The URL can be used to link to this page

Home My WebLink About06-12-13 _ _ - - -.,�. � 15�561�1�5 REV-1500°`�°�"'��" � PA Department of Revenue P�Y�vanis OFFICIAL USE ONLY Bureau of Individuat Taxes °`""�`"`°""°"° �0°"�`� Y� �� pp gpx 2go6o1 INHERITANCE TAX RETURN Harrtsburg,PA�7izs-o6oi RESIDENT DECEDENT �� '�� 'I �� ENTER DECEDENT INFORMATION BELOW Social Secusity Number Date of Death MMDDYYYY Date of Birth MMDDYYYY � � � os292� lZ � � r � i °f2 �5 DecedenYs Last Name Suffbc DecedenYs First Name MI C� � � L L- L ?/�-�.� V�l.,- � �E (If Appllcable)Erksr Survlving Spouse's InMrtnation Below Spouse's last Name Suffbc Spouse's First Name M� spouse's soc�a�security Number TM�5 RETURN MUST BE FlLED IN DUPLJCATE WITH THE REGISTER OF WILLS FILL IN APPROPRU►TE OVALS BELOW � 1.Original Retum p 2.Supplemencal Relum p 3. Remainder Retum(Date of Death Priorto 12-13-82) O 4.Limited Estate p 4a.Future Interest Compromise(date of p 5. Federal Estate Tax Retum Required death after 12-12-82) O 6.Decedent Died Testate O 7.Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes (Attach CoPY of Will) (Attadi Copy of Trust) O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 17. Elecfion to Tau under Sec.9113(A) Belween 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT-THIS SECTION MU8T BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTUIL TAX INFOI�IIATION SH�lID BE qRECTED T0: Name Daytime Telephone Number �� i t- L � ,�-r� �. l��l uS I-{ 6f�i'V� Z l� C� ��3 �� oF us� �. .� rn � c7 � U' � � r�,, r r� :-r; �� Frst Line of Address r � m tv :� �' g �r �- c�� .��.��c � N � � �= .� , ..� Second Line of Address t.,y p -�,- .� --! � c � `�: C� ' � � �_" C%7 City or Post Offlce Sfate ZIP Code 'U DA7E Fa Fe' Gt� O L�.o � ,�.�� --- C � a �f 3 Comesponderh's e-ma��addresa: 1 en"Y—��►"5►��1��.CQ✓�'1 Under penaldes of perjury�I dedare thet I have examirred ttds retum�indudirg aa»mpanying sdiedules and statements,and to the best of my W�owledge and bellef, it is Vue,correct arb complete.Decleratlon ot preparer other then the peroonat repreeerNative is besed on aii infamatia�of which preperer hes any Imowledge. SIGNAT�IRF�OF SON F�S�NSIBLE OR FILINCa RETURN w J --�".'" DAT lo�� j� '��[� l�<<.�..C �� (,.�04�- �� `� +p SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE UsE ORIGiNAL FORM ON4Y Side 1 L, 150561d105 1505610105 J ��.�. _ _ _ _ _ _ _ _ _ _ - _ . _ _, . - _ - _._ _. _- - _ _ _ _ - __�-, _ J 1505610205 REV-1500 EX(FI) DecedenYs Social Security Number Decedent's Name: ' � � �� /� RECAPITULATION 1. R�1 Estate(Schedule A). ............................................ 1. �' 2. Stoc�cs and 8onds(Sc�edula B) ....................................... 2. ,.� 3. Clasety Held Corporation.Parfnership or Sole-Proprietorship(Schedule C) ..... 3. �' 4. Mortgages and Notes Re�ivabte(Sc�tedule D)........................... 4. ,� 5. Cash,Bank Deposits and MisceNaneous Persona!Property(SchedWe E)....... 5. � 6. Jointly Owned Property(Schedule F) O Separate 8ilting Requested ....... 6. 1� 4 ��P 7. Inter-V'rvos Transfers&Misoel�neais Non-Probate Property � " (Scheduie G) O Separate BiNing Requested........ 7. � 8. Total Caross Assets(total Lines 1 through 7)............................. 8. , Ct y'ZR�Q I s. Funera+E�enses and a�ninistrative costs(sc�edu�e H>................... s. /� �r 10. Debts of Decederrt,Mortgage Liabilities and Liens(Schedufe I)............... 