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HomeMy WebLinkAbout02-25-13COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1 ]128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 017227 PTASZEK ROBERT S 111 ADAMS ROAD CARLISLE, PA 17015 mie ESTATE INFORMATION: FILE NUMBER: 2112-1297 DECEDENT NAME: PTASZEK BARBARA E DATE OF PAYMENT: 02/25/2013 POSTMARK DATE: 02/25/2013 COUNTY: CUMBERLAND DATE OF DEATH: 11/29/2012 REMARKS: CHECK# 2451 ACN ASSESSMENT CONTROL NUMBER REV-1162 EXI11-961 AMOUNT 12168924 ~ 51,246.18 TOTAL AMOUNT PAID: 51,246.18 INITIALS: HEA SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA REV-1162 EX111-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 H ARR188URG, PA 191280601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT N0. CD 017226 PTASZEK ROBERT S 111 ADAMS ROAD CARLISLE, PA 17015 ACN ASSESSMENT AMOUNT CONTROL NUMBER --_--_- mla -_-__-- -_--__ ESTATE INFORMATION: FILE NUMBER: 2112-1297 DECEDENT NAME: PTASZEK BARBARA E DATE OF PAYMENT: 02/25/2013 POSTMARK DATE: 02/25/2013 COUNTY: CUMBERLAND DATE OF DEATH: 11/29/2012 REMARKS: CHECK# 2451 SEAL 13100949 ~ 5219.36 13500324 ~ 5574.15 13500322 ~ 5226.25 13500320 ~ 51,925.44 13500237 ~ 5350.65 13500235 ~ 5495.93 13500233 ~ 5230.58 13500354 ~ 5205.35 13500366 ~ 51,548.24 TOTAL AMOUNT PAID: 55,775.95 INITIALS: HEA RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSV LVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1 ]128-0601 RECEIVED FROM: PTASZEK ROBERT S 111 ADAMS ROAD CARLISLE, PA 17015 -__ -- mle PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT ESTATE INFORMATION: FILE NUMBER: 2112-1297 DECEDENT NAME: PTASZEK BARBARA E DATE OF PAYMENT: 02/25/2013 POSTMARK DATE: 02/25/2013 COUNTY: CUMBERLAND DATE OF DEATH: 11 /29/2012 ACN ASSESSMENT CONTROL NUMBER REV-1162 EX111-961 NO. CD 017225 AMOUNT 12167265 ~ 585.52 12167267 ~ 5819.98 12167268 ~ 5178.47 12167269 ~ 5678.40 12167271 ~ 5616.00 12167273 ~ 5848.08 12167276 ~ 5575.38 12167278 ~ 5265.06 13100948 ~ 5586.37 TOTAL AMOUNT PAID: REMARKS: SEAL CHECK# 2451 INITIALS: HEA RECEIVED BY: 54,653.26 GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS BUREAU OF INDIVIDUAL TAXES PO BOX 200601 HARRISBURG PA 17120-0601 $ 13,716.30 X 100 ~ Pennsylvania DEPARTMENT OF REVENUE aev-~saa ex m~exec ,ae-~a FILE NO. 2112-1297 AGN 13100948 DATE 01-09-2013 ROBERT S PTASZEK APT 202 5 ALLIANCE DR CARLISLE PA 17013-4140 Estate of BARBAR Dale of Death 11-29-2012 County CUMBERLAND C O ~ ~ ~ 'G rn ~ 't1 7a r ~ v ~ z ~~ n ~.~ c:.> ORRSTOWN BANK provided the department with the information below indicatilt~ above-named decedent you were a joint owner or beneficiary of the account idpnt Account No. 4000036879 Date Established 03-05-2010 Account Balance Percent Taxable Remit Payment and Forms to: REGISTER OF WILLS 1000RTHOUSESOUARE CARLISLE PA 17013 C7 rn Type of Account Savings Checking X Trust Certificate o ~ `-'' m cm-A T 1 ^i ~ O ~^ ~ ,S7 tp .~ ~ N T19 ~t ~=' ~ cs ~ _ -ry -n ,, -.:? It at the'de~.tD Dt the Ified. ~ ~: v> '~ Amount Subject to Tax $ 13,716.30 I Tax Rate X 0.045 Potential Tax Due $ 617.23 .b S$(~ . 3 7 NOTE': If tax payments are made within three months of the decedent's date of death, deduct a 5 percent discount on the tax With 5°1° Discount (Tax x 0.95) $ (see NOTE") due. Any inheritance tax due will become delinquent nine months after the date of death. PARr Step 1: Please check the appropriate boxes below. 1 A ~ No tax is due. g The information is correct. G ~ 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. 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 will be sent with my response. Proceed to Step 2 on reverse. Do not check any other boxes. Pennsylvania Inheritance Tax Information Notice And Taxpayer Response 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 incorcect 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 rasa Total Enter on Line 5 of Tax Calculation) $ 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 [hat 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%, eta.j 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 your relationship to the decedent: 1. Date Established 1 _ 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate S. 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. Work'~(7- 6os-78f8 ~l~-Z`FI-oSSS ZSFeb ~"i3 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 BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 1]128-0601 Pennsylvania Inheritance Tax Information Notice And Taxpayer Response ~ Pennsylvania DEPARTMENT OF REVENUE xev-~sas zr ne~zFec ,oe-~z, qty FILE NO. ~~~--~a.~~~J / ACN 12167278 DATE 12-13-2012 Type of Account ROBERT S PTASZEK 111 ADAMS RD CARLISLE PA 17015-9209 Estate of BARBARA E PTASZEK Date of Death 11-29-2012 County CUMBERLAND C~ C O ~ ~ rD .A ms a' n r A ~ :.! C7 L"> Ci C~ '.: 7 C 7J ~V Savings Checking ,~ X Trust o Ce~icate w rrl ?i ~ O c~ r m rn ~ r m ^~ Ul .-~ o r~, m rL7 X] C7 a o C7 ....,., ~ ~T 'rT _ _,-. rl i: "- f._., : -.1 Y"' Gin Vl !tY C~ ~ ''1 MEMBERS Isr Pcu 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. 