JOINT OWNERS SURVIVING JDINT OWNERS
Example: A joint asset ragisteretl in the nano of the decedent antl two other persons:
1 DIVIDED BV 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) ~ .167 X 100 16 J porcenf (TAXABLE TO EACH SURVIVOR)
B. The De rcentage taxable for assets created within one year of the tlecedent's death or accounts owned by the decedent but heltl
in trust for another in tli riduel(s) [trust benef icia ties):
1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED BY 100 = PERCENT TAXABLE
OWNERS OR TRUST BENEFICIARIES
Ezamplev Joint account repiste retl in the nano of the decedent and two other persons antl established within one year of death by
the decetlent.
1 DIVIDED BV 2 (SURVIVORS) _ .50 X 100 ~ 50 aercent (TAXABLE FOR EACH SURVIVOR)
4. The anount subs act ko tax (line 4) is tlete rni Wed by nul tiplying the account balance (Line 2) by the percent taxable CLine 3).
5. Enter the total of the debts and deductions listed in Part 3.
6. The amount taxable (L ina 6) is determined by subtracting the tlebts and dada cYions CLine 5) from the amount subject to tax (Line 4).
7. Enter the appropriate tax rata (Line 7J as date rained bel ar.
Date of Death Spouse Lineal Sibling Collateral
07!01194 to 12/31/94 3 percent 6 percent 15 portent 15 percent
01/01/95 t0 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
sThe Tax rata inposetl on the net value of transfers fron a deceased child 2 years of ape of Younger at
tleath to or for the use of a nahral parent, an adoptive Darent or a stepparent of the child is 0 percent.
Tha lineal class of heirs includes Brantlparents, parents, children and other lineal daseentlen YS. "Children" inc !atlas natural children
whether or no4 they have bean atlopted by others, atlopted chiltlren antl step children. ^L ineal tlescentlants" includes all chiltlren of the
natural pa ranks and Their de sc¢ntlents, whether or not they have been atlopted by others; atlopted descantlents antl their tlescentlants;
and step-tlescan dents. "Siblings" are defined as intlivitluals who Nava at least one oarenk in tonnon 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 tlatluc loons era tle to rained as follows:
A. You are Lega11Y responsible for paynant, or the estate subject to administration by a personal representative is insufficient
to pay the tletluctible 3tens.
B. You actually paid the debts after the death of the decetlent and can furnish proof of payment.
C. Oeb is being cl aim ad oust be itemizetl fully in Part 3. If additional svace is nestled, use 8 1/2" x 11'• sheet of paper. Proof of
pavnent nav be requestetl by the PA Depa Mnent of Revenue.
BUREAU DF INDIVIDUAL TAXES
PD BOX 280601
HARRISBURG PA 1]128-0601
pennsyivania
DEPARTMENT OF REVENUE
RFV-1563 Er .RFr t05 -I l)
PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE FILE NO. 21
AND ACN 12114344
TAXPAYER RESPONSE DATE 02-28-2012
MARK H MYERS
100 W VINE ST
SHIREMANSTOWN PA 17011-6346
EST. OF ANNA J MYERS
SSN 186-24-9996
DATE OF DEATH o2-15-2012
COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS TD:
REGISTER OF WILLS
1 COURTHOUSE SgUARE
CARLISLE PA 17013
TYPE OF ACCOUNT
® SAVINGS
CHECKING
TRUST
CERTIF.
MEMBERS 1sT FLU provided the tlepa rtment with the information below, which was used in calculating the inheritance tax due.
Records indicate that at the death of the above named decedent. you were a joint owner/beneficiary of this account. If y0U are the spouse Of the
deceased and any amount other than zero is reflected below on the Potential Tax Due line, note no tax may be due, but you must
nottfy the department of your relationship to the deceased by checking Box C 1n PART 1 below and writing "spouse" in PART 2.
If you believe the information is incorrect. please aDta in written <orrecti on Prom the Financial institution. attach a copy to this form and return
it to the above address. Please call 717-7 R7-8327 with Dues ti DnS.
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 275431-05 Date D1-19-2006 To ensure proper credit to the account, two
ESLab135Ae0 copies of this notice oust accompany
pavnent to the Register of Wills. Make check
Account Balance ~` 1.877.91 payable to "Register of Wills, Agent".
Percent 7axaDle X 50.000
NOTE. If tax payments era matle within three
Amount Subject to lax ??` 938.96 months of the decedent's date of death.
Tax Rate X . 045 deduct a > percent discount an the tax due.
Anv inheritance tax due will become del3nguent
Potential Tax DUe $ 42.25 nine months after the tlate of death.
PART TAXPAYER RESPONSE
A. ~ The above information and tax due is correct.
Remit payment to the Register of Wills wi to two copies of th i.s notice to obtain
a discount or avoid interest, or return this notice to the Resister of wills antl
CHECK an official assessment will be issuetl by the PA Dapartnent of Revenue.
ONE ~
BLOCK B. ~ The above asset has been or will ba reported and tax void with the Pennsylvania inheritance tax return
ONLY filetl by khe estate representative.