10. � �1. Total Deaucaons(cotal unes s ana 10>................................. t1. � 12. Net Value of Esfate(Line 8 minus Line 11).............................. 12. �I y Z.� ( 13. Charitable and Govemrt�ental BequestslSeC 9113 Tnists for which � an eledion to tax has not be�made(Schedule J} ........................ 13. 14. Net Vatue Subject to Tax(Line 12 minus Line 13) ........................ 14. �I 4Z•(�j 1 TAX CALCULATION-3EE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxabie � at the spousal tax rate,or transfers under Sec.9116 � (ax1.2)X.p_, 15. 16. Amount of Line 14� at lineat rate X A ' ! yZ,� I 16. � S�' �2 17. Amount of Line 14 taxable at sibling rate X.i2 17. � 18. Amount of Line 14 taxable at collateral rate X.15 �g_ � 19. TAX DIfE ......................................................... 19. �I. �� 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 � 1505610205 15D5610205 J . _ _ _,r-� REV-1500 EX(FI) Page 3 Fils Numbsr Decedent's Complete Address: �ceoErrrs r� �—�` �t� S�� V — - -- -- ---- — _ crrr � — — - ` �t �A � �P O I Tax Payments and Credlts: �I �Z 1. Tax Due(Page 2,Line 19) �� 2. CreditslPayments A.Prior Payments ---`��L B.DiscouM _—_- — rotai c�a�c A+B y �2> S l•�L 3. Inter�st c3> �' 4. if Line 2 is greater tl►an Line 1+Lina 3,enter the differen�. This is the OVERPAYMENT. Fill In oval on Page 2,Llne 20 to request a refuund. (4� � 5. If Line 1 +Line 3 is greater than Line 2,enter the d'tlference.This is the TAX DUE. (5) � --T Make chedc payabte to: REGISTER OF WILLS,AGENT. PLEASE ANSWER THE FOLLOWiNG QUESTIONS BY PLACiNG AN"X"iN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: y� � a. retain the use or inc;ome of the property bansfetred.......................................................... ................................ ❑ b. retain the right to designats who shall use the propeRy transferted or its income............................................ ❑ '� c. retain a►everslonary ir►terest.............................................................................................................................. ❑ � d. receive the promise for life of effher payments,benefits or care?...................................................................... ❑ (� 2. If death occurted aft�er Dec.12,1982,did decedent transfer properly within one year of death without receiving adequate c�nsideration?.............................................................................................................. ❑ � 3. Did decedeM own an"in trust for"or�yable-upon�death bank account or security at his or her death?.............. ❑ � 4. Did decedent own an ind'+vidual retirement account,annuit}+or other non-probate properry,which contains a beneficiary designa6on? ........................................................................................................................ ❑ � IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST CONIPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1,1994,and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 perceM[72 P.S.