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Home My WebLink About06-12-13 _ _ __ _ . _ w��r BUREAU OF INDIYIDUAL TAXES Penns Ivania lnheritance Tax � pennsylvania PO BOX 280601 Y HARRISHURG PA 17126-0601 Information Notice DEPARTMENT OF REVENUE An T�p��a r Response REV-1543 EX DocEXEL (OB-l2) �E�� ;� Q��1,`,�C� Vr FILE N0.2170 ACN 13106392 RE�� F ��'�"� DATE02-08-2013 r'.fJl3 JUN 12 P�1 3 OS Type of Account CLERK OF Estate of ESTHER W HUMPHREY Savings, 0 R P H A N S� C 0 l�RT SSN Checking ELLA J NICHOLS ountyCUMBERLAND13 X Certficate 1208 REDWOOD HILLS CIR ��MBEaLAND CO•� P CARLISLE PA 17015-9735 MEMBERS isr 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. 129411 Remit Payment and Forms to: Date Established 05-22-2010 REGISTER OF WILLS Account Balance $20,817.39 1 COURTHOUSE SGIUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $10,408.70 Tax Rate X 0.045 Potential Tax Due $468.39 NOTE*: If tax payments are made within three months of the decedenYs 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 Ste � : Please check the a i p ppropriate boxes below. A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. g �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°/a 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). p �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. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid 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 decedenYs percentage owned by the number of sunriving 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. Work Home 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 T�ES Penns Ivania lnheritance Tax � DennsVlvania PO BOX 280601 y ■ ✓ HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE NEV-1543 EX DocE%EL (OB-12) And Taxpayer Response FILE NO.2170 ACN 13106393 R E C 0 R D�D 0 r��'� DATE 02-08-2013 REGf�TER UF �t�}l_�.S ?G13 �UN 12 t I I 3 a� TYPe of Account Estate of ESTHER W HUMPHREY Saving�s SSN Checking C(�E f�f� �F Date of Death 01-29-2013 Trust ELLA J NICHOLS pRPHANS' COURi CountyCUMBERLAND x cert�ficate 1208 REDWOOD HILLS CIR CARLISLE PA i�oi5-9��MBERLAND CO., PA MEMBERS isr 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. 129411 Remit Payment and Forms to: Date Established 09-02-2008 REGISTER OF WILLS Account Balance $5,949.76 1 COURTHOUSE SGIUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $2,974.88 Tax Rate X 0.045 Potential Tax Due $1 g3.87 NOTE"`: If tax payments are made within three months of the decedenYs 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. 1 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 Potentia!Tax Due. g �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 � �2%o I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(including none). p �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 +nheritance 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. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid 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 decedenYs 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. tf 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. Tau 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 Home 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: i-800-447-3020 _ _.._ . . . . . . . . _ _ _ . . _ �R,� _ .. _ BURE/IU OF INDIVIDUAL TAXES Penns Ivania lnheritance Tax � enns Lvania PO BOX 280601 y P Y HARRISBURG PA 17128-0601 Information Notice DEPARTMENTOFREVENUE And Taxpayer Response pEV-1543 E%DocE%EC �oa-�2> FILE NO.2170 ACN 13106394 DATE 02-08-2013 l��ES� ��fi 0�' �:!l�.LS 1i �3 JUN 12 P� 3 Type of Account ��' ��ate of ESTHER W HUMPHREY Savings SSN Checkirng ELLA J NICHOLS CLERK OF Date Of Death 01-29-2013 Trust 1208 REDWOOD HILLS CIR QRPHANS COURTCounty CUMBERLAND X CertifiG�te CARLISLE PA 17015-9735 EUMBERLANd CO., PA MEMBERS isr 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. 129411 Remit Payment and Forms to: Date Established 10-16-2010 REGISTER OF WILLS Account Balance $1 g,g2g.1� 1 COURTHOUSE S�UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $9,464.06 Tax Rate X 0.045 Potential Tax Due $425.88 NOTE*: If t�payments are made within three months of the decedenYs date of death,deduct a 5 percent discaunt 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 $te 1 : Please check the a p � p ppro riate boxes below. A �No tax is due. f 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 nof check any ofher boxes and disregard the amount shown above as Potential Tax Due. g �The information is The above information is correct, no deductions are being taken,and payment wiff 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. (Selsct correct tax rate at `t'' right,and complete Part � �2��o I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �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 7ax 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. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the foliowing 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 inierest 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 7 00%divided by the total number of owners inciuding 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,piease 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 $ $ 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 Home 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 ON LY: 1-800-447-3020 . _ _ _ _ .