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Home My WebLink About07-17-13 BUREAU OF INDIVIDUAL TAXES Pennsylvania lnheritance Tax � pennsylvania PO BOX 280601 HARRISBURG PA 17128-0601 II1fOfCTIatIOC1 NOtIC@ � DEPARTMENT OF REVENUE And Taxpayer Response ` REV-1543R EX DocEXEC <oe-�2� FILE NO.2113-0667 ACN 13502434 �, �..., _.,�,{�.._ DATE 07-09-2013 . � ;.�:; ,. I' ,:r ; ��I�_;. U ',�ag..�.� Type of Account ,�l"13 �J�_ �7 !�� ESi�t�of RHODA I TOMLINSON Security SSN 177-10-0804 X SEC Acct ��:�ff �:�:- Date of Death 06-07-2013 Stock ANN L TIMASHENKA f �� , r . CountyCUMBERLAND Bonds 4 JAMESTOWN SQ OFt�tiAP�� UdJIJi�T MECHANICSBURG PA 17050-688 UMBERL��) ��'.. i'A AMERIPRISE 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.20154146 Remit Payment and Forms to: Date Established REGISTER OF WILLS Account Balance $37,235.82 1 COURTHOUSE S�UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $ 18,617.91 Tax Rate X 0.045 Potential Tax Due $837.81 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 � 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. Comp/ete 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 nof 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°/a 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: �� s�� ` � �`�� , � �� 1. Date Established 1 ��;��.� � �� .� � �e�� 2. Account Balance 2 $ `.� �� ' �� ` ' � � 3. Percent Taxable 3 X � �' ` \ �� y �.. 4. Amount Subject to Tax 4 $ � � � .�� '�,� �� \��\�� . �-_ �� 5. Debts and Deductions 5 - ��, �� . '� \�� :.�,� _�� .._� 6. Amount Taxable 6 � � �� ,�V' `�� `�`��'�� ' ` � \� , � � 7. Tax Rate 7 X �� . ' � � � � \. � �� . � ��. �� 8. Tax Due 8 � � �\�� 9. With 5% X `�\\ � �.� � �,. � � � ��'�s Discount(Tax x .95) 9 \�� e�� u��A\\��Y� Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wilis 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 I�l - 7 3� ' 8��a/ Home 7 /(� / Tax ayer Signat Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA 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 � pennS�/LVa111a Po BoX 280601 ' DEPARTMENT OFREVENUE HARRISBURG PA 17128-0601 Information Notice And Taxpayer Respo nse � ` REV-1543A E%OocE%EG (OB-12) FILE NO.2113-0667 ACN 13502435 .; i� --, -� ;��;;-'�'r�^,:•' �,� DATE 07-09-2013 �i�� `�i�:i� �it' ' :,"...�.,� , Type of Account ;'i.};3 �i.f�_ �7 �� state of RHODA I TOMLINSON Security i E... SSN 177-10-0804 X SEC Acct C L��1�; �r� �ate of�eatn os-o�-zoi s stock RICHARD W TOMLINSON D��s,��p��' �� CountyCUMBERLAND Bonds 899 HAWTHORNE AVE MECHANICSBURG PA 17055-��E�(�A�a� �4,,�„ p,�"� AMERIPRISE 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.20154146 Date Established REGISTER OF WILLS Account Balance $37,235.82 1 COURTHOUSE S(�UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $ 18,617.91 Tax Rate X 0.045 Potential Tax Due $837.81 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. � 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 � 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. Comp/ete 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 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 indicatin a different tax rate, lease state ��`�� '� � � �� `\� 9 P �A\� �\ �. � � �� your relationship to the decedent: �`� ° �� ° �� : 1. Date Established 1 �� 2. Account Balance 2 $ `�� '� 3. Percent Taxable 3 X � � ` �� ` �� ;A . �� -. �� 4. Amount Subject to Tax 4 $ � �� '�� , � � 5. Debts and Deductions 5 - � �� \ e��`�� A� �� ... �.� ��.. �\\\\�� 6. Amount Taxable 6 $ ;� ` `\\o \��\��; '� \�� `��\� ��\� 7. Tax Rate 7 X �� \ � .� �� ' .