§9116(a)(1.1)(i)). For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)j.The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disdosure of assets and filing a tax retum are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death b or for the use of a natural pareM,an adopGve parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2]]. • The tax rate imposed on the net value of transfers to or for the use of tl�e decedenYs lineal berreficiaries is 4.5 percent,except as noted in[72 P.S.§9116(aK1)J. • The tax rate imposed on the net value of transfers to or for fhe use of the decedenYs siblings is 12 percent[72 P.S.§9116(aj(1.3}].A sibling is deflned, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. - - _,�,.. _ � REV-1737-5 IX+i5-OB) � SCMEOIILE F, P�AlT 1 c�.,f+oFre�NSw�.wwu► �OINTLY-OM/N�p PRQMRTY iNHERITANCE TAX REli1F�t NONRESbEWi DECEDB�IT ESTA'i'E�I � �� FlLE NUMBER 4 ��. �, �� 2 1��7 Part 1 must include jointly-owned real estate and tangible personal praperty Ipcated in Pennsylvania.Complete Part 2.on reverae side to Include all ott�er joiMly heid property wt�eR►ever bcated ONLY wNen the proport{onate method of tax computatlon Is elected. If an asset was mad�joiM wtthfn ons yqr of ths dee�denYs dab oi dsathi,B must bs rsporNd oe Schsdule G. SURVIVING JOMIf TENAMT(S)NAME ADDFESS RELATqNSFIP T0 DE((�EENT A. W�11�z,�,, �. ,e��l�z,� 9`��f(�� t�►u•� f.��1��r7 u�'3 so� B. �2� 5. �X�►��*-� �'tSSr�MD��iv�y� �2, �e,r�t� !�� lZ Sch�t� c. . �r� or►� nESCw�raN oF�ao�rr a�-r�oF o�r►+ �� oF o�ni rrnu r-aA.►orrr � oECUS va.uE oF � -rauwr .ionrr na�a�aaea for' reei e�e. v�oF�ssEr u�re�sr oc�oeirs rn�s�' ,. A. �)�la� Sn��gs�k�- m �c�B�- ��o�:�7 lG.�� a so.go 4. �t- 4' ��3, �L� ��- ,vi �. i $�..�-(,� i�Sp•SZ. ��647 �1��1� �r � ro� �I t�2��6� s �urr s rda� P�oportionate MeB�od O�ly(From re►+erse side.) ; TO�L (Also eMer on line 6, Recapitulation-) s I��2.�0 (if more space is needed,use additional sheets of paper of the same size) _ - - - - _ _ _- _ _ _,r�* _ _ REY-1737-5 EX+(6-08) REI�EFiSE ��*� �' �nnsytvania SCN�01lLE F, P�AlT S Use Sdredule F,Part 2.oN�r fo� DEPARiMENT OF HEYENUE �O,�r�Y�lAE� �� P►opord°nate melhod of iax computation. INHdQTANCE TIU(RETURN NOqpESIDB�Ii OEC�Cilf ESTATE OF �� FILE NUM@ER D��1,� .J ��V�u:�.e. L., Zt[�.- —t f �, � Part 2 must includs jolMly-ovrned seal�tate and IMangibls psrsonai propsrty wherever located. �-r� n�r�oF a�o�r %oF o��o�ni' r�+ r�t.iorrr oa�� r�eme or sr��aei r�w�aoa mrr�a000ur�r.mer a s�r �n-r��a�ni nEC�s va�t�oF NuMae� �r .iaNr � r.,mner�aeea�or�orry�en�eei eea�e. vat�oF� x�r�ESr o�e�rrs s� 1. A M!T Z �'O�dL � c�«�u�z�,.> s (If more space is needed, use additional sheets of paper of the same size) _ _�.�, �i.��i: w�ircin i�.ir„� i+�i�3. i.+ii�u�i�i-i..-��:, '.-'....«....:..._. '�c_-- --•�.Ti'�'�i]'i�-F �'::i`L:ii.�E-y.i�:.' ..�.� C.:. 2'.;7. .w�.��3f i��i cat�n�av�ti�:�e�rti�p��„_.:��,�.t�_�. _ ._: __ _ - . � isi�wiviti'-.+ - ��.ti'�' _: . ;r�:.c,,C::o��''r� . ��^i.�,i;i �po sox aaaa ��: � �::a�.;..�.:. _ ...- � ��_� LE�i1�„ c,r �,n'. 1%CY 1.G� C�z �31��.CI: LL. . . _. ."__ r�Tw 73:�m7�..r- G6i673'.i�3 �^.--_ ..._,: ... .�.. -�n n;:=t - �.l!'° `�riliir v i�iai"i1c i..- � ti.� .-::1L l_;L t'uu�l�. �rx_...ial_ � - ,. . , :. - . ...,_ ... .. . . _.... . .,. " . ... . � �.•_�.._:_-' ,.. ,� . �--.�-'� .,. -_': _`..'__.�i �,_,�� .,,::�__�_ w__ � ,, , u�_n�# . r:� �r�m the e�rar�c ::f cex=-ain �eceased 7°eripients , .. .. , � : _._ _�:�.,,_ �. ,...,_ .. . ;:�._ ..�� ., - - � � . :. , - � , , . ,. _ ,. , , ,. - , ' ct3:iBC.:i t�Y Y_:;E_ L-, ..[iC-. UUd.✓iii.�.�".