403 Remit Payment and Forms to: Date Established 10-13-2010 REGISTER OF WILLS Account Balance $ 6,200.17 1 COURTHOUSE SQUARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $ 6,200.17 Tax Rate X 0.045 Potential Tax Due $ 279.01 NOTE': If tax payments are made within three months of the decedent's date of death, deduct a 5 percent discount on the tax With 5% Discount (Tax x 0.95) $ (see NOTE') 2 ~ S, O 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. g ®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. 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 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 z 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 Amount Paid Pavee Description Total Enter on Line 5 of Tax Calculation $ .St@p 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on [he 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. ,~.-y~ ~` ~~' `-(~- ~ ~l d~~ Work 7 I ~7~ 6 OS- Ifs ~S Home X17-Z`Ff-osSS ZS F~6 2~~ 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 BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 ROBERT S PTASZEK 111 ADAMS RD CARLISLE PA 17015-9209 Type of Account Estate of BARBARA E PTASZEK Savings ~ Checking Date of Death 11-29-2012 X Trust Ccunty CUMBERLAND Certificate ~ ~ ~ m o m g ~ -n c~ ~ Q'z' r^ x ~ ~ o v~~ ~ ~ m rV _, ~, s°rr m ~ U' =~ cn .o ~ . ~ p ca c~ c', c:~ ~~ '+t ''~ O ~-• = ti7 . o -t x* cn r ~' -O rt MEMBERS lsr 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. 403 Date Established 10-10-2008 Account Balance Percent Taxable Amount Subject to Tax Tax Rate $13,459.19 X 100 $ 13,459.19 X 0.045 Potential Tax Due $ 605.66 With 5% Discount (Tax x 0.95) $ {see NOTE') S~ S 38 Remit Payment and Forms to: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 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. g ®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. 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 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. Pennsylvania Inheritance Tax Information Notice And Taxpayer Response ~ pennsylvania O EPARTMENT OF REVENUE PEV-1543 EM GocEMEC (OB-Itl FILE NO.217t1-~f ~'~-~/%Z97 ACN 12167276 DATE 12-13-2012 PART z -1 2 $ 3 X 4 $ 5 - 6 $ 7 X 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 t aitl Total Enter on Line 5 of Tax Calculation $ 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 instftutlon 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, your relationship to the decede 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amcunt Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due 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 tc "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. Work ~ ("'- loos-~~4SS Taxpayer Signature Debts and Deductions /-2'fl- c~SS~ 2S FP~ 2~1? Telephone Number Date CIF 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 BUREAU OF INDIVIDUAL TAxES PO BO% 280681 HARRISBURG PA 1]128-0601 ROBERT S PTASZEK 111 ADAMS RD CARLISLE PA 17015-9209 Pennsylvania Inheritance Tax Information Notice And Taxpayer Response ~ Pennsylvania DEPARTMENT OF REVENUE xcvasae zz m~zxzc sae-~z~ FILE NO.24'10' a ~ - ~'~~~ ~-I ACN 12167273 DATE 12-13-2012 Estate of BARBARA E PTASZEK Date of Death 11-29-2012 County CUMBERLAND C ~o ~ ~ -€1 '~Tn s~>, ~= m ~~ti~ . ~,. Type of Account Savings Checking X Trust n Certificate `' ~' m m (? ~ G j ~ CO en .-t T r~, --r rr cn j"~'1 r~r ~~ r~ ,. (j _77 ;~ `rY 'Vy _.,.r ~ ;"7 ~:) ~' rrrt r...- ` V'7 Crs ~ -`: -l.t MEMBERS lsr 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. Remit Payment end Forms to: Account No. 403 Date Established 10-20-2011 REGISTER OF WILLS Account Balance $ 19,838.01 1 COURTHOUSE SQUARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $19,838.01 Tax Rate X 0.045 Potential Tax Due $ gg2,71 NOTE*: If tax payments are made within three months of the decedent's date of death, deduct a 5 percent discount on the tax With 5% Discount (Tax x 0.95) $ (see NOTE') S `f8, off' 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. g ®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 an 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 deateh. 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 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 informption 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. Prooeed 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 z 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) $ PART TaX Ca~CU~atlon 3 If ou are makin a correction to the egtablishment date Line 1 account balance Line 2 or y g ( ) ( ), percent taxable (Line 3), please obtain a written correction from the financial instkution and attach it to this farm. 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 ~s taxable to you. a. First, determine the percentage owned by the decedent. i. Accounts that are held "in trust fpr" 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. ~. 