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HomeMy WebLinkAbout9-28-12~~, PENNSYLVANIA INHERITANCE TAX ~~~ .>,,,- ~ ,~ INFORMATION NOTICE FILE N0. 21 --~ / BUREAU OF INDIVIDUAL TAXES Nj E ~-~- Po Box zso6ol ~,_ r~s,~l~ j AND ACN 12132012 HARRISBURG PA 1712s-o6o1 ~~ ~€An~?~EriT;p~~•. _~~ TAXPAYER RESPONSE DATE 05-18-2012 REV-1543 EX AFP (OS-11) ~~~ SAP 2g ~~ +~ ; j. ~ TYPE OF ACCOUNT ~+ EST. OF NORMA J HEWITT ~ SAVINGS ;- ~_. SSN 193-20-1855 ~ CHECKING f. ^a ~ ~ << : T _ DATE OF DEATH 04-?~~-2012 ~ TRUST ~~~~~~ ~ ~ `'~~~'~' ~ ~ _ ~~ ~~~~ COUNTY CUMBERLAND ~ CERTIF. CU~B~Rf..~1D CO., PA REMIT PAYMENT AND FORMS T0: NANCY L SULLIVAN REGISTER OF WILLS 1027 DOGWOOD LN 1 COURTHOUSE SQUARE ENOLA PA 17025-2041 CARLISLE PA 17013 M E T R 0 B A N K provided the department 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 yoU 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 notify the department of your relationship to the deceased by checking Box C in PART 1 below and writing "spouse" in PART 2. If you believe he information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. Please call 717-787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 32062820 Date 04-27-1996 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance 13, 067.32 payment to the Register of Wills. Make check payable to Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 6,533.66 months of the decedent's date of death, Tax Rate ~( 1 rj deduct a 5 percent discount on the tax due. Any inheritance tax due will become delinquent Potential Tax Due $` 980.05 nine months after the date of death. PART TAXPAYER RESPONSE FAILURE TO RESPOND WILL RESULT IN AN OFFICIAI TAX .ASSESSMENT A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or return this notice to the Register of Wills and 0 N E an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return 0 N L Y filed by the estate representative. C. ~ The above information is incorrect and/or debts and deductions were paid. Complete PART ~2 and/or PART ~ below. PART If indicating a different tax rate, please state QFFICIAL USE ONLY ~ AAF relationship to decedent: D PA DEPARTMENT OF RE1/ENUE TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Date Established 1 ~~ ~~ ° ~°a~T j 2. Account Balance 2 $ ~~ ~~~n ~i ~ 2 3. Percent Taxable 3 X ,~'-f> • G C? z~ ~) 4. Amount Subject to Tax 4 $ f ~ rvO~r d ~ C~ 5. Debts and Deductions 5 - ~ ( / ~ n ~ G7 ~- 5 6. Amount Taxable 6 $ ~ 6 7. Tax Rate 7 X i~~ 7 8. Tax Due 8 $ © g PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIPTION AMOUNT PAID O I ~ ~CtC~ CO V'h- ©~ Ll~ - nG ti VYl "~'' (~ a r TOTAL (Enter on Line 5 of Tax Computation) S Under penalties of perjury, I declare that the facts I reported above are true, correct and complete to the best of my knowledge and belief . HOME C ~~, ) ~~,~ ~ o~ n( ~ ~p TAXPAYER S ATURE TELEPHONE NUMBER DATE ~Jv~~E~°St`i~~`°~~:' ~11L..~L ~~alacd ~~''',~ si~`~ ~ ~ ,. '` -, ,. L' e., : ~ i 1 i ~ I ..~.tJ ~~~t~ r~(>;- t~~i` ~::titltt(t~, ~;> +~. ~ ~ ~!2 SEP 28 A~ i f « 40 ( _. , .,_ ,~ _. , ~, ~ . - --__ ------ ___ _ ~ tc~~ °~ _~_- - Type/Print In COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH • VITAL RECORDS Permanent CERTIFICATE OF DEATH Black Ink State File Number: 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (Mo/Day/Yr) (Spell Mo) Norma J Hewitt emale 193-20-1855 Apr 23, 2012 Sa. Age-Last Birthday (Vrs) Sb. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/Day/Year) (Spell Month) 7a. Birthplace (City and State or Foreign Country) Months Days Hours Minutes Philad@) hia, Pa 85 November 7, 1926 7b. Birthplace (County) Phlladel hia 8a. Residence (State or Foreign Country) 8b. Residence (Street and Number -Include Apt No.) 8c. Did Decedent Live in a Township? PA 335 Wesley Dr Ves, decedent lived in LOWer All@rl twp. 8d. Residence (County) Cumberland 8e. Residence (Zip Code) 17055 ~ No, decedent lived within limits of city/boro. 9. Ever in US Armed Forces? 10. Marital Status at Time of Death Q Married Q Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage) Q Ves X] No (] Unknown ~] Divorced Q Never Married l] Unknown 12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last) Lynford A Hewitt Clara Margaret Jamieson 14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City, State, Zip Code) Nancy L Sullivan DAUGHTER 1027 Dogwood Lane Enola, PA 17025 ~ 1 a: Place o Deat C eck on one _ tPom+,, ~~++55 ..................................... ~ ..........................................................µ........ P ...................................;... Y.......1.............................. .................................... ac If Oeath Occurred in a Hospital: LJ In silent ~If Death Occurred Somewhere Other Than a Hospital: U Hospice Facility I,J Decedent's Home ° Q Emergency Room/Outpatient (] Dead on Arrival ~ Nursing Home/Long-Term Care Facility Q Other (Specify) ag 15 b. Facility Name (If not institution, give street and number; , 15c. City or Town, State, and Zip Code lSd. County of Death Z Sarah A. Todd Memorial Home Carlisle, PA 17013 Cumberland 16a. Method of Disposition (] Burial ~] Cremation 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place) C° ~ Removal from State ~ Donation ~ Apr 24, 2012 Evans Cremation Service Other (Specify) ~ 16d. Location of Disposition (City or Town, State, and Zip) 17a. S' nat a of Funeral ervice Licensee,~or Person in Charge of Interment 17b. license Number d LeOla, PA 17540 C__._- .lohn c. sullivan FD-011897-L ° 17c. Name and Complete Address of Funeral Facility Sullivan Funeral Home 51 N. Enola Dr. Enola, PA 17025 m 18. Decedent's Ed ucaiion -Check the box that best describes the 19. Decedent of Hispanic Origin -Check the 20. Decedent's Race - Eheck ONE OR MORE races to indicate what ~° highest degree or level of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be. 0 8th grade or less is Spanish/Hispanic/Latino. Check the "NO" $] White ~ Korean ~ No diploma, 9th - 12th grade box if decedent is not Spanish/Hispanic/Latino. Q Black or African American Q Vietnamese High school graduate or GED completed jJD No, not Spanish/Hispanic/Latino Q American Indian or Alaska Native Q Other Asian ~ Some college credit, but no degree (] Yes, Mexican, Mexican American, Chicano 0 Asian Indian Q Native Hawaiian ~ Associate degree (e.g. AA, AS) Q Yes, Puerto Rican ~ Chinese Q Guamanian or Cha morro Q Bachelor's degree (e.g. BA, AB, BS) ~ Ves, Cuban Q Filipino Q Samoan Q Master's degree (e.g. MA, M5, MEng, MEd, MSW, MBA) ~ Yes, other Spanish/Hispanic/Latino ~ Japanese ~ Other Pacific Islander ~ Doctorate (e.g. PhD, EdD) or Professional degree (Specify) (] Other (Specify) e. MD, DDS, DVM, LLB, JD) 21. Decedent's Single Race Self-Designation -Check ONLY ONE to indicate what the decedent considered himself or herself to be. 22a. Decedent's Usual Occupation -Indicate type of work g] White (] Japanese (] Samoan done during most of working life. DO NOT USE RETIRED. ~ Black or African American ~ Korean (] Other Pacific Islander office elerK ° Q American Indian or Alaska Native Q Vietnamese Q Don't Know/Not Sure Q Asian Indian (] Other Asian Q Refused 226. Kind of Business/Industry Chinese ~ Native Hawaiian Q Other (Specify) Q Filipino Q Guamanian or Chamorro Healthcare a ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pronounced Dead (Mo/Day/V r) 23b. Signature of Perso Pro . ou ncing Death (Only when applicable) 23c. License Num er BY PERSON WHO PRONOUNCES OR ~ ~ CERTIFIES DEATH /, i f ~ 3 /., ..