�. ... .,' _'."' _'_ . _. ., . ... ._.. . ��7ease provide th� followina information c�r forward this form tc the deceden�' � nex� �i la��rainn �j�me� 9110t21Q auvi�� thf3 Depzrtment Wt1B��EY th5.t� fO.i'ID 1188 Ae��A iosx+:±�'i9�tT cY2]Q lr 50, ples�e provide the forwaz-ding name and sddreas on a copy ot this forg�. , . . ..s. ..:��.� ..6 f1�� fr��.�m i n i c+�>>'.1". eic. Q�.43Si? cYf�uYt�].ta`.n, i�i�. .>. .., _ ..� ._..n° , _:._ .t�a3 � . rE!t.v.. .�c)s.� s:� :5� i:...ru _a�� _ __ _.._ .. �pply, indicat� with "N/A° i�^* ��p�-icabl2) , Parins not cnntp�+��:ely fiiieu i�r: wi-�=� �:� r?t�:rned. . . - F'iE'i't1Y_'Tl rr;t; :::Y;;: .t:? rnf� .�i-��•lri.�;f`:i . _ ..- � "f'::��' i-'J�L.�;:s�� i��l.�i C,SVt_�Ci�;z V.'�i.ii� �i i..-, . _ -. . ..._ _--- -- ,�l t d�idr a Yeu hat*e any questic-�ns regazuing Estate Law, pleas? c:ontaci. u.� a�.��,.��y. If ��au have aay cuprtiona concez�ninq thic� farm, p2ease call the ERtate Recovery Hotline at 1-8c7Q-528-37��3. .::�v_..o..___ . _..___ �_�.-. _ _.� _ _. _ -. _ _. - - nar��r oeH�n. � � �y �� 12-� _. �__..� �- _,--..,...,o�_ .._�_ _ �_�..._ ...��. ____ _ _--- Ss�rti�itl4?`.+puuse: # �.�(Yj�-3 �, � ___._. . : _ __. � _ --- -- - _ ... _� Executor/Admimstrator/Next of K�n �� j � � ��(�S � ��'(� �___ �`_'��-1�� _ .___„_.. __ __.�_...�.�,�-..--�.,, F.� - „ . -_�- _- .-------�-_---= � (telr�tionsi�i4►to!),��c�.ita�t: ��,i y�� 1 ,.:<-�--. .,_. .-_ ....:_. ,_ .__ ._ .. _._ ,__ ^.�_ _ - __ ____.... . Complete Address: �j�'� �� Ir ��t� �.._ T /a�nR r11f.4�lv ��. � l�17� . �� ' y . - --.- _-. ��..ti v ti+ i ' . �{ _�_',._.-__ _:._,.;_��_�...._.�.-.,.__..� __--�.."__-�..�.,....- ___ ___ - _',- -� --^— =�..z.. _. �3 � � �iVti{YiC pE10R�: � ` / �"� ""� ��`� � Q�� F . ..._ ...,.__, . .. ._ _ .. _. ._.. . . . _ . __ ._. .-.._....__ _.. . .._ . . . .. _ . . _`,{i: � �.ttornev t'o��:state af i3eieder�t: � �(��.,,;r ' -__: ._�.�...,- __:. -' - - -_._..�_____. ��._ . _ .�._- .__ _ ---— - _ . . _... — - - ; {:arnuicte Adtlress; �<:�. _ � � � C - - ,. .._. .� __ -._. __. _. ---. . _.._m -_ ___ _.-�____-, _ - - — - � — � � . _ r:' t � , � � - ,..-._:._ .. .:-.. -..,..e-... . F ....- -_ __ �.__.-.._._ . .__:... . .__. .___.. _. _ . ._ :�, . . _.�i . - . _. _ .. . _ . _ . . . . . . . . _ . _ . . . .. . . _ . .. _ . _. _ .. _ _,�,,,, - « k� � C , -.= . . _`v;•s..t�a fi4::13�31.<f.:.si f� +r��i9�T's �... ....__'__. ��m .. .� _.__ ... .. zas3•�i. ""-'�""_� � �`.. � ...��. . �.......y ��i�G�'N��`� 1 � : ;' • � Yro}�ecty; Kea� �:�iafz� : ... .. � I � Uwned bv tne��c�a; ��i `�..�� _ _ � s • -----___ ___ . � � tf � � . 4�� '- - � � f =f t 3 � � (�wncrs as livtrd un i.e��*� r _1` { §F � r�,,, ��— � � � � � � f\/�-S `�"L�_ , � � � } ! :_i�ccn oi�c. "i cnaui�m Cr„�uuu;:�� j "Jo;iu-i�.n,�,s�,�; �, . .:��.�.� :;��;�° � � � � "f enants b5 the F.n'� ; ; : i i�,��..,,i t,,,.,i� i i � . ._ ... . . i . _ _ i t_. ' . . . . __ ...._ . ____ . j ... ... . � .� . .--. ._ _ ..y � ' `-� :��{�vc�r l'�S �O 2!al' ol'th�follarvin� �V�t1�iC �t l�s�Rt�l �V�IIi� �ifl4'1 � � {�. • ,:=tt3. €iE�in +.h��cif,lt�r dsc�auntfsi in the far j -, � �1'I��i�'fll��n,nc ' i ( � . .._ . . i .. . .. _ .. -- _ _. _._._._:._ ._.. -::_ . . �._.. _.. . ..:..�:... ..._�,_ `. . --...-,i� ._ . 13ank Accuunt:� iii� t3anlc Ac.cc�unt(s) ls this a�o�nt accouni:' � llece�lcat`s��arr.e� _�_ � � � N�, � f I C�^• ; ` � � � ,� i>t� t �t'ck�nv Yr c � � � — --- - - - ,�- � _-'--� •- r � �'t. �u v i 1 i`k�,\ � �.4....Jy }'<O �s :1'�" ,,,� � ��U.