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 your relationship to the decedent: 1. Date Established 1 2. Account Balance 2 $ 3. Percent Taxable 3 x 4. Amount Subject to Tax 4 $ 5. Debts and Deductions 5 - 6. Amount Taxable 6 $ 7. Tax Rate 7 x 8. Tax Due 8 $ 9. With 5% Discount (Tax x .95) 9 X $t~.'p 2: Sign and date below. Return TWO'completed and signed copies to the Register of Wilts listed on the front of his form, alortp with a check for any payment you are making. Checks must be made payable to "Register of Wills, Agent ° Do not end payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts ~ have reported above are true, correct and complete to the best of my kngwledge and belief. -~ ~ Work 7~7- 605"-`7~SS Home 717- ~`tl-oSSS ZS~~>l Zof3 Taxpayer Signature Telephone Number Date IF 1(OU NEED FURTHER ASSISTAN¢E, CONTACT CUMBERLAND COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR `THE INHERITANCE TAX DIVISION AT 71~-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 BUREAU OP INDIVIDUAL TAXES PD BOX 280601 HARRISBURG PA 17128-0601 Pennsylvania Inheritance Tax Information Notice And Taxpayer Response ~ pennsylvania DEPARTMENT OF REVENUE xev-sus ex moexec ~oena p y FILE NO.333802f-/a-~~-/ / ACN 12167271 DATE 12-13-2012 ROBERT S PTASZEK 111 ADAMS RD CARLISLE PA 17015-9209 Estate of BARBARA E PTASZEK Date of Death 11-29-2012 County CUMBERLAND Type of Account Savings Checking X Trust Certificate n w ° 31 ~o `"' rnry rn ~ W ~ O m s ~ m cn ~I ~ ~ m ~ rsi rn C> Ss -27 ~r -vr GJ C: : ~: t`S y,. CJ-1 G'f C', MEMBERS lsr Fcu provided the department with the information below indicating that a~tthe death of the above-named decedent you were a joint owner or beneficiary of the account identified. Account No. 403 Date Established 08-18-2012 Account Balance Percent Taxable $ 28,818.69 X 50 Amount Subject to Tax $14,409.35 Tax Rate X 0.045 Potential Tax Due $ 648.42 With 5% Discount (Tax x 0.95) $ (see NOTE') 16, D o Remit Payment and Forms to: REGISTER OF WILLS 1000RTHOUSESOUARE CARLISLE PA 17013 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. g ~ 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. 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 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 [ax 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 z 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 $ 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 oorrectlon 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 your relationship to the decedent: _ 1. Date Established 1 2. Account Balance 2 3. Percent Taxable 3 4. Amount Subject to Tax 4 5. Debts and Deductions 5 6. Amount Taxable 6 7. Tax Rate 8. Tax Due 9. With 5% Discount (Tax 7 X 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. Work ~1f~-~o5-~BSFf -2`FI-c~SSS Zs~<6 2~/ 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 BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 ~ Pennsylvania DEPARTMENT OF REVENUE xrvnus ex m~exsc coe-~z~ FILE NO. X79 ~ "I~,-I ~q 1 ACN 12167269 DATE 12-13-2012 Estate of BARBARA E PTASZ~C Date of Death 11-29-2012 ~ ROBERT S PTASZEK 111 ADAMS RD CARLISLE PA 17015-9209 County CUMBERLAND m r- n r <~ ~: Type of Account ti vings ~^' ecking ~ ~ T USt rn ~ rtificate 2 n p R N 1 Z C :3 '!:7 ~s c'~ ~ + _3 r C,- .. - a;7 as r--. ` rn _._ _~ ~ <~s n MEMBERS lsr Pcu 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. 403 Remit Payment and Forms to: Date Established 06.01-2009 REGISTER OF WILLS Account Balance $ 15,868.87 1 COURTHOUSE SQUARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $ 15,868.87 - Tax Rate X 0.045 NOTE`: If tax payments are made within three months of the Potential Tax Due $ 714.10 decedent's date of death, deduct a 5 percent discount on the tax With 5% Discount (Tax x 0.95) $ (see NOTE') ~C~(S. `FD due. Any inheritance tax due will become delinquent nine months after the date of death. PART st@p 1: Please check the appropriate boxes below. 1 A ~ No tax is due. g ®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. 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 will be sent with my response. Proceed to Step 2 on reverse. Do not check any other boxes. Pennsylvania Inheritance Tax Information Notice And Taxpayer Response 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 PART Tax Calculation 3 If ou are makin a correction to the establishment date Line 1 account balance Line 2 , or y g ( ) ( ) percent taxable (Line 3), please obtain a written corcection 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. your relationship to the decedent: 1. Date Established 1 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. Work ?I'- 6oS-7f~S$ Home f'7-Z`fi/-o5-5S ZS Fed 213 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 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. BUREAU OF INDIVIDUAL TAXES PD BOX 2806D1 HARRISBURG PA 17128-0601 pennsylvania ~~ 1 DEPARTMENT OFREVENUE REV-1561 EZ OocEFEG (OB-121 q FILE NO. 2] 7El ~I -~ ~ ~~-/ 7 ACN 12167268 DATE 12-13-2012 ROBERT S PTASZEK L11 ADAMS RD CARLISLE PA 17015-9209 Date of Death 11-29-2012 County CUMBERLAND n C W m r n i ;> _~ 7';.. Type of Account Savings Checking r-„ X Trust c' ertificate o ' ' m n A 7 t r-E-i G? O = n ' Co V ~ _t a ~ z rv cri ~-r, rn ~ V D ~ c~ - ;~ o n ~~ Yl ~ ~ -,~"fi C_ _., , ,... ,a _" .. E- ~, :7 .