�� BURFAU OF INDIVIDUAL TAXES Penns Ivania inheritance Tax � pennsylvania - PD BOX 280601 y HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE REV-1543 E%DocE%EC(08-12] And Taxpayer Response FILE NO.2170 R E L'Q�j� �} �j;=;n;�s_ �� ACN 13106395 ., DATE 02-08-2013 . .r c.�... -. zOt3 JUN 12 �� ,� ��j Type of Account Estate of ESTHER W HUMPHREY Savings ��K U I� SSN Checking Q R P M A N S� ��(J��j" Date of Death 01-29-2013 Trust ELLA J NICHOLS County CUMBERLAND X Certific�tte 1208 REDWOOD HILLS cik3UMBERLAND Ct3., P,1� CARLISLE PA 17015-9735 MEMBERS isT 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. 129411 Remit Payment and Forms to: Date Established 09-12-2005 REGISTER OF WtLLS Account Balance $19,462.05 1 COURTHOUSE SOUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $9,731.03 Tax Rate X 0.045 Potential Tax Due $437.90 NOTE': If tax payments are made within three months of the decedenYs 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. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who waB 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do npt check any other boxes and disregard the amount shown above as Potential Tax Due. g �The information is The above information is correct, no deductions are being taken,and payment wiH 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). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as app�opriate 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 nof check any other boxes. Please sign and date the back of the form when finished. _ _ . PART Debts and Deductions 2 Ailowable 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 i 1"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation) $ PAR7 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 taxabie 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 decedenYs 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 taxabie. 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. Pereent Taxable 3 X 4. Amount Subject to Tax 4 $ 5. Debts and Deductions 5 - 6. Amount Taxable 6 $ 7. Tax Rate � 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 Home 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 HEARIN AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 �,� _ BURFAU OF INDIVIDl1Al TAXes Penns Ivania lnheritance Tax � enns�/lvania PO BOX 260601 Y P J HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE And Taxpayer Response REV-1543 ES DocEl(EL <oa_�z� FILE NO.2170 ACN 13106396 ��C ��' DATE 02-08-2013 REG(5*�"R OF o�dLLS l�013 Ji1N 12 P� � ! TYpe of Account Et.i�e of ESTHER W HUMPHREY Savings SSN Checking C L E R K p F Date of Death 01-29-2013 Trust ELLA J NICH�LS ORPHANS� COUR'�ounty CUMBERLAND CertifiC�te CAR8ISLEWPAD1701559735 CUMBERLAND �p,� PA MEMBERS isr 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. 131248 Remit Payment and Forms to: Date Established 02-13-1993 REGISTER OF WILLS Account Balance $2,pgg.gg 1 COURTHOUSE SQUARE Percent Taxable X 16.667 CARLISLE PA 17013 Amount Subject to Tax $348.32 Tax Rate X 0.045 Potential Ta�c Due $�5.67 NOTE`: If tax payments are made within three months of the With 5%Discount Tax x 0.95 decedenYs date of death, deduct a 5 percent discount on the tax � ) $(see NOTE*) due. Any inheritance tax due will become delinquent nine months after the date of death. PART St@p 1 : Please check the appropriate boxes below. 1 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 6oxes and disregard the amount shown above as Potential Tax Due. g �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). p �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 ta�c 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. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid 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 financiaf institution and attach it to this form. 1. Enter the date the account was estabiished 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 deduct+ons 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,pfease state your relationship to the decedent: 1. Date Established 1 2. Account Balance 2 $ 3. Percent Tauable 3 X 4. Amount Subject to Tax 4 � 5. Debts and Deductions 5 - 6. Amount Taxable 6 $ 7. Tax Rate � 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 Home 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 F4R TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 _ _ _ _ . _,�.,. BURE4U OF INDIYIDUAL TAXES Pennsylvania inheritance Tax � pennsylvania Po BOX 2so6o1 DEPARTMENT OF REVENUE NARRI56UR6 PA 17128-0601 Information Notice And Taxpayer Response REY-0543 Ex oo�EXE� <oe-�z� FILE NO.2170 RECORBs�..