� .'�%,�. If you answer Yes for either account,piea�e �t��t.�� =:l��3i� d cQpy af ihc ha�k statcme�t at th: time � R a ; �6t�c�K1h Nt�t� a s��r�1y'�)t k�i��ri�;itlxi �.i�it-t..zc:t� ' x � ca�t�. . _ _ .V_ __ _ � - --_, _ � _. ,�.,, � i�U:t•SlTI� �'�Amt, �i.�..�r.i�:� ` . �f � �_ r � [ �:; :.' !E. � '' i �' � �,:ii r �Cfi f}if�?4 t ' � i • �.__._ _ . _ .E __ . . __._ _ __-- ' S - -- -._. . _ � � I)ecedertt's Hariat }3ii�a1 Account(s) � �'re��ir� T uneral "t.°;n ,,rs� ,r � 1 � u ,f �. � - � 7l%:i 7♦ _�d'i) _... y7 ;�.', �'�ii � �l� ��l � '� � �f, , � ! ... � �: . i� j'. .' .,?:' � � 'Y cs �o Y es ''Vo � `" � . � � „ -� _ ___-- _ _. .. • ; � Q t ��t,:-' S/��..��t,b; �3t��°s-� . : � E � � . . - � ° �-��,�.. � ' 1�3 ��.if'4�:'-�F°S Ct.l!t1t'.� �...t . � �� d._...__ �_____,_.. __._,- , _- ___ _ -__ _. ___ _— _ __�. ��_ � �,�SIt� .�?.,s. ��i"1�fib�� _S ..,54. �'L' 1.., i�... � t i ' ' , i . � , � 'Y�c'.; ',V t? _ 4<`t? �''C) __ � �' � ,a � � � � �- ` �f � sC. .:ii�ac. y '�1�ui3�; 4 t l ...-�' ; 4 . � i�t _. ! � _ . 6 t`.F:. ktlt�t'x�d1�lEE' Q'.t3lf:ii.'.t1 �Yf'`i �;ES 1�+,,.<,%�� t� . �*•`t � .. t � �, � � , � t �. � j ��tne:�c�ary ivaine %' I �. i . �. � � S •-`�{ f�� - ; .. � 4 7 C �ti 1 l.',-} �Ve} R � � � =tS.i`.�Z�S.1(1�`� ��'�i..a. ... ! i f t c e ._ .... _.-�..s_...._.e-� ?�-�.,a�."—__.._..�. . __., . .. . .i... .... ._..._..-.-�.- -� . . _.. . ._ _ _. . � . .. . . .. .. _ . i .E�_'Ci!vE1L't'R,E:f}C:[�:'t'F�� i t F(�� E"l�E.}�!43.�'1'ff1`y f Ff1��'�'.S�%!'�f,&F:I�f 1+v 4'e!�^:i�t�I.!kt �:ti;i�}��3•:�"€ #(} 1'1;5� E`#�:hi;tl,��Ml:6;`;l-:E 3-t�i��i,3;'v t8 i'A('.�.��?�i�.4E�rtatir3�[i;u��sw�or►r faiyi�e�tivn to autharitiesi N.;�:ne {a .-.�i�. nr't-t��i . !,?<]ri_y1 Si "zr;.3t�.�r:e t_��li _ .. ,?;an �n .�nic� [)..__ 1 �?llf.? i�l (il:iF`:� , ..-.. _ _ . . ',t�ir I��I�_-7 .�it2t'i _ . ,,,��, � G � .. _.. :: �_ _ . _..."' '. s" x' .. ��. -��F..M� l�i F�:�y . ., _. ." .. .. _ _ . .. .. . =_ . . ..t'+S�''� {�<�r6..3'��T� o ',):::,NTy plir P...f.t:,.: �, . <,. f 5 ��i�'�� ,�� a.x...� _ _-_ , __ _ ___ _ ; ; ;_ �.�)i.v 1.-�- . .� t�� C� ��. ( , �;L ( -_ _ _ i -- ��-a�.��iti7 I UE�.EDF'v7 S SUCIA�SEGURITY NUhABtfl � ' _�..i CAIk-Jf k ..�.. ._. . .. . .'...�_ . . . . _' rr , U A1 ._ . ; _,- . . �- 1`^n ;i'_\1 ' -i � .,.: �.....�.„v.. , � _ , .t � C.J I . , , ._ . : _ � ; _ ___: _ —? � — - , , , I i nr;t a:SS or��c t��:rvr .` _ __� _------ ..a__-- - _ .__ _ - �r... , � _ .___ _.«v .� � � �s ��"�'�t t j �1� --�X:'�.1�t'�� -tti`��n`� �' ! � � i��►+ !�� _ - L-��L�'l ___ - , �� -I � " ( f ,:,-..�., u; �„ ,..:.,.:_ . _ __ ._.__ _ . , --- . . ... .,. � '` �=- I � �� ' L �,�:«,.�f;;h a ; , �� _>[>,{t _ _ _ IR�C't`� iY�/�f. d 1 1 �` 5��\ .'Ir' r w�i �J��viv 7a r C � V � ! � � � t �/ . ' i ' ;� I v, i F� :,,,.�� i'� ;�� , ` ;,,, ��.f � �h C) V � ,�l ; ! � 7 �. �w r.nnn n�-tr � - : : � : IAV1 ..ii�12.5:1.'� ..._ ._. .....>_... _ ._... ... i � . .:t .. �'. I P13:�Nt.NI.J✓r�:_�Z � _ _ ' � �] ' , — (t� Z... 'Z.s- �- � '�"(� i.,; (� r _.,._ .... . r: - t �..� . � _� ._°- .��!_... ----- -- -- . . � _..__ __ __..__ _ -- - -- -�-.. �-.. � :.- ; � 1 i i�i.- qi:' .-��r�:.��iT � �,, � ;�:�i�iiVL-.�. tv'� (:Fii_\.P�tIVCi i. I Yti�� !�! l.t..hi!i. ,4!',°i. ,;I' i�Ci'Se..i 1 __I Q.��'i��`� i I _ % __ � AGC CJU�!I - ___ __ i � kC;i OUN'�6AlANGF(�tvCLUUE 'Nl � T jU UATC OI-UEATHj .. . .......