- F i r'v1 u._ r "~'1 MEMBERS lsr 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. 403 Date Established 04-03-2009 Account Balance Percent Taxable Amount Subject to Tax $ 4,174.73 X 100 $ 4.174.73 Remk Payment and Forms to: REGISTER OF WILLS 1000RTHOUSESOUARE CARLISLE PA 17013 Tax Rate X 0.045 NOTE*: If tax payments are made within three months of the Potential Tax Due $ 187.86 decedent's date of death, deduct a 5 percent discount on the tax With 5% Discount (Tax x 0.95) $ (see NOTE') ~ 17 $, '~7 due. Any inheritance tax due will became delinquent nine months after the date of death. PART Step 1: Please check the appropriate boxes below. 1 A ~ No tax is due. g ®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. 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 will be sent with my response. Proceed to Step 2 on reverse. Do not check any other boxes. Pennsylvania Inheritance Tax Information Notice And Taxpayer Response 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 torm. 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 z 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.) Uate Paitl Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If ou are makin a correction to the establishment date Line 1 account balance Line 2 or Y 9 ( ) ( ), percent taxable (Line 3), please obtain a written comection from the financial instRution 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 ycu. 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 your relationship to the decedent: 1. Date Established 1 2. Account Balance 2 $ 3. Percent Taxable 3 x 4. Amount Subject to Tax 4 $ 5. Debts and Deductions 5 - 6. Amount Taxable 6 $ 7. Tax Rate 7 X 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./~ "~ l~'~~~~ Work ~I~-~~S-78S~ Home X17- z~{(- ossS ZS Fc/, z~/3 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 BUREAU OF INDIVIDUAL TAXES PD BOX 280601 HARRISBURG PA 17128-0601 I am the spouse of the deceased or 1 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. ~ Pennsylvania DEPARTMENT OF REVENUE PEV-1545 EX OocEYE[ <4B- 31 !~ '1 FILEN0.~1.70~j-~~jL`~~/ / ACN 12167267 DATE 12-13-2012 ROBERT S PTASZEK 111 ADAMS RD CARLISLE PA 17015-9209 n ~ O Date of Death 11-29-2012r-. L+ r'- County CUMBERLAND _A ~ -~ 7 ~ r+ C'1Y lJ -r„ 7. (.' :.~„ ,.... i CA rte; Typeaf Ac Ba~ rn rn ~ Savings m rn Checking rv r~~ Trust cn ~; o Certificate _~ a w, -~ _.~ a7 ~ , _. G 7 ., r~' fr. ca t:..~ _,9 MEMBERS lsr 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. 403 Date Established 10-16-1997 Account Balance $ 38,361.73 Percent Taxable X 50 Amount Subject to Tax $19,180.87 Tax Rate X 0.045 Potential Tax Due $ 863.14 With 5% Discount (Tax x 0.95) $ (see NOTE*) 8 f 9.98 Remit Payment and Forms to: REGISTER OF WILLS 1000RTHOUSESOUARE CARLISLE PA 17013 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. g ®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. Pennsylvania Inheritance Tax Information Notice And Taxpayer Response 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 z Payee 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 Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If ou are makin a correction to the establishment date Line 1 account balance Line 2 or y g ( ) ( ), 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 your relationship to the decedent: 1. Date Established 1 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate X Debts and Deductions 8. Tax Due 8 $ 9. With 5% Discount (Tax x .95) 9 x .St@p `l: 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. , Work ~ 17- 605-7858 Home 7f7-z~(-osSS ZS ~b 2°j3 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 BUREAU OF INDIVIDUAL TASES PD BOx 268601 HARRISBURG PA 17128-8681 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. ~ Pennsylvania DEPARTMENT OF REVENUE PEV-156] E[ OeeEFEL (OB-I]) FILE NO. Pfi'fB ~- ~~'I wl~ ACN 12167265 DATE 12-13-2012 Type of Account ROBERT S PTASZEK 111 ADAMS RD CARLISLE PA 17015-9209 Estate of BARBARA E PTASZEK ~ Savings SSN 208-24-4523 Checking Date of Death 11-29-2012 X Trust County CUMBERLAND Certificate n :'' ~ ~° ~ m~ '~ rn °n Oo 0 m=~ m ins ~ a r N --Y c:s a ~ rrY cn ~ c n PrI rn ,.~, cs ~_. .~ YJ K'1 f..) _ ~ cz o `~I ?Y ~ c: - ~ ~~ ~c> ' r11 W `]7 MEMBERS lsr 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. 403 Date Established 10-01-1974 Account Balance $ 4,000.76 Percent Taxable X 50 Amount Subject to Tax $ 2,000.38 Tax Rate X 0.045 Potential Tax Due $ 90.02 With 5% Discount (Tax x 0.95) $ (see NOTE') ~ SS. S2 Remit Payment and Forms to: REGISTER OF WILLS 1000RTHOUSESOUARE CARLISLE PA 17013 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. g 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. Pennsylvania Inheritance Tax Information Notice And Taxpayer Response 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 $ PART Tax Calculation 3 If ou are makin a correction to the establishment date Line 1 account balance Line 2 , or Y 9 ( ) ( ) percent taxable (Line 3), please obtain a written correction from the finenclel 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 [he 