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HomeMy WebLinkAbout01-08-13BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 ' Y 1~ ~~ G i 3.- }~ Pennsylvania Inheritance Tax Information Notice And Taxpayer Response ~_r: - ~ ;~ ~~~_-• _ ~ pennsyLvania DEPARTMENT OF REVENUE ~~~~~~~~~ REV-1543 EX DocEXEC C08-12) FILE NO. 2170 ACN 12166215 DATE 12-10-2012 -*n "' , ~ e of Account i f ~ ~ r ~ ~~ t, `~ TYp ,~ ~, `E~ate of ROSA R SLAYTON Savings 3 ~ a~ SSN 226-24-7283 X Checking ~' ~' ` ` •~ ~ JOHN W SLAYTON ° ~ Date of Death 11-13-2012 ~ ~ ~ Trust C~Ct,"~'~j~a~s ~; ~~- County CUMBERLAND C rtifi t 807 MICHIGAN AVE LEMOYNE PA 17043-1 e ca e G~~~~~.~ ~~ ~3 ~ 207 ~~ # SUSQUEHANNA BANK prov ided 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. 1583508088 Remit Payment and Forms to: Date Established 09-07-2011 REGISTER OF WILLS Account Balance $ 1,284.96 1 COURTHOUSE S(~UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $ 642.48 Tax Rate X 0.150 Potential Tax Due $ 96.37 NOTE*: If tax payments are made within three months of the With 5% Discount Tax x 0.95 ( ) decedent's date of death, deduct a 5 percent discount on the tax $ (see NOTE*) due. Any inheritance tax due will become delinquent nine months after the date of death. PART Ste 1: Please check the a 1 p ppropriate boxes below. A ~ No tax is due. 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. B ~ The information is correct. C ~ The tax rate is incorrect. (Select correct tax rate at right, and complete Part 3 on reverse.) D ~ Changes or deductions listed. E ~ Asset will be reported on inheritance tax form REV-1500. The above information is correct, no deductions are being taken, and payment will be 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 Debts and Deductions 2 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 PART Tax Calculation 3 If you are making a correction to the establishment date (Line 1) account balance (Line 2), or percent taxable (Line 3), please obtain a written correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First, determine the percentage owned by the decedent. i. Accounts that are held "in trust for" another or others were 100% owned by the decedent. ii. For joint accounts established more than one year prior to the date of death, the percentage taxable is 100% divided by the total number of owners including the decedent. (For example: 2owners = 50%, 3 owners = 33.33%, 4 owners = 25%, etc.) b. Next, divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate, please state Official USe Only ^ AAF your relationship to the decedent: PA Department ©f Revenue 1. Date Established 1 2. Account Balance 2 $ PAD X ~ 3. Percent Taxable 3 2 4. Amount Subject to Tax 4 $ 3 5. Debts and Deductions 5 - 4 6. Amount Taxable 6 ~ ~ 7. Tax Rate 7 X ___d_ -_~-__ _-~ 6 7 8. Tax Due 8 ~ $ 9. With 5% Discount (Tax x .95) 9 X 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. ~ ~ 1 ..