__ . .AC'CUUM�NUh1E5 F .. .. -.. .... ; !Rf°�k�i�lf�:!�C1�'� i `;�� „�c� , �y��'� �',k 1 = � - -1 { ' 1 i _ � . 1 c > �c t.;,� ��^ '� " . , , 1 !l� ��r , � 1 1 t�C�-f� 4��y f u �`!5! i_:-�f�5��t '�"�5 j r n�.;i O�l^�; i I,�E r5 a�� AHS Uv 5-GNn1„rtF c.,�r:�.�ori cu � � �;,�t�.3iNn� :,,,� ��l �.=ta.� _ � ��::�14� ` c, f ` ,_'.----°- � ��) ��v.V�'` J / �.�V 4� � 1�- �1 r r <<-v��e I i� 3'"^ }�� `� i _.__�w... _ uvl , � __ _ ___-_ _ ,..._. ,_...:��.r--. ,...__._._._ •--,._. ,.�... � Rf� „ i -: . ' NA��'L('asri /� tF .�t� .__.. . _ _._ �'�''� .. .,� ` � - d�e iniG�:. 1 /. . t } . "r-�"n�' 11 f�,�!�I �DE 1 Mid f -+� �---• � � j,.�{ �t.i J{�e�E� (,1,��l �� (i`i j"i! 1 �.,� + t�'�'�'r�' '_ � �tlRVlVti�lC A'rnr��:ss� f.�,•,�:r�= rF.r..��s�.� w..., ;� � �,��; �� i' �—� �..,. t �'�\V G I ,; — , . . __ , , , .ry i : i 1tVr�.':",�.�:'�TlC�J i � �` ,1�, y�'�t� �� 7 �' "<; � —. `' i �-t� _ � � 1 ir�.:,, �r VN.iif;i t��n':;r rs _ _ E i - - __ _---• . � o H� '.'�HC' 'v 3k-�? � �InX GG(F.. . . - ti � � . -��'' �-� . � . , �� . ; .w_.� ; . _... , r � iv.. .. _. . � � . - , . .. .r. �. ..: � � _ . . - , . . ..�. . . . . .. .. i ;-`, i,,, ^, � t� , ;_:.yw} � . . .. ��t�a ♦ � ��>�t,. . ; �� . , , ' i lt.�\_y �1 ?y 1='v `_ r � L.f.. F.�'% t . . _,.. . ._. ., . �P - .. . . .._ _ . .. . _..._.. _ ... . ._ -�rrevpnt.F _ . ,. �:.s .,<�.,,� :.. � , ' , . . _ . .. . . . � } C ' '_ � 1 j�! i.- i' i 4 \ � i -. �,.� �� • . , ..i .._, .. � � .. � -:� . _. I ��a�YtJ� �)j(�f?�+4ni - �" 1 � ' ' . < - . _. .'. "_' , _.. ' _ _'_ . " . . ,.... _-.__ . ... . . . ..._ �, .. • � �- �" �. � - . _". . .. � , �- .t�^ r)�.tfl � .. . . -. , � °i ... . _. �) :-.r -.'^t i� - � �i j.v j � ... . -� . . .� '-. ..: _. . . . . _. .. _ . ... � . �4. . ±6��!..r. . . , � .. . . .. � . . .. . _ �r . � .. , . _ ... �� . . . :. . . -,.., . _ . -- .:- -. .:_ . - . � .. - ��'�"� • _ . _ . . . . - .- . -' . . , __ .. .. .,�. ' ..: � .....�. . . . -._ -_:_.-_-_- � . - . _ . .._.�� _- �� , .,.. . ._�. _. _.--. � �-._ �:�. ._ :: . . � �.._ . , . _ ._ _ . �"��'^.�� [/ .. � ` f _ ,: , -.: � re'..'—'_� . .5')S�o� : : . _ , : , . , ; : :--_ . .:.� ��.�, � Z . _�,.�,_ � COMMONWEALTH OF PENNSYLVANIA REV-1162 EX�11-96) DEPARTMENT OFREVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HAFRISBURG,PA 1 71 28-060 7 �� PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT N0. CD 016735 DENSHM WILLIAM J 208 SENATE AVE APT 214 CAMP HILL, PA 1701 1 ACN ASSESSMENT AMOUNT CONTROL NUMBER ------- told """"" '__"'_' 101 � 551 .42 ESTATE INFORMATION: ssrv: I FILE NUMBER: 21 1 2-1 1 67 I DECEDENT NAME: O'DELL JACQUELINE L � DATE OF PAYMENT: 1 1/05/201 2 I POSTMARK DATE: 1 1/02/201 2 I courvTY: CUMBERLAND � DATE OF DEATH: 05/29/2012 I � TOTAL AMOUNT PAID: $51 .42 REMARKS: CHECK# 2174 INITIALS: DMB SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS TAXPAYER _ _ _ _�,�, BUREAU OF INDIVIDUAL T,�ES PennsVIvania lnheritance Tax � DennsVLvania PO BOX 280601 1 r J HARRISBURG PA 17126-0601 Information Notice DEPARTMENT OF REVENUE And Taxpayer Response REV-1543 EX UocE%EL �oa_,2� FILE NO.2170 ACN 12157283 DATE 10-17-2012 Type of Account Estate of JACQUELIN L DENSHAMODELL Savings SSN Checking Date of Death 05-29-2012 Trust WILLIAM J DENSHAM CountyCUMBERLAND CertifiC�te 844 KIEHL DR LEMOYNE PA 17043-1205 M $ T 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. 