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. your relationship to the decedent: 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 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. Work ~(7- (ooS- ($~g ~~ Home ~I7-Z`f(-©SS~ Z~Fe~i Zvf3 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 BUREAU Of INDIVIDUAL TAXES PD BOX 280601 HARRISBURG PA 17128-0601 Pennsylvania Inheritance Tax Information Notice And Taxpayer Response "' REVISED NOTICE "' ~ Pennsylvania DEPARTMENT OF REVENUE xev-~se5 cx m~Exec ,ee-~z, FILE NO. 2112-1297 ACN 12168924 DATE 02-18-2013 Type of Account ROBERT S PTASZEK 111 ADAMS RD CARLISLE PA 17015-9209 Estate of BARBARA E PTASZEK Date of Death 11-29-2012 County CUMBERLAND a C m r- n z r~ C7 O -t3 a O v s ~ n r a- m ~ ~~ • x n r,-.~ O -t C A ~~ Savings Checking X Trust Certificate ~m m '*I h rn ~ Q ~ cn ~ rv _t o r-rz r-n cn :n n ~ 0 0 '+`t ~~= C> r__ cn cn o w 'n SUSQUEHANNA BANK 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. 10005034128 Remit Payment and Forms to: Date Established 07-01-2008 REGISTER OF WILLS Account Balance $ 29,150.49 1 COURTHOUSE SQUARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $ 29,150.49 Tax Rate X 0.045 Potential Tax Due $ 1 311.77 NOTE': If tax payments are made within three months of the ' With 5% Discount (Tax x 0.95) , $ (see NOTE') decedent s date of death, deduct a 5 percent discount on the tax (12y-to, I $ 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. g ®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. 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 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 z 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 81/2" x 11"sheets of paper.) Date Paid Payee Description Amount raio Total Enter on Line 5 of Tax Calculation $ IIF 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 ON LY: 1-800-447-3020 BUREAU OF INDIVIDUAL TAXES Penns Ivania Inheritance Tax PO BOX Y ~ DennsVlvania r J 280601 HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE And Taxpayer Response "`° """"°°""` `°'"~' FILE NO. 2112-1297 ACN 13500366 DATE 02-01-2013 PTASZEK ROBERT S 111 ADAMS RD CARLISLE PA 17015-9209 I am the spouse of the deceased or 1 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. n f7 CJ ~ ~-- :17 ~ -i XY. Type of Account 0 ~;, avings T hecking r*1 Trust n ~' ertificate ~ rn rv r*i nn :a cJl ~~ t~ ~ O cs [~ - ~ ~ ~ Yr ~§' y~ ~. ~ I ~• ~+ ..' C7 r" rTt r C7l CA O C..J 'rl EDWARD JONES 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. Remk Payment and Forms to: Account No. 270 Date Established REGISTER OF WILLS Account Balance $ 72,432.45 1 COURTHOUSE SQUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $ 36,216.23 Tax Rate X 0.045 Potential Tax Due $ 1,629.73 NOTE': If tax payments are made within three months of the decedent's date of death, deduct a 5 percent discount on the tax With 5% Discount (Tax x 0.95) $ (see NOTE') ~~ S'{~, Z7{ 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. g 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. Estate of BARBARA E PTAS~K SSN 208-24-4523 ~ O Date of Death 11-29-2012 w ~ County CUMBERLAND ~ z r D r ~ Z Cn 0 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 torm. 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 uescnpnon Nmoum raw Total (Enter on Line 5 of Tax Calculation $ 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 BUREAU OF INDIVIDUAL TAXES PD eox zaosBl HARRISBURG PA 17128-0601 ~ Pennsylvania DEPARTMENT OF REVENUE FILE NO. 2112-1297 ACN 13500354 DATE 01-31-2013 PTASZEK ROBERT S 111 ADAMS RD CARLISLE PA 17015-9209 :'? r,> "+7 A C W rn r x~ r~ O :U R7 z Y ul r> c] C', :'Y .i Type of Account Savings Checking Trust Certificate `~; ~' m r.T-rn ~ O c5 m cn ~ m r~-r rn .^r u-I ~u c.+ '~ Ck d t't.. rrl -_ cn cn o C.J '*7 AMERICHOICE 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. 35165 Date Established Account Balance Percent Taxable Amount Subject to Tax Tax Rate Estate of BARBARA E PTASZEK SSN 208-24-4523 Date of Death 11-29-2012 County CUMBERLAND Remit Payment and Forms to: REGISTER OF WILLS $ 9,607.07 1 COURTHOUSE SQUARE X 50 CARLISLE PA 17013 $ 4,803.54 X 0.045 Potential Tax Due $ 216.16 With 5% Discount (Tax x 0.95) $ (see NOTE') $2~S 3 S 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. g ~ 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. 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 Taz Due. 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. Pennsylvania Inheritance Tax Information Notice And Taxpayer Response 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 uescription Hmount raic Total Enter on Line 5 of Tax Calculation $ 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 "intrust 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 your relationship to the decedent: 1. Dale Established 1 2. Account Balance 2 $ 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 $ 5. Debts and Deductions 5 - 6. Amount Taxable 6 $ 7. Tax Rate 7 _ X 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. ~j Q~~ Work -7/'- 6os-74sX /10 ~``,~4 ~'L Home~l7-Z~l-e~SSS 2S FeI, 20l 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 1717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 1]128-0601 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. ~ Pennsylvania DEPARTMENT OF REVENUE xsvasasx ex oo~sxsc wean FILE NO. 2112-1297 ACN 13500324 DATE 01-25-2013 PTASZEK ROBERT S 111 ADAMS RO CARLISLE PA 17015-9209 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. CENTRIC BANK 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. 