~ Home ~ ~ ~~',. ~~~ ~-~~,~~ ~/~~~ ~c~' r~ ~ ~ Taxpayer Signature Telephone Number Date ` 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 ENROLLMENT FOR GROUP INSURANCE TO PROPOSED INSURED (Please Print) 5 LA ~~oN ?DS f~~ Last First Residence - No. and Street HOMESTEADERS LIFE COMPANY P.O. BOX 1756/DES MOINES, IOWA 50306/800-477-3633 ~ ~ 3.23-123 89 Z Z~ 2~f 7~$3 Initial Sex Birthdate (M/D/Y) Age SS No. LeMav ~~ P~ 1'7oy3 7- ? • ?3~ ~D36 ity or Town State Zip Phone No. APPLICANT/OWNER (lf Other than Proposed Insured) Last First Initial ~ Address City State Zip SS No. Relationship to Insured BENEFICIARY ~t~~N W- sL~ yTu~/ ~oi/ (After payment under any assignments, remaining proceeds are to be paid Relationship to Insured to the estate of the insured unless a beneficiary is specified above.) R E Q U E S T E D B E N E F I T S ^ SINGLE PAYMENT PLAN For issue ages 0-80, if the insured does not sign the enrollment form, ^ Certificate Face Amt. $ the initial face amount of the certificate will be equal to 1.005 times ^ Rider Premium $ 2$ ~ ~ •~ ~ the premium paid. ^ MULTIPLE PAYMENT PLAN (The proposed insured must sign the /f the following questions are both answered "no," we may issue a enrollment form to qualify for the Multiple Payment plan.) certificate providing an immediate death benefit equal to the face Years amount. Premium Face Amt. $ OPTIONAL HEALTH HISTORY (Multiple Payment Plans) Payable 1. Is the insured now bedridden, or currently admitted to or been Premium $ advised to enter a hospital, nursing home, hospice program, or The death benefit payable during the first six months will be the sum of any extended care facility; or been diagnosed as having or been treated for AIDS or ARC? ^ yES ^ NO the remium p paid plus 5%. Death benefits payable after the first six months are as follows: 2 Within the ast five ears has the insured been dia nosed or p y g treated for any of the following ailments? Years Premium Payable Heart Disease Liver Disease Alcohol Abuse Less than 5 years 6 Months-1 Year = 50% of Face Amt. Circulatory Disease Kidney Disease Drug Abuse Year 2 = Face Amt. Stroke Anemia Nervous Disorder 5 years or greater 6 Months-1 Year = 35% of Face Amt. Lung Disease Cancer ^ ^ Year 2 = 70% of Face Amt. YES NO Diabetes Year 3 = Face Amt. If death by accident during the limited period, the face amount is payable. Payment Method ^ Monthly ^ Annually ^ Semiannually ^ Quarterly ^ Multiple Bill - (List other policies for PAC or MB) ^ Direct Bill ^ Preauthorized Collection (PAC-See Reverse) Dividends ^ Purchase Additional Insurance ^ Accumulate at Interest ^ Paid in Cash ^ Reduce Premium Replacement-Will the proposed certificate replace any existing life insurance or annuity contracts? ^ Yes No (If "Yes, "complete replacement papers) DECLARATIONS-To the best of my knowledge and belief, all statements and answers on this enrollment form are complete and true. It is agreed that no insurance shall take effect until the premium has been paid and a certificate has been issued while the insured is living. I certify, if I am applying for insurance on behalf of the insured, that I have an insurable interest in the pro osed insured's life, and have full authority to use his/her funds as premiums on the insurance applied for. I have paid $ yn g l 5.OD with this enrollment form. Signed at ~ ~'.r ~~ Date ~ ~ ~~ ~`'°~ ,pity , ~l State i ~~ than Proposed Insured) Signature of Proposed Insured Agent's Statement: By my signature I certify that, to the best of my knowledge, all information contained in this enrollm f is rrect, was recorded accurately, and confirm this enrollment form was signed in my presence. f' ~'" ~~ 2 I ~ 1 ~ - C ~ - U ~ ~ Security Option Agent's Signature Agent Number Prod. Code Mkt. Code ^ Advantage Option GP-201-VA Copies: White -Homesteaders; White -Homesteaders; Pink -Provider; Canary -Owner Rev 0312 + PRENEED FUNERAL AGREEMENT AND ASSIGNMENT EXHIBIT 1 -STATEMENT OF FUNERAL MERCHANDISE AND FUNERAL SERVICES NOTE: THIS AGREEMENT IS TO BE FUNDED BY THE ASSIGNMENT OF INSURANCE BENEFITS FOR THE BENEFIT OF I~OSA~ I~- ~ ~ay~'rl (Funeral Recipient/Insured) 1~- / (ddress if differ nt than below)1 (Phone) IN AGREEMENT WITH AND ASSIGNMENT TO ~v ~~-1 ~- ~i~G.'