L. ~ The above inf orna ion is incorrect and/or debts and de tluctions were paid.
Complete PART ~ and/or PART ~ below.
ppg7 If indicating a tliff¢rent tax rate. please state ';~~ 'ti i~ ~~~~}~;h, `,
~
relationship to decedent: 4° ~~~
'~i
TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS
~
~
~
LINE 1. Date Established 1 ~
~
2. Account Balance 2
3. Percent Taxabl¢ 3 X
4. Amount Subject to tax 4 $
5. Debts and Detluctions 5
6. Amount Taxable 6 $
7. Tax Rate 7 X
8. Tax Due B $
PART DEBTS AND DEDUCTIONS CLAIMED
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
WORK C )
TAXPAYER SIGNATURE TELEPHDNE NUMBER DATE
Untler penalties of periury, I declare that th¢ facts I reportetl above are true, correct and
complete to the best of my knowledge antl belief. HfIMF C
GENERAL INFORMATION
1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on info rn ation
submitted by the financial institution.
2. Inhe ritanc• tax becomes tlelinauent 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 maktar of convenience.
4. Accounts (including those held between husband and wife) the dated ant out in joint names within one year or for to
death are fully taxable.
5. Aceounts established jointly between husband and wife no re than one year prior to death are not taxable.
6. Aceounts held by a decedent "in trust for" another or others are fully taz able.
REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE
1. BLOCK p - If the inf ornation and calculation in the notice are correct and deductions are not being claimed, place an '•X•'
in Block A of Part 1 of the ^T ax payer Response'' section. B1Bn kwo copies and subnit to en with a check for the anount of
tax to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment
(FO rn REV-1548 IX) upon receipt of the return from the register of wills.
2. BLOCK B - If the asset specified on this noti to has been or will be reported and tax paid with the Pennsylvania inheritance
tax return filed by the estate's represent ati va, place an "X" in Block B of Part 1 of the "Taxpayer Response^ section. Sign two
copies and return to the register of wills of the county indicated.
3. BLOCK C - If the notice information is incorrect and/or deducti onz are he ing cl aimed, check Block C and complete Parts 2 and 3
according to the instructions below. Sian two copies and subnit then with your check for the amount of tax parable to the rapist er
of wills of the county indicated. The PA Department of Revenue will issue an official assessment CForn REV-1548 IX) upon recei of
of the rata rn fron the register of wills.
TAX RETURN - PART 2 - TAX CALCULATION
LINE
I. Enter the date the account originally was est ablishatl or titled in the manner axi skins at date of death.
NOTE+ For a tlecedenf who died after 12/12/82. accounts the tlecatlent out in joint manes within one rear of death are
fully taxable. How ev err there is an exclusion not to exceed 03x800 per transferee. reeartlless of the value of
the account or the nupber of accounts hel tl.
If a double asterisk (r.) appears before your first name in the address Dort ion of khis notice, the 03,800 exclusion
was deducted fron the acepunt balance as rep orked by the financial institution.
2. Enter the total balance of the account including iota rest accrued to the dace of death.
3. Tha percentage of 4he account that is taxable io each survivor is tleterminetl as follows:
A. The plrce ntape taxable of joint assets established pore than one year prior to the tlecedenf 's death:
1 DIVIDED BY TDTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE
JDI NT OWNERS SURVIVING JOINT DWNERS
Example: A ioint asset raeiste red in the nave of the tlecatlent and two other persons:
1 DIVIDED BY 3 (JOINT OWNERS) DIYI DED BY 2 (SURVIVORS) _ .167 X 100 16.T oertent (TAXABLE TD EACH SURYIVOR)
B. The percentage taxable for assets created within one year of the decedent's tlo ath ar accounts owned by the decedent but held
in trust for another intliv idual (s) (trust benef ic3aries):
1 OIY IOED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED BV 180 = PERCENT TAXABLE
OWNERS OR TRUST BENEFICIARIES
Example: Joint account registered in the name of the tlecatlent and two other persons and established within one Year of death by
the decedent.
1 DIVIDED BY 2 (SURVIVORS) _ .58 X 180 = 50 oertent (TAXABLE FOR EACH SURVIVOR)
4. Tha anoun4 subi act to tax (Line 4] is tleterninetl by nultiplyi ng 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. Tha anount taxable (Line 6) is date rained by subtracting the debts and deductions (Line 5) fron the amount subj eft to tax (line 41.
7. Enter the app ropriete tam rate (Line A as daternined below.
Date at Death Spouse Lineal Sibling Collateral
07/01/94 to 12/31/94 3 percent 6 pert enk 15 percent 15 percent
01/01/95 to 06/30/00 D percent 6 percent 15 percent 15 percent
07/01!00 to present 0 percent 4.5 percent • 12 percent 15 percent
•:ne sex rasa lmpasem on Tne net value of [roost ers 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 hot rs includes grandparents, parents, child ran and other lineal descendents. "Children" includes natural child ran
wheth ar 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, whakher or nok they have been adopted by others: adopt etl descendents and their descendants;
and step-descendants. "Si bl3nes" are de tined as intlivitl uals who have at least one parenk in cannon with the tlecatlent, whether by blood
or atlop ti on. The Collateral class of hairs includes all other beneficiaries.
CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED
Allowable debts and deductions are determin etl as follows:
A. Vou era legally resDOnsible for payment, or the estate subject ko adninist ration by a personal representative is in sufficien4
to Dav the deductible items.
B. You actually paid the debts after the death of the tlecatlent and can furnish proof of payment.
C. Debts peinp claimed aus4 be itemized fully in Part 3. If adtlit tonal space is needed, use 8 1/2•' x 11•' shack of paper. Proof of
Daynent may be reouastetl by 4he PA Departnent of Revenue.