3055720 Pennsylvania Inheritance Tax Information Notice And Taxpayer Response Estate of BARBARA E PTASZEK Date of Death 11-29-2012 County CUMBERLAND Type of Account Savings X Checking Trust Certificate c w m o m i n a n p p ' "SI r n ~ O m$~ m Cn .Z1 o nv ~~~a cn •~ ~ c-n r, --~ cao -«~, -*i K') C.) 'rI -'3 ..pl !D CC 37 F--^ ~~: 47 ,- _t7 -1 rY7 P' qy Cf~ CI') ~ W 'n Remit Payment and Forms to: Date Established REGISTER OF WILLS Account Balance $ 26,861.03 1 COURTHOUSE SQUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $13 430 52 , . Tax Rate X 0.045 Potential Tax Due $ 604 37 NOTE': If tax payments are made within three months of the ' . decedent s date of death, deduct a 5 percent discount on the tax With 5% Discount (Tax x 0.95) $ (see NOTE') ST`f. I S due. Any inheritance tax due will become delinquent nine months after the date of death. PART StI?p 1: Please check the appropriate boxes below. 1 A ~ No tax is due. g 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. 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 z 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 [he department. (If additional space is required, you may attach 8 1 /2" x 11"sheets of paper.) Payee Description Amount Paid Date Paid 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due 9. With 5% Discount (Tax x .95) X 7 X 8 $ g 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 1 have reported above are true, correct and complete to [he best of my knowledge and belief. Work X17-Gos-7K Taxpayer Signature Telephone Number rl~-2°F~-oSS-S ZS (=e6 2013 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 BUREAU Of INOIVIDUAI TAXES PO BOX 280601 HARRISBURG PA 17128-0601 $10,787.70 X 50 ~' Pennsylvania ~iT DEPARTMENT OF REVENUE REV-ISf}} E% UocE%EL IYB-13) FILE NO. 2112-1297 ACN 13500233 DATE 01-21-2013 PTASZEK ROBERT S 111 ADAMS RD CARLISLE PA 17015-9209 Estate of BARBARA E PTASZE~ Date of Death 11-29-2012 m County CUMBERLAND ~ r =' Z SA ~ ~ c^, C? t_> c' ~ ._. ~r ~ ..... Type of Account ~. ~' mgs `" cking co , ; m "- RASt ~rtificate r- cn n ~ ~ r~-~ C} - ..~~ C5 ~'7 ~ ry ~-. > ~ p d't^Y l..., ~ ~ S r. rl G"F Cl !..J ll ALLIANCE DEVELOPMENT FUND 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. 22835 Date Established Account Balance Percent Taxable Amount Subject to Tax Tax Rate $ 5,393.85 X 0.045 Potential Tax Due $ 242.72 With 5% Discount (Tax x 0.95) $ (see NOTE') 23 D. 8 Remit Payment and Forms to: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 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. g ~ 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. 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 will be sent with my response. Proceed to Step 2 on reverse. Do not check any other boxes. Pennsylvania Inheritance Tax Information Notice And Taxpayer Response 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 /orm. 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. 8. 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 $ 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 instRution 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 [he 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. It indicating a different tax rate, please state your relationship to the decedent: 1. Date Established 1 2. Account Balance 2 $ 3. Percent Taxable 3 x 4. Amount Subject to Tax 4 $ 5. Debts and Deductions 5 - 6. Amount Taxable 6 $ 7. Tax Rate 7 X 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. ~, Work 717- 6oS-7$SS Home ~("7-Z~(- ass s ~S FQG Zola 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 BUREAU DF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 11128-0601 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. Pennsylvania ~.~T DEPARTMENT OF REVENUE REV-154]R EF UeeE[EC 149 13) FILE NO. 2112-1297 ACN 13500235 DATE 01-21-2013 PTASZEK ROBERT S 111 ADAMS RD CARLISLE PA 17015-9209 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. Type of Account Savings X Checking Trust Certificate n o C O h ~ w ' 70 '~ ~ m O o ~ ~ n *n m c > ~ ~ ~ » r^ A ~" r,i N ~ ni ro .~ ~_' O ~ .SJ F... `- C"~ ~ ....1 r' r.~ ALLIANCE DEVELOPMENT FUND provided the department with the informationt`t)elow indi~ting+trlslat the death of the above-named decedent you were a joint owner or beneficiary of the accoun dentifie~. Remit Payment and Forms to: Account No. 22388 Date Established REGISTER OF WILLS Account Balance $ 23,201.22 1 COURTHOUSE SOUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $11,600.61 Tax Rate X 0.045 Potential Tax Due $ 522.03 NOTE': If tax payments are made within three months of the ' decedent s date of death, deduct a 5 percent discount on the tax With 5% Discount (Tax x 0.95) $ (see NOTE') $ 9 S, 9 3 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. g ®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. Pennsylvania Inheritance Tax Information Notice And Taxpayer Response Estate of BARBARA E PTASZEK SSN 208-24-4523 Date of Death 11-29-2012 County CUMBERLAND 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 o/this /orm. 