15004200470843 Remit Payment and Forms to: Date Established 07-19-1996 REGISTER OF WIILS Account Balance $5,704.67 1 COURTHOUSE SG?UARE Percent Taxable X 16.667 CARLISLE PA 17013 Amount Subject to Tax $950.80 Tax Rate X 0.045 Potential Tax Due $42.79 NOTEk: If tax paymer►ts are made within three months of the decedenYs date of death,deduct a 5 percent discount on the tax With 5%Discount(Tax x�.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. 1 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 sent 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��, 1 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 approprrate 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 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 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 tiUed 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°/a 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 Taxable 6 $ 7. Tax Rate 7 X 8. Tax Due 8 $ 9. With 5% Qiscount(Tax x .95) 9 X Step 2: Sign and date below. Return TWO completed and signed copies to the Register of�Ifs 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 � ��1 �7 2� --'L7�-- Home 711 (o� _3� v� 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 FQR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 ._ _ _._ - _��, BUREAU OF INDIVIDUAL TAXES PennsVIvania lnheritance Tax � DennsVLvania PO BOX 280601 7 r �+ HARRISBUR6 PA 17128-0601 Information Notice DEPARTMENT OF REVENUE And Taxpayer Response REV-1543 E%DocE%EC �oa-,z� FILE NO.2170 ACN 12157284 DATE 10-17-2012 Type of Account Estate of JACQUELIN L DENSHAMODELL Saving� SSN Checking Date of Death 05-29-2012 Trust ALAN J DENSHAM County CUMBERLAND Certifia�te 515 SADDLE RIDGE DR IRWIN PA 15642-9204 M & T 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. 15004200470843 Date Established 07-19-1996 REGISTER OF WILLS Account Balance $5,704.67 1 COURTHOUSE SQUARE Percent Taxable X 16.667 CARLISLE PA 17013 Amount Subject to Tax $950.80 Tax Rate X 0.045 Potential Tax Due $42.79 NOTE': If tax payments are made within three months of the decedenYs date of death,deduct a 5 percent discount on the ta�c 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 wa� 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do nat 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 nof 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 � 12qo I am a sibling of the deceased. 3 on reverse.) � 15°/a All other relationships(including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. Iisted. 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 additionai 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 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 ihat the facts I have reported above are true,correct and complete to the best of my knowledge and belief. � Work �iZ7" s(�-33�1� Home �a - sl3 -7 a J Taxpaye ignature 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 PennsVIvania lnheritance Tax � pennsylvania PO BOX 280601 1 HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE And Taxpayer Response REY-1543 E%UocE%EC <oe_,z� FILE NO.2170 ACN 12157281 DATE 10-17-2012 Type of Account Estate of JACQUELW L DENSHAMODELL Savings SSN Checking Date of Death 05-29-2012 Trust WILLIAM J DENSHAM CountyCUMBERLAND Certifi¢�te 844 KIEHL DR LEMOYNE PA 17043-1205 M � T 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.45534435 Remit Payment and Forms to: Date Established 11-30-1993 REGISTER OF WILLS Account Balance $�,�50,82 1 COURTHOUSE SQUARE Percent Taxable X 16.667 CARLISLE PA 17013 Amount Subject to Tax $ �g1,g� Tax Rate X 0.045 Potential Tax Due $8.63 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 month5 after the date of death. PART Step 1 : Please check the appropriate boxes below. 