~ r~~lrl~Cr~ ffi~titL dZ ao 3 ~ ?3 GUARANTEED PROFESSIONAL SERVICES Services of Funeral Director and Staff $_ Embalming (See Agreement and Below*) $_ Other Preparation $_ Visitation Days at $ /Day $_ Funeral Ceremony/Memorial Service $_ Other Use of Facilities and Staff (Specify) (Funeral Director #) Product Number Exterior Description Interior Description Transfer of Remains to Funeral Home $ Outer Burial Container $ If beyond a mile radius, which is our service area, Product Name there will be a charge of $ per mile one way. Product Number Family Car(s) at $ each $ Limousine Hearse $ s Manufacturer Cremation $ Constructed of Forwarding/Receiving Remains $ Other Guaranteed Merchandise (Specify) Other Services/Facilities/Equipment (Specify) TOTAL GUARANTEED SERVICES $ TOTAL GUARANTEED MERCHANDISE NON-GUARANTEED CASH ADVANCES Death Certificates at $ $ Escort Flowers ~~~'t' "r~9~ $ 3! ~.DD Grave Opening and Closing I~IGREi4s~ s Music $ Memorial Cards/Book Honorariums M~N~ S1~c~~ $ 2 00 ~~ O Clothing (Specify) Obituaries lnlc~t~EtSGS $ 30a •op Monument/Marker Hairdresser $ Engraving Shipping Container $ Sales Tax Estimate Other (Specify) "1"~At1EL- L,OD6ING $ 1 e~00.On Other (Specify) I,.~t)C,q~l. 6A-'tNfR~~1G $ tzr-~r~~. We charge you for our services in obtaining: (Funeral Provider Name) GUARANTEED MERCHANDISE Casket Manufacturer Product Code $ ~oo.cx~ $ moo , da $ TOTAL NON-GUARANTEED CASH ADVANCES ADJUSTMENT TOTAL GUARANTEED AND NON-GUARANTEED FUNERAL PRICE $ 2815-DO $ 2815.00 *REQUIRED PURCHASES-Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain the reasons in writing below. tRREVOG,ABIILITY--By initialing. here ( }, ypu ~rrevoeak~ly assiggn ownership of the life insurance funding this car~tracE to the named funeral home to qualify for Medicaid or other public assistance. SEE REVERSE FOR TERMS OF IRREVOCABILITY. EXHIBIT 1 ABOVE AND THE PRENEED FUNERAL AGREEMENT AND ASSIGNMENT ON THE REVERSE SIDE SHALL CONSTITUTE THE TERMS AND CONDITIONS OF THIS AGREEMENT. AGREE E11jT AND ASSIGN T BAY; AGREEMENT AND CCEPTANCE BY; i ure of Purchaser) ~ ~ (Date (Si atur of Pr vi r' Autho resentative) (Agent's License #) (A dre~ ~ n~ ~Ph~) (Fu I Pr~~ e 'Address) ~ ~ „~ L~3 (-at ~r~~ 6 ~l/ _ ~ / ~/ ~7 / ,S ( ity, State) (Zip) ( i y, State, Zip) (Phone) HOME SALES ONLY: You, the Buyer, may cancel this transaction at any time prior to the third business day after the date of this transaction. See the attached Notice of Cancellation form for an explanation of this right. P255 ©HLC, 2011, All rights reserved. No use or reproductions without expressed permission. Rev 0911 Copies: Original -Homesteaders Life Company; Canary -Purchaser; Pink -Provider X-G-I-VA <r• ~ ` v F 2012 ~' ~i Y K ~ .~ R $ ~ t i' ~ i ~~ ~~~ ~ ~'~ r~ .~~ ~'~ },~ C s. ^...d .:j .~' .:.j •„ ;~.~.. 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