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Home My WebLink About03-21-13 (4) BUREAU OF INDIVIDUAL TAXES Pennsylvania Inheritance Tax pennsylvania PO BOX 280601 Al DEPARTMENT OF REVENUE HARRISBURG PA 17128-0601 Information Notice REV-1543 EX DocEXEC (08-12) And Taxpayer Response FILE NO:-2170 Z1 -I0-cam ACN 13106799 C�'o `� ;^ � DATE 02-11-2013 REC)STE;R OF ?{13 11811 21 Fil 1 18 Type of Account Estate of ADAM R COOK Savings CLERK SSN X Checking Date of Death 01-09-2013 Trust JOHN L HYATT SR ORPHANS COURT County CUMBERLAND Certificate 457 MOUNT OLIVETC R t1 AJ40 r' 'A FAWN GROVE PA 17321- Y MEMBERS 1sT FCU provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No.439606 Date Established 11-15-2011 REGISTER OF WILLS Account Balance $502.97 1 COURTHOUSE SQUARE Percent Taxable X 16.667 CARLISLE PA 17013 Amount Subject to Tax $83.83 Tax Rate X 0.045 Potential Tax Due $3.77 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*) due. Any inheritance tax due will become delinquent nine months after the date of death. PART Step 1 : Please check the appropriate boxes below. A No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. B I The information is The above information is correct, no deductions are being taken:and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. C The tax rate is incorrect. 4.5% I am a lineal beneficiary(parent,child,grandchild, etc.) of the deceased. ' '(Select correct tax rate at right, and complete Part 12% I am a sibling of the deceased. 3 on reverse.) 15% All other relationships (including none). D Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back of this form. E Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. n 0 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 ` 3 ' 0-L-et 41 nn v Lae -FO., 1)1,02€0,Y ys 4, a�, c f 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. 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:2 owners=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 st e 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 � �� ve�v�� 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. y / Work �7 16 Home �/0� ad l ��` `�(17‘L7 Taxpayer Sidnature 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