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 z 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) $ 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. Far 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. your relationship to the decedent: 1. Date Established 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. ~~ Work 717 - 6 ~S- ~ ~Sg Home `717-Z`~l-~SSS 25 Frb Zv13 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 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. BUREAU OF INUIVIOUAL TAXES PO BOX 380601 HARRISBURG PA 1]128-0601 $ 16,404.32 X 50 ~ pennsylvania DEPARTMENT OF REVENUE xzvasna cx oocezec roeaz, FILE NO. 2112-1297 ACN 13500237 DATE 01-21-2013 PTASZEK ROBERT S 111 ADAMS RD CARLISLE PA 17015-9209 Estate of BARBARA E PTASZEK S Date of Death 11-29-2012 County CUMBERLAND Type of Account Savings Checking Trust Certificate C ~ O c,i ~ ~ o' a ~ ~ h 'Tt r m n co z n r- c~ c;, ~ ~y~ ~ hY r ~ i q :7 ~ -^ Q C) ~ ell indicating t~at_ 'a't the ALLIANCE DEVELOPMENT FUND provided the department with the information death of the above-named decedent you were a joint owner or beneficiary of Account No. 22387 Date Established Account Balance Percent Taxable Amount Subject to Tax Tax Rate $ 8,202.16 X 0.045 Potential Tax Due $ 369.10 With 5% Discount (Tax x 0.95) $ (see NOTE') ~ 350, (~ S Remit Payment and Forms ta: REGISTER OF WILLS 1000RTHOUSESOUARE CARLISLE PA 17013 Gn p 'rt 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. g ®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. 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 will be sent with my response. Proceed to Step 2 on reverse. Do not check any other boxes. Pennsylvania Inheritance Tax Information Notice And Taxpayer Response 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.) uate raio rayee Description Amount Paid Total (Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If ou are makin a correction to the establishment date Line t account balance Line 2 , or Y 9 ( ) ( ) 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. your relationship to the deced 1. Dale Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due 9. With 5% Discount (Tax x Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of [his 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. /t /d / ~~ Work~I~-dos-7~SS S.X//1 Home 71~- 7`~(-oSS"S ZS Feb Zola 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 BUREAU GF INUIV IGUAL TAXES PO BOX 288681 HARRISBURG PA 17128-0681 Pennsylvania Inheritance Tax Information Notice And Taxpayer Response ~ pennsylvania DEPARTMENT OF REVENUE REV-15631 EX OocEXE[ (OB 12) FILE NO. 2112-1297 ACN 13500320 DATE 01-25-2013 PTASZEK ROBERT S 111 ADAMS RD CARLISLE PA 17015-9209 Estate of BARBARA E PTASZEK Date of Death 11-29-2012 County CUMBERLAND c 3. o ~ ~ 'b m=om ~ n r n ~ ~ (/~ ~ ~ n O C7 d .ry.i O C iO 'D ~ n Type of Account Savings Checking Trust -~ w ~ Certificate - rn ~ *, rn ~ O ~ ~~ rV _q tl U"1 rwt m :Ra 4 _~ O t'~ ~ 'ry ~, °.': ~... m P"' CJ-i G"> O fV '*1 VANGUARD 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. 88014595918 Remit Payment and Forms to: Date Established REGISTER OF WILLS Account Balance $ 90,079.21 1 COURTHOUSE SOUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $ 45,039.61 Tax Rate X 0.045 Potential Tax Due $ 2,026.78 NOTE': If tax payments are made within three months of the decedent's date of death, deduct a 5 percent discount on the tax With 5% Discount (Tax x 0.95) $ (see NOTE`) 19 2 S, `/- 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. g ®Theinformationis 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. 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 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 z 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 $ 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 ft 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. a. 