1 A �No tax is due. 1 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 nof 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��0 �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 departmeni. (If additional space is required,you may attach 8 1/2"x 11"sheets ot 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 cornection 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 tauable 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 Ta�c 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 payabls 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�7�1')Z �2-7Z Home 71"7 !e 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 SPECIA� HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 _ - - - - _ _ _ _ _ _ _,,,�. - • BUREAU OF INDIVIDUAL T,��s Penns Ivania lnheritance Tax � pennsylvania PO BOX 280601 y HARRISBURG PA 17126-0601 IC1fOr111atIOC1 NOtICe DEPARTMENT OF REVENUE And Taxpayer Response REV-1543 EX DocEXEC �oB-�2� FILE NO.2170 ACN 12157282 DATE 10-17-2012 Type of Account Estate of JAC(�UELiN L DENSHAMODELL Savings SSN Checl�i�g Date of Death 05-29-2012 Trust ALAN J DENSHAM County CUMBERLAND CertifiC�t� 515 SADDLE RIDGE DR IRWIN PA 15642-9204 M & T 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.45534435 Remit Payment and Forms to: Date Established 11-30-1993 REGISTER OF WILLS Account Balance $�,15p,g2 1 COURTHOUSE S4UARE Percent Taxable X 16.667 CARLISLE PA 17013 Amount Subject to Tax $ �g1,g1 Tax Rate X 0.045 Potential Tax Due $8.63 NOTE*: If taac 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 ofhe�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% 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. Complete Part 2 and part 3 as appropriate on the back of this fo�m. 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 Sfep 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 foilowing 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 t+tled 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 comp�eted 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��-z��333l,5 Home - =7 a l� Taxpayer Si ture Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT CUMBERLAND COUNTY REGISTER OF WILLS, PA EPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 17-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS � ONLY: 1-800-447-3020 .__�. _�. �____ Z_ � Z� s-= ,�� _ � �C�r � � � � • � � r �� , � c � � � � — � � � -- r C� .� � :a r r /� � r' Ri � G V J �- - C, u� C-h � ' � C.. �� w ft i - -_ ` ;�'1 V / t,.: _. � "�'�. �e '. ._r �, y. F"-.. �.a r"'� .�,, � ,� %.�.,�• _..�, f�) �,,..f .. (�, Q -- � . • �, r..,, � V � `-� �^ ,-,, -T� ;� ",y � � \�:.� ``ry . F—+ _ :':? � � ._.,� f\� ;,.._ r.�1 � � �� _.L' CJ') � � '� -�.] . ''G G ^ . �—� ---►� ,� ` 4 � V � .-... � = lJ� _ �c °z F m � o m O � a, � o [ �� n N m v 0 W � 2 L � ___� o .�, ".L 3iZ 3 . l ; _D - �� 0--�.1Z _ �W� Z^ovl _ ONO� �.-�� . i � W z - o -p