�� \ \ \\ �\ \�\\��\\�a �� . . �� 8. T� Due 8 $ � `V�`� yV ` ` ��; � � �A �� s � � �� ? �_� 9. With 5% Discount(Tax x .95) 9 X �`�\�� s��a��'��\�� 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 y►? -�?,'1 - 87(� ( Home 7 ( / Taxp yer Signatur Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA 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 � pennS�/LVd111a Po BOX 280601 ; DEPARTMENT OFREVENUE HARRISBURG PA 17128-0601 Information Notice �� , REV-1543 E%OocEXEC (OB-12) And Taxpayer Response FILE NO.2113-0667 ACN 13136207 �j ��1;;��;°� ''�"t`�^?' ��' DATE07-01-2013 �: r:��`'rs . .,;; CC= '+��.�.S ,,, Type of Account �� J�(� 1 7 �� tatL�f RHODA I TOMLINSON Savings SSN 177-10-0804 Checking ��-��;� �s,�Date of Death 06-07-2013 X Trust RICHARD W TOMLINSON (�i�.t.��p�� j(�t�ntyCUMBERLAND Certificate 899 HAWTHORNE AVE MECHANICSBURG PA 17055-5732C�F=��R�,�C�7 �;�,, �� PNC BANK NA 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.5002002029 Date Established 05-06-2009 REGISTER OF WILLS Account Balance $45,541.00 1 COURTHOUSE S(�UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $22,770.�0 Tax Rate X 0.150 Potential Tax Due $3,415.58 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°/a Discount(Tax x 0.95) $(ses NOTE`) due. Any inheritance tax due will become delinquent nine months a�ter the date of death. PART Step 1 : Please check the apprapriate 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 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 � 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. Comp/ete Part 2 and part 3 as appropriate on the back ofi 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 taxabie(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. �� y � � � ��,,� �� ,» � .; �� ` �� If indicating a different tax rate, please state ��y��A\ . � � �� \ �� your relationship to the decedenr `��V�� °` ` °� ` ` �`; �� : .:, �� \\�� . � � � �� 1. Date Established 1 ��\��A,. � \ � �� ..\\��\\ \ ��.�. � 2. Account Balance 2 � �� _ `� �"��' \ � � � ` � 3. Percent T�xable 3 X �� ' �O� ' � ` � � � �� o �'� �� : �� o o � 4. Amount Subject io Tax 4 $ ��, �� ,�� A� �.,� � ��\\� �� \ � o��\ � � \ ��t�� 5. Debts and Deductions 5 - �V ` � �� ` � �� °�� \ � \�y\\��, \� .� ��.\\\� 6. Amount Taxable 6 $ �� ` \� �� ` �� ` `� �s \ � �� \. ��, `\� 7. Tax Rate 7 X �� `��`.�� . � :a� �� \ 8. Tax Due 8 $ �� ` �� / ��oA��A ��V��c.AA A.. . �� A... A . _ �..��VA� 9. With 5��a Discount(Tax x .95) 9 n �� o\��\��\o�� \�� \O\� Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wilis 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 717- ?3 7-87� Home � � Taxp yer Signatur Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA 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 B�R�� oF INDIVIDUAL TAXES Pennsylvania lnheritance Tax � pennS�/LVa111a PO BOX 280601 = DEPARTMENT OFREVENUE HARRISBURG PA 17128-0601 Information Notice � '�-�� REV-1543 E%OocEXEL (OB-12) And Taxpayer Response FILE NO.2113-0667 ACN 13136208 DATE 07-01-2013 L �J:;:.��,_ .. � . .�.,�_ �?E�" ;;'` ,� GE' ?'.i...�..S Type of Account ?,;, 1 p � � �tate of RHODA i TOMLINSON Savings i ��' �3 ��t� '`� � v SSN 177-10-0804 Checking Date of Death 06-07-2013 X Trust ANN L TIMASHENKA v��ti� �� CountyCUMBERLAND Certificate MECHANICSBURG PAE17055-57�t�y�A��, �`"'`�� CU��BEF�Lf�s�� (��., �'� PNC BANK NA 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.5002002029 Date Established 05-06-2009 REGISTER OF WILLS Account Balance $45,541.00 1 COURTHOUSE S(�UARE CARLISLE PA 17013 Percent Taxable X 50 Amount Subject to Tax $22,770.50 Tax Rate X 0.045 Potential Tax Due $ 1,024.67 NOTE*: If tax payments are made within three months of the decedenYs c�ate 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 l3eiow. 1 A �No tax is due. I am the spouse of the cteceased ar J 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% 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. Comp/ete 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 decedent's percentage awned 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 ��y�� ,�y��. � �� your relationship to the decedent: �� o�� • � �� \�� ,�\� 1. Date Established 1 ��`�� ' � ` �� A �� . ��\ � \ , 2. Account Balance 2 $ �� ,�w�� `� �e.