� ��'�1�� QF ACN 13106397 _ i,, , DATE 02-08-2013 10I3 �UN 12 t � i � C'� Type of Account Estate of ESTHER W HUMPHREY Savings C�E�K G i SSN Checking 4 R P H A N S' C a U R7 Date of Death 01-29-2013 7rust �ISA ,1 HATHCOX County CUMBERLAND Certifieate 1208 REDWOaD HILLS cigUMB�RLAND CO., PA CARLISLE PA 17015-9735 MEMBERS isr 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.131248 Remit Payment and Forms to: Date Established 02-13-1993 REGISTER OF WILLS Account Balance $2,pgg.gg 1 COURTHOUSE SDUARE Percent Taxable X 16.667 CARLISLE PA 17013 Amount Subject to Tax $348.32 Tax Rate X 0.045 Potential Tax Due $15.67 NOTE*: If tax payments are made within three months of the decedenYs date of death,deduct a 5 percent discount on the tax With 5°lo Discount(Tax x 0.95) $(see NOTE`) due. Any inheritance tax due will become delinquent nine months after the date of death. PAR7 Step 1 : Please check the appropriate boxes below. 1 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 an reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. g �The information is The above informat+on 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 ofher 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). p �Changes or deductions The information above is incorrect andlor 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. PART Debts and Deductions 2 Allowabie 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+f requested by the department. (If additional space is required, you may attach 8 i/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 g ( ) { ) percent taxable(Line 3j, please obtain a written correction from the financial i�stitution 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 decedenYs percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to t�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. Work Home 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 _ _,�.�„ BURFAU OF INDIVIDUAL TAXES Pennsylvania lnheritance Tax � pennsylvania PO BOX 280601 DEPARTMENT�F REVENUE HARRISBURG PA 17128-0601 Information Notice REV-1543 EX DocE%EC<08-]2) And Taxpayer Response FILE NO.2170 ��G�'��:� �� flF ACN 13106398 R�G!S T�t g� 0 F '��L L 5 DATE 02-08-2013 �'�� `�U� �� P� � 06 Type of Account CLERK OF Estate of ESTHER W HUMPHREY Saving� SSN Checkiing 0 ft P H A N S� ��R� Date of Death 01-29-2013 Trust ELLA J NICHOLS �UM��F�tLAHD CQ., PQ CountyCUMBERLAND Certific;�te 1208 REDWOOD HILLS CARLISLE PA 17U15-4735 MEMBERS isr 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. 131248 Date Established 09-28-2010 REGISTER OF WlLLS Account Balance $3,300.52 1 COURTHOUSE SOUARE Percent Taxable X 16.667 CARLISLE PA 17013 Amount Subject to Tax $550.10 Tax Rate X 0.045 Potential Tax Due $24.7� NOTE*: If tax payments are made within three months of the decedenYs date of death,deduct a 5 percent discount on the tax With 5°lo Discount(Tax x 0.95) $(see NOTE') due. Any inheritance tax due wil{become delinquent nine montFrs after the date of death. PART Step 1 : Please check the appropriate boxes below. 1 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 nof check any other boxes and disregard the amount shown above as Potential Tax Due. g �The information is The above information is correct, no deductions are being taken,and payment wi{I be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5°!o I am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased. (Select correct tax rate at right, and complete Part � �2% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complefe 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. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficient to pay the deductibie 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), pfease obtain a written correction from the financia!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 decedenYs 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 dif�erent 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 Wilis, 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 Home 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 Pennsylvania lnheritance Tax � pennsylvania PO HOX 280601 HARRISBURG PA 17128-0601 Information Notice DEPARTMENTOFREVENUE And Taxpayer Response REV-1543 EX OocEXEC �oe-�z� FILE NO.2170 ACN 13106399 R E C a�'�.�� r DATE 02-08-2013 ��5�� 0� �"��.�_$ �� Type of Account ,�j3 ,�N �� te f HER W HUMPHREY Savings SSN Checking C L��(D�t�of Death 01-29-2013 Trust LISA J HATHCOX QRPHANS��vU�I MBERLAND CertifiRate 1208 REDWOOD HILLS CIR CARLISLE PA 17015-4735 GUMBERLAND CO., �A MEMBERS isr 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. 131248 Date Established 09-2&2010 REGISTER OF WILLS Account Balance $3,300.52 1 COURTHOUSE S�UARE Percent Taxable X 16.667 CARLISLE PA 17013 Amount Subject to Tax $550.10 Tax Rate X 0.045 Potential Tax Due $24.75 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. 1 A �No tax is due. 