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BUREAU OF INDIVIDUAL TAXES
PG BOX 280601
HARRISBURG PA 17128-0601
Pennsylvania Inheritance Tax
Information Notice
And Taxpayer Response
~ Pennsylvania
DEPARTMENT OF REVENUE
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FILE NO. 2170
ACN 12170228
DATE 12-31-2012
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MARK A KANE
6118 GEISLER RUN RD
HUNTINGDON PA 16652-5234
Estate of ELIZABETH B KANE
Date of Death 04-25-2012
County CUMBERLAND
Type of Account
Savings
Checking
Trust
Certificate
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SDVEREIGN 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.
AccountNa.1051138809
Date Established 12-20-2006
Account Balance $ 3,053.01
Percent Taxable X 16.667
Amount Subject to Tax $ 508.85
Tax Rate X 0.150
Potential Tax Due $ 76.33
With 5°f° Discount (Tax x 0.95) $ (see NOTE'
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 StBp 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 /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
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 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 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.
lr indicating a different tax rate, pl
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.
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Taxpayer Signature Telephone Number Date
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
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.
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DATE PAID PAYEE DESCRIPTION AMOUNT
4/27/12 GOLDEN LIVING CEN TER RESIDENT $ 573.93
CARE FACILITY
5/27/12 ANTHEM BLUE CROSS MEDICAL INSURANCE $ 200.45
Sj24/12 COMCAST TV CABLE SERVICE $ 136.87
7/12/12 MOBILEX USA XRAY CHARGE $ 41.35
7/18/12 PSERS RETURN RETIREMENT PAY $ 56.79
7/20J12 PEOPLES UNITED DONATION PER $2000.00
METHODIST CHURCH DECENDENT WISHES
10/15/12 MINISTER FUNERAL SERVICES $ 100.00
1Of15/12 KELLEY'S LANDING FUNERAL RECEPTION $ 120.00
10/15/12 FLOWER SHOP FUNERAL FLOWERS $ 100.00
10/15/12 TRAVEL EXPENSE TRANSPORT REMAINS TO $ 63.73+
GREENVILLE, MAINE
LAST EXPENSE LISTED CLOSED OUT ACCOUNT BUT NOT ENOUGH TO COVER
ACTUAL CO STS.