�" �. � ,, �- .. 3. Percent Taxable 3 X �' � ' �-� � � �� 4. Af1lOUfl�SUbJBCt t0 T3X 4 $ � � A 1 -- ��..:_ � � �� :�.�.�� ti �� _:� � �� .� � ' �� ..A�V�� `� � �� 5. Debts and Deductions 5 - ��\��\ \ ,\�`�\�� \�� ` �\ � � �� 6. Amount Taxable 6 � ��\ : �\ \��\�� \. \ `�� `�� 7. Tax Rate 7 X �� ,�_�. ��.� � � � � � �� ti � �� . � �� .. � � 8. Tax Due 8 $ '��A �� .�� ` o ,( ��\��\ \ .\�� ..�. .. \\.�\.\ .�� . \ �\\ 9. With 5/o Discount(Tax x .95) 9 ��a��\ ��o�''\�� O� �� o�.��s �� 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 � ��1- �3� - 81101 Home 7 1(��3 Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA 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 Penns �vania �nheritance Tax � � � Per1r1S�/LV8111a PO BOX 280601 Y HARRISBURG PA 17128-0601 IIIfOCfllat1011 NOtICe ' DEPARTMENT OF REVENUE � � REV-1543 EX OocE%EC (08-12) And Taxpayer Response FILE NO.21 ,� '�, � .,,.E�. a�-¢^i ,�i ACN 13134208 ��'��g=;� ^� ' DATE 06-25-2013 i�:_�;:.� k :.�b: �' ��,__. ?�,�� _ �� "� � �� Type of Account Estate of RHODA I TOMLINSON Savings � `-•>� �� SSN 177-10-0804 Checkin �'�`""''� �`'y Date of Death 06-07-2013 X Trust 9 ANN L TIMASHENKA �;ri��1�i��+ �� CountyCUMBERLAND Certificate 899 HAWTHORNE AVE ��L�� ;�� G4 J sa,,� MECHANICSBURG PA 17W�5'9'�5�'3� �" f 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.338008 Date Established OS-10-2011 REGISTER OF WILLS Account Balance $81,626.65 1 COURTHOUSE S�UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $40,813.33 Tax Rate X 0.045 Potential Ta�c Due $1,836.60 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. PARr Step 1 : Please check the appropriate boxes below. y 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 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 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 y`-='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 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 ��v.. �� - � � � � o� �. � �� .�,�' \ your relationship to the decedent: ��V�� . ��\\��\� � 1. Date Established 1 �� \ \� \ �� 2. Account Balance 2 $ �:'�;a, . � �� ` 3. Percent Taxable 3 X �� $ \\�� . � �� 4. Af110Uf1t SUb�@Ct t0 T3X 4 � �� '• ' .\�� A \\ � .� yV�� \��\��\\�\�\ �� \\\�� , :� 5. Debts and Deductions 5 - ,�� y�� " �� `:� `�..'�� ._ ::�� :��. _ . � � 6. ARIOUfIt T8X8b�@ 6 $ �0�� \ 7. Tax Rate 7 X �� A� �\V�\�A �V��a� � V � � .��:� 8. T� Due 8 � �� ' 9. With 5%Discount(Tax x .95) 9 X ��\�\\�� '�� eo��u�� '��a� �� Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wilis 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 7i 7' 7�7 - 87(0� Home � �(� /3 Taxpayer Signat r Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA 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 Penns �vania �nheritance Tax � pennsylvania PO BOX 280601 y DEPARTMENT OFREVENUE HARRISBURG PA 17128-0601 Information Notice �� REV-1543 EX DotEXEL (OB-12) . And Taxpayer Response FILE NO.21 ACN 13134207 ,,-n, t:;-;� ; °` !��'°' "� DATE 06-25-2013 . �" • i o s.�r: i:� yf e 3, �-. :::� �..a) 1! ��.i i .i\ �1 ,. _ .. Type of Account '''' � 7 �(i � `!