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. g �The information is The above information is correct, no deductions are being taken,and payment will be,ent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �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). p �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 I�heritance 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. PART Debts and Deductions 2 Ailowabie 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 qf 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 Calcuiation 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. Enier 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 decedenYs 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 ta�c 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 compieted 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 Home 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 _ _ . _ � � _ BURFAU OF INDIVIDUAL T�ES Penns Ivania lnheritance Tax � pennsylvania PO BOX 280601 y DEPARTMENT OF REVENUE HARRISBURG PA 17128-0601 Information Notice REV-1543 EX DocEXE[ (09-12) And Taxpayer Response FILE NO.2i 70 ��C�� re•�� ACN 13106400 s DATE 02-08-2013 �i � �(�i� �(�� Os Type of Account � Estate of ESTHER W HUMPHREY Savin� ��,��}( ��= SSN X Checki g Date of Death 01-29-2013 Trust ' ELLA J NICHOLS Q��NANS' COURT County CUMBERLAND CertifiC`t� 1208 REDWOOD HILLS CI��}MBERLAND CO., PA CARLISLE PA 17015-973 � I I� � I ,� 1 MEMBERS isr 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.131248 Remit Payment and Forms ta I Date Established 02-13-1993 REGISTER OF WILLS Account Balance $3,445.74 1 COURTHOUSE SGIUARE Percent Taxable X 16.667 CARLISLE PA 17013 Amount Subject to Tax $574.30 Tax Rate X 0.045 Potential Tax Due $25.84 NOTE': If tax payments are made within three months of the , decedenYs 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. 1 �� PART Step 1 : Please check the appropriate boxes below. , A �No tax is due. 1 am the spouse of the deceased or I am the parent of a decedent who was�'I� 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. g �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% ►am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased. (Sefect correct tax rate ai right,and complete Part � 12% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Camplete Part 2 and part 3 as appropriate on the back of this form. Ili E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Ta�c i� 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. . �J :, PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legaliy 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 tf 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 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 Ta�cable 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, t declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. Work Home 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 DlVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 _ _. ,�, _ . �, � � pennsylvania �'�' I' BUREAU OF INDIVIDUAL TAXES Penns Ivania lnheritance Taac I PO BOX 280601 Y HARRISBURG PA 17128-0601 I11fOCillatl0ll NOtICE DEPARTMENT OF REVENUE I REV-1543 EX UocE%EC (OB-12) I And Taxpayer_Response F�tE No.2i�o �� I ACN 13106401 i ; ;;-� r DATE 02-OS-2013 ��s��P`� l�� fi4..�...�7 � �; Type of Account �I `,�13 �� l� �� Ofi Estate of ESTHER W HUMPHREY Saving i:. SSN Chec�i gr �(��( (��= Date of Death 01-29-2013 Trust L ISA .1 HATHCOX County CUMBERLAND Gertifi� t� 1208 REDWOOD HILLS c�RPNANS� COURT CARLISLE PA 17015-��ER�.A�� a., PA � ,'Y , � ,4 'a = �i MEMBERS isr Fcu provided the department with the information betow indicating that at the death of the ,', above-named decedent you were a joint owner or beneficiary of the account identified. "� ` Account No. 131248 Remit Payment and Forms to: Date Established 02-13-1993 REGISTER OF WILLS Account Balance $3,445.74 1 COURTHOUSE SOUARE Percent Taxable X 16.667 CARLISLE PA 17013 i ! Amount Subject to Tax $574.30 � ': Tax Rate X 0.045 Potentiaf Tax Due $25.84 NOTE*: If tax payments are made within three months of the i decedenYs 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 II�� , after the date of death. i��, ; �g PART Step 1 : Please check the appropriate boxes below. � 1 ;! A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was I�' ` 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. g �The information is The above information is correct,no deductions are being taken,and payment will be sent correct. with my response. P�oceed to Step 2 on reverse. Do not check any othe�boxes. C �The tax rate is incorrect. � 4.5°/a f am a lineal beneficiary{parent,child,grandchild, etc.)of the deceased. (Se{ect correct tax rate at right, and complete Part � j 2q, I am a sibling of the deceased. 3 on reverse.) � 15°lo All other relationships(including none). ',!, '; p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complefe Part 2 and part 3 as app�apriate on the back af this/orm. 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. i� ;, REV-1500. Proceed fo Step 2 on reverse. Do not check any other boxes. ';Ci �, Please sign and date the back of the form when finished. �, � PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid 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(l.ine 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 decedenYs 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 $ � 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 Home Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT CUMBERLAND COUNTY REGtSTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVlSION AT 717-787-8327. SERVICES FOR TAXPAYERS WiTH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020