~ - ~~ ~ ~ ~` ~ / N _~ ~ ~ / / y ~ _ 23d., (?ate Signed (Mo/Day/Yr) 24. lme of Death V V L- ~ / ~ Zz ~ G/ ~ `j/1 25. Was Medical Examiner o oroner Contacted? (] Ves No CAUSE OF DEATH Approximate 26. Part 1. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest Interval: respiratory arrest, or ventricular fibrillation without showing the etiology. DO NO/T ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary Onset to Death IMMEDIATE CAUSE ---------------> a. ~S~t`~.b{`ta~ V ~ J CS.., \~~ ~1J~~`t~V V n kv4~. (Final disease or condition Due t0 (or as a consequence of): resulting in death) b. Sequentially list conditions, Due to (or as a consequence of): if any, leading to the cause listed on line a. Enter the c. UNDERLYING CAUSE Due to (or as a consequence of): (disease or Injury that W initiated the events resulting d. ~ Due to (or as a consequence of): W in death) LAST. V 26. Part II. Enter other significant conditions contributin¢ to death but not resulting in the underlying cause given in Part I 27. Was an autopsy performed? (] Yes No O 28. Were autopsy findings available to complete the cause of death? ~,i i 0 i~ i °i If Female: 29 30. Did Tobacco Use Contribute to Death? 31. Manner of Death i a ~, E . Not pregnant within past year ~ Yes Q Probably Q k ~ Natural Q Homicide Accident (] Pending Investigation u° ° ' ] Pregnant at time of death [ nant within 42 days of death re t b t nown Q No ~ Un Q Suicide Q Gould not be determined ~ g , u p 0 Not pregnan s to 1 year before death t 43 da b 32. Date of Injury (Mo/Day/Vr) (Spell Month) ~ y ut pregnan Q Not pregnant, ~ Unknown if pregna ni within the past year 33. Time of Injury 34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, City, State, Zip Code) 3fi. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred: ~ Yes Q Driver/Operator Q Pedestrian Q No (] Passenger ~ Other (Specify) 39a. Certifier (Check only one): Certifying physician - To the best of my knowledge, death occurred due to the cause(s) and manner stated er stated d mann Q Pronouncing 8. Certifying physician - To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) an and manner staled and due to the cause(s) l e d ac , p of examination, and/or investigation, in my opinion, death occurred at the time, date, an On the ba (] Medical Examiner/Coron ~sJ. r ` ~ "(\ 6 L ~ ) Nrv Title of certifier: License Number: ~~ ~l b Z Signature of certifier: ~ ~ 39c. Da Sig d (Mo/Day/Vr) 39b. Name, Address and Zip Code of Person Completing Cause of Deaih (Item 26 ~ tv~5o>r. "~ ~`~VC. Crz.r-t_~~ 4c, PA lZotS rti-p -[ `~f Z~c l Z . GG o ~, P - dr Zr Svl~rlr~ d ~ ' 42. Registrar ile Date Mo/Oay/Yr) s Signature 40. Registrar's District Number 41. Registrar ,~fa ~t a ~ a a ( 43. Amendments Disposition Permit No. ~1/ .7 ~ ~~ / - REV 07/2011 L~t~ ~~ 1 , f '~ ~': r , ! ~ ~~ ~ ~J ~~ ~ '~ ~ CUM~~P~}p Cu PA U ., i ~-- ~~ ++ ~ --t-• ~~.. ~.r ~~" ~~ \~+~/) V V ~~ ~~. 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