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6��,� oF INUIYSOWI TAXES Pennsylvania lnheritance Tax � pennsylvania
ro eax 280601 ��� DEPAR7MENTOFREVENUE
141RRIS6UItG Pp 1]128-0601 Information Notice
And Taupayer Response "`""'"°°"�" °• "'
FILE NO.2170
� ACN 13128087
DATE 05-28-2013
RE6ISTER OF �JIILS
Type of Account
?�13 JUN 1"i P� 2E�of CHAALES A CARPENTER �Savings
S Checking
C L E R K p F Date of Death 03-27-2012 Trust
6323 FORREST DRCARPE ORPNANS� COURTount CUMBERLAND Certificate
MECHANICSBURG PA i�oso-za�MBERLAND CO., PA
SOVEREICN lANK provided the department with the information below indicating that at the death of the
above-named decedent you were a 'oint owner or beneficiary of the account identified.
Account No.1681721767 Remit PaymeM and Forms to:
Date Establiahed 01-23-1998 REGISTER OF WILLS
Account Balance $1,587.02 1 COURTHOUSE SOUARE
Percent Taxable X 50 CARLISLE PA 17013
Amount Subject to Tax $793.51
Tax Rate X 0.750 NOTE': If tax paymeMS are made within three months of the
Potential Tax Due $ 119.03 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[ax due will become deli�uent nine months
after the date of death.
PART St@p 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�ot check any other boxes and dis2gard 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 tau rate is incorrect. � 4.5°/, I am a lineal beneficiary(parent,child, grandchild, etc.)of the deceased.
(Select corceot 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 aboye is incorrect andJor debts and deductions were paid.
listed. Complete Part 2 and part 3 as appropn9te on Me back of this lorm.
E �Asset will be reported on The above-identified asset has been or will be reported a�d tau 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 81/2"x 11"sheets of paper.)
Date Paid Payee Description Amount Peid
Total Enter o�Line 5 of Tax Calculation $
PART Tax Calculation
3 If you are m�kiny e cortectlon to the ast#W�shma�t d�(Ll�e 1)�rN��ro(Llne 2),or percent taxabk(Line 3),
_ _ please obhin a written cortection hom the Nnandal instllution and attach it to thla 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 texable to you.
a. First,determine ihe percentaye 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 eptaplished rtw!e than one year prior to the date of deaih,the percentape taxaWe is 1�0%divided
by the total number of owners including the decedent. (For example:2 owners=50%,3�dvu�i�s t 33.33'�l,;48Nmers
=25%�etC.)
b. Next,divide the deceder�Ya pmfceMaye owned bythe number of surviving owners or beneficiaries.
4. The amount subject to tax is detsrmined by multiplying the account balaoce 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 artrount subject to tax.
7. Enter the appropriate tex rate 6om Step 1 based on your relationship to the decedent.
If indicatinga dlifemnttaz rate,pleese state
your reF�ationship[o tt�e decedent:
1. Date Established 1
2. Account Balance 2 $
3. Percent Taxable 3 X
4. Amount Subject to Tax 4 $
5. DeMs and Deductions 5 -
6. Amount Taxable 6 $
7. Tau Rate � X
8. Tax Due 8 $
9. With 5%Discount(Tax x .95) 9 X
S�@p�: Sign and da[e bebw. Refum 7W0 comp�eted and signed copies to the Register of Will�listed on the front of this form,
atong with a check for any payment you are making. Checks must be made payabte to"Register of Wil�,Agant" Do not send
payment directly to the Department of Revenue.
Under penalry of perjury, I declare that the facts I have reported above are true,correct a�d complete to the best of my knowledge and
belief.
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Taupayer Signature Telephone Number Date
IF YOU NEED FURTHER ASSISTANCE, CQNTAGT CUMB�FtI`AhJO COlJh1TY REGIS�ER OF VAtiE.LS, PA
DEPARTMENT OF RE1fEN#1E DISTRICT OFFICE, OR THE INHERITANCE TAX Dt�IS10N AT
717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAK►NG NEEDS
ONLY: 1-800-447-3020