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 intlicating a tlifferent tax rate, please state your relationship to the decedent: 1. Dale Established 1 2. Account Balance 3. Percent Taxable 3 X 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 5 - X 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, 1 declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. Work ~I ~' ~ ~ S ~fSSB n-z~-f- o s F<b zol3 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 WdTH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 BUREAU OF INDIVIDUAL TAXES Pennsylvania Inheritance Tax PD BOX 280601 HARRISBURG PA 1T12B-0601 Information Notice And Taxpayer Response ~ Pennsylvania DEPARTMENT OF REVENDE PEV-154!1 E% OocE%EC (OB-13) FILE NO. 2112-1297 ACN 13500322 DATE 01-25-2013 PTASZEK ROBERT S 111 ADAMS RD CARLISLE PA 17015-9209 CENTRIC BANK 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. Remit Payment and Forms to: Account No. 3053618 Date Established REGISTER OF WILLS Account Balance $10,584.90 1 COURTHOUSE SQUARE CARLISLE PA 14013 Percent Taxable X 50 Amount Subject to Tax $ 5 292 45 . , Tax Rate X 0.045 hi h h f h d i ' ree mont : If tax payments are ma e w t n t s o t e NOTE Potential Tax Due $ 238.16 decedent's date of death, deduct a 5 percent di$count on the tax With 5% Discount (Tax x 0.95) $ (see NOTE') 2Z , 2 S 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. g 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 inheritanc2 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 will be sent with my response. Proceed to Step 2 on reverse. Do not check any other boxes. Type of Account Estate of BARBARA E PTASZEK Savings SSN 208-24-4523 Checking Date of Death 11-29-2012 n ~=; Trust County CUMBERLiAND c o c..; l'~ltificate ~ ~7 1n ~ C7 m=~ ~ -~ r m cn ~~.T -. r 3 D ~ r1'I N .l : rrl r+1 C7 ~ ~ _~ O rJ C7 ~ -n O C. ~ ~ Y _a r- ~ n cn in o N 'rt 4.5% I am a lineal beneficiary (parent, child, grandchild, etc.) of the deceased. 12% I am a sibling of the deceased. 1 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 reve~'se. Do not check'any other boxes. , , Please signiand date the back of the form when finished. ' ~ - P 2RT Debts and Deductions Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible fdr 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 $ PART Tax Calculation 3 It ou are makin a corcection to the establishment date Line 1 ,account balance Line 2 or Y 9 ( ) ( ), percent taxable (Line 3), please obtain a written corcealon from the flnanclal 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 tha) 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 1 QO% 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 ~urviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account b}lance by the percent taxable. Enter the total of any debts and deductions claimed from Part 2. The amount taxable is determined by subtracting the debts and dedu bons from the amount subject to tax. 7. Enter the appropriate tax rate from Step` 1 based on your relationship~o the decedent. If indicating a different tax rate, please state your relationship to the decedent: 1. ~~ Date Established 1 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due 9. With 5% Discount (Tax x .95) 9 x Step 2: Sign and date below. Return TWQ completed and signed copies to the Register of Wills listed on the front o((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. ~~ Work 71~-6a5-7gS~ Home ~(7-ZK(-oSSS z S (=c~ Ze~l3 T2xpayer Signature Telephone Number Date IF 1'OU NEED FURTHER ASSISTAN E, CONTACT CUMBERLAND COUNTY REGISTER OF ILLS, PA DEPARTMENT OF REVENUE DI TRICT OFFICE, OR .THE INHERITANCE TAX DIVI"ION AT 71p-787-8327. SERVICES FOR TA PAYERS WITH SPECIAL HEARING AND/OR SPEAKIN NEEDS Of~LY: 1-800-447-3020 BUREAU OF INUIV IUUAL TAXES PO BOX 280601 HARRISBURG PA 1]128-0601 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. ROBERT S PTASZEK APT 202 5 ALLIANCE DR CARLISLE PA 17013-4140 ~ pennsylvania DEPARTMENT OF REVENUE xev-ssas ez oa~ezec ,aeaa FILE NO. 2112-1297 ACN 13100949 DATE Ot-09-201 w ~ "*i m ~j ~ ~y~e ~Acc t cn ~ Estate of BARBARA E PTASZEK a ~ ~ ~i}~s , s Ei/iet~hing Date of Death 11-29-2012 ~,, ~., ra X ~ruab County CUMBERLAND ~ ~;_, "1 .;-i 21efNficate :.`r :t ~-- T v ~ 6 ' R oRRSrowN BANK 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. 4000042564 Date Established 08-12-2011 Account Balance $ 10,262.00 Percent Taxable X 50 Amount Subject to Tax $ 5,131.00 Tax Rate X 0.045 Potential Tax Due $ 230.90 With 5% Discount (Tax x 0.95) $ (see NOTE') Z j9, 3 ~ Remit Payment and Forms to: REGISTER OF WILLS 1 COURTHOUSE SOUARE CARLISLE PA 17013 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. g ®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 farm 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. Pennsylvania Inheritance Tax Information Notice And Taxpayer Response 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 [his 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 z 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.) uate Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation) $ PART Tax Calculation 3 If ou are makin a correction tc the establishment date Line 1 account balance Line 2 , or Y 9 ( ) ( ) percent taxable (Line 3), please obtain a written correction from the financial institution and attach It to this form. t . 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 "intrust 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 [he 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, pl your relationship to the decedent: 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 6 ~ 7. Tax Rate 7 X 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. Work '"% I~- 6oS-7b'S8 Home~l7-Z`/-/-os~S 25 Fe Taxpayer Signature Telephone Number Date 2of 3 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