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BIiREAU OF INDIVIDUAL TAXES Pennsylvania Inheritance Tax
PCB BOX 280601 J
HARRISBURG PA 17128-0601 ~~.('fld~ll' f ation Notice
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,y- v ~~. I I payer Response
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CHERYL L BAKER
121 BRIAN DR
ENOLA PA 17025-1565
of~F~H~,iV~~ G%t)f~r
ct~~~E~~,a~v~ co., PA
~ Pennsylvania
DEPARTMENT OF REVENUE
REV-1563 E% DocE%EC (OB-127
FILE N0.2170 ~. ~ - ~ '~ - 1 ~~ ~-h
ACN 12161620
DATE 11-07-2012
Estate of MARTIN E BAKER
SSN
Date of Death 10-27-2012
County CUMBERLAND
Type of Account
Savings
Checking
Trust
Certificate
MEMBERS 1sT Fcu provided the department with the information below indicating that at the death of the
above-named decedent you were a joint owner or beneficiary of the account identified.
Account No. 7108 Remit Payment and Forms to:
Date Established 03-31-1964 REGISTER OF WILLS
Ac~~ount Balance $ 4,000.71 1 COURTHOUSE SQUARE
Percent Taxable X 16.667 CARLISLE PA 17013
Amount Subject to Tax $ 666.80
Ta:t Rate X 0.045
Po~lential Tax Due
With 5% Discount (Tax x 0.95) $ 30.01
$ (see NOTE*) ~ NOTE*: If tax payments are made within three months of the
decedent's date of death, deduct a 5 percent discount on the tax
due. Any inheritance tax due will become delinquent nine months
after the date of death.
PART Step 1: Please check the appropriate boxes below.
1
A ^ No tax is due.
B ~~The information. is
correct.
C ~] The tax rate is incorrect.
(Select correct tax rate at
right, and complete Part
3 on reverse.)
p ~] Changes or deductions
listed.
E ~] Asset will be reported on
inheritance tax form
REV-1500.
I am the spouse of the deceased or I am the parent of a decedent who was
21 years old or younger at date of death.
Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount
shown above as Potential Tax Due.
The above information is correct, no deductions are being taken, and payment wilt tx sent
with my response.
Proceed to Step 2 on reverse. Do not check any other boxes.
~4.5% I am a lineal beneficiary (parent, child, grandchild, etc.) of the deceased.
12% I am a sibling of the deceased.
15% All other relationships (including none).
The information above is incorrect and/or debts and deductions were paid.
Complete Part 2 and part 3 as appropriate on the back of this form.
The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax
Return filed by the estate representative.
Proceed to Step 2 on reverse. Do not check any other boxes.
Please sign and date the back of the form when finished.
PART
2
Debts and Deductions
Allowable debts and deductions must meet both of the following criteria:
A. The decedent was legally responsible for payment, and the estate is insufficient to pay the deductible items.
B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department.
(If additional space is required, you may attach 8 1/2" x 11"sheets of paper.)
Date Paid
Payee
Description
Amount Paid
Total Enter on Line 5 of Tax Calculation $
Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form,
along with a check for any payment you are making. Checks must be made payable to "Register of Wills, Agent." Do not send
payment directly to the Department of Revenue.
Under penalty of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and
belief.
~ n _ /~ „ Work
Signature
Telephone Number
IF YOU NEED FURTHER ASSISTANCE, CONTACT CUMBERLAND COUNTY REGISTER OF WILLS, PA
DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT
717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS
ONLY: 1-800-447-3020
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