-`�i� ��_ 1 � Estate of RHODA I TOMLINSON Savings SSN 177-10-0804 Checking `�`"'0 Date of Death 06-07-2013 X Trust �;�w��n �:�; RICHARD TOMLINSON ,, R � �� r CountyCUMBERLAND Certificate 899 HAWTHORNE AVE O�'��'�'rt+�'��'�� e��Jii� MECHANICSBUR6 PA 1705��2��L�� (;�,� �;� 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.338008 Date Established 05-10-2011 REGISTER OF WILLS Account Balance $81,626.65 1 COURTHOUSE SGIUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $40,813.33 Tax Rate X 0.045 Potential Tax Due $ 1,836.60 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% 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 decedent's percentage owned by the number of suroiving 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 �\��.�y� �� '� , ��\\��\ � � your relationship to the decedent: A�`\��A�� . �� 1. Date Established 1 ��\\ � � ` � � � � 2. Account Balance 2 $ �„�' ��; A � �"' � � 3. Percent Taxable 3 X �` �� ' �� 4. Amount Sub'ect to Tax 4 $ `�,�� \�� ,\ \� '�\ �� 5. Debts and Deductions 5 - �� ' `�� 6. Amount Taxable 6 � �� \\ 7. T� Rate 7 X �� :.� ��:��' ��\\ ,.� � � � �� A ; 8. Tax Due 8 $ � \\ 9. With 5% Discount(Tax x .95) 9 X ��v �o�� \�� '�� o�� \ Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wilis 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 knowiedge and belief. Work �1�' 737-8��0� � Home 7 /(� / Taxpayer Sign re Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVtSION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 �,�x-� � -,�_.,� ,�...M:�,.�t-,�.� ��,� .� � m-r_�-��,��,,�.� ,�..�...�.�. -,,�.�.� _.� �,��. � ,�_�� BUREAU OF INDIVIDUAL TAXES Penns �vania lnheritance Tax � � � Per1r1S�/LV8111d PO BOX 280601 y HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE '�� REV-1543 E%DacEXEC (OB-12) And Taxpayer Response FILE NO.21 ACN 13134206 ra�: ��;.:; �•_ r�-�-�;��- DATE 06-25-2013 ��`� : : u�` `� ;�.�_� 4`!!i,� 4�i�i_ �� j� � C TYPe of Account �tate of RHODA I TOMLINSON Savings SSN 177-10-0804 Checking ^� '' `" ^' Date of Death 06-07-2013 ANN L TIMASHENKA ��:"R ;��' Count CUMBERLAND X Trust 899 HAWTHORNE AVE �i( � ��;�i'`�� ;;��J�� y Certificate MECHANICSBURG PA 17055-��q��-�4�;{;,,;;.x ��,},� nFj 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.338008 Date Established 04-21-2011 REGISTER OF WILLS Account Balance $46,164.23 1 COURTHOUSE S�UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $23,082.12 Tax Rate X 0.045 Potential Tax Due $ 1,038.70 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 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 � �2qa 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 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 indicatin a different tax rate, lease state ��o �� '��' �� - 9 P �� ,�.v. � � � �:� � � � � your relationship to the decedent: y�� ` � �� ' � � �`:�\�` 1. Date Established 1 ��\�� 2. Account Balance 2 $ ,�„�� =��` ` ` ` ' � 3. Percent Taxable 3 � � X �� .� � � � `� 4. Af110Uf1t SUbj@Ct t0 T3X 4 $ �� `�� \� �� ;� \��\\ � �, \ ` \�\\ 5. Debts and Deductions 5 - � � � � �� \�� .� . A 6. Amount Taxable 6 $ ��`� � ` �� \ � . 7. Tax Rate � X ��\��.� � :.�. . �.� . .�.� � � ,� 8. T� Due 8 $ \ � � , � � 9. With 5% Discount(Tax x .95) 9 X �� '\�s�� V �\� � � ��`� ��'�� Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wilis 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 I� - 7 3'7_ Q7(D 1 �' Home � 1 Taxpayer Signatur Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA 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 Penns Ivania lnheritance Tax � pennsylvania PO BOX 280601 y HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE '�� REV-1543 EX DocEXEC (OB-12) � And Taxpayer Response FILE NO.21 ACN 13134205 _„, , .-��,.� 1 E, DATE 06-25-2013 r .a+ ; ��..— ",`.�i�..�.J �yk_`:..�. 1 ,ii . Type of Account �ti 1.� �Ui_ �7 ! I 1 aEs�of RHODA I TOMLINSON Savings SSN 177-10-0804 Checking °� � � Date of Death 06-07-2013 X Trust RICHARD TOMLINSON ��`�" � �� C�A untyCUMBERLAND Certificate 899 HAWTHORNE AVE (�i;i i2,il`m�� C!��;vi�i MECHANICSBURG PA 17055-573��I,`±J��i� ��., �r� 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.338008 Date Established 04-21-2011 REGISTER OF WILLS Account Balance $46,164.23 1 COURTHOUSE SGIUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $23,082.12 Tax Rate X 0.045 Potential Tax Due $ 1,038.70 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 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 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. ��0�� . ;� � a��;: �� If indicating a different tax rate, please state � �,.�.� `� � ;�� \ � your relationship to the decedent: �\VA� .. � �� \ � \ � � � � 1. Date Established 1 �A�� \. A � � � 2. Account Balance 2 $ :;,:�o' '�" '� ` '\ 3. Percent Taxable 3 X � s�, � � �\� . � . � � 4. Amount Sub'ect to Tax 4 $ \��\� � �� . � �\ � ��\�� \ \\ V � \ \ \�� 5. Debts and Deductions 5 - �� 6. Amount Taxable 6 $ � � ` " ' � ` `� � V" o 7. T� Rate 7 X `�:..��. A �.. �� Y�� :: ��\� . � O\. . �\� ��. ��V � �: � 8. T� Due 8 $ \�\ � � �. � 9. With 5/o ��\�. �.�� \.�e �v� \�o� � \ �� o�� ° 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 7r7- ?37- �j� I Home � /!� �3 Taxpayer Signatu Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA 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 BURE/1U OF INDIVIDUAL TAXES Penns �vania lnheritance Tax � � Per11'1S�/LVa111a PO BOX 260601 y DEPARTMENT OF REVENUE HARRISBURG PA 17128-0601 Information Notice REV-1543 EX OotEXEC (OB-l2) And Taxpayer Response FILE NO.21 ACN 13134204 ��`, �?��- ��_ DATE 06-25-2013 P��C'" �� i�. � � .�_ , : ,� �, �, � , ;�� Type of Account .�i3 �� _ ; , � .1 � Estate of RHODA I TOMLINSON Savings SSN 177-10-0804 Checking �,:�i r " `` Date of Death 06-07-2013 X Trust ��..��. ,. , ANN L TIMASHENKA ��:�.;�ay�,�� , ,' CountyCUMBERLAND Certificate 899 HAWTHORNE AVE MECHANICSBURG PA 17055-5Q�(��:�' : ;�. . 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.338008 Date Established 04-26-2012 REGISTER OF WILLS Account Balance $71,048.55 1 COURTHOUSE S�UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $35,524.28 Tax Rate X 0.045 Potential Tax Due $1,598.59 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 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 � 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. Comp/ete 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. y 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. o�� :A� , . ��, � � , �., If indicating a different tax rate, please state ��,��s��, �� ;�' � � ._� ., � �� °��. your relationship to the decedent: �� \� � � � � 1. Date Established 1 `��\��\\�� `�� , � ��S �� \ � 2. Account Balance 2 $ �,,,=,�-��y-� �� 3. Percent Taxable 3 X \� �� . �� \� �. � � � 4. Amount Subject to Tax 4 $ �� .� � ��'��\\� � � \\� �\ \ \� \\� 5. Debts and Deductions 5 - �\�� o��,��. �� , �� 6. Amount Taxable 6 $ �� - � � � �� `� � �� s�� ,� �\\ , \\ � \ \ �� 7. Tax Rate 7 X �� :�� ;:c�� '�;�;��\' �� ' � 8. Tax Due 8 $ � �� , � A 9. With 5% Discount(Tax x .95) 9 X �\ `s\\��v� �o�� '�� . �� \� �� \�� 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 7/7- 137- 7[�I Home /_.3 Taxpayer Signat Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA 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 _ .. � 4- , .� � ��;- .�� .� � ,�, ,�..��,� ,�� . � � . �� s.�.,,�..� �. �� .�� ' BUREAU OF INDIVIDUAL TAXES Penns �vania lnheritance Tax � Per11'1S�/�V81118 PD BOX 280601 � HARRISBURG PA 17128-0601 If1fOCI71atIOC1 NOtIC@ DEPARTMENT OF REVENUE � � REV-1543 EX DocE%EC (OB-12) � And Taxpayer Response FILE NO.21 ACN 13134203 nr n, ;� r. ;� r •anr_ !1 .. ;�,_4,�, ; , . j., DATE 06-25-2013 � t'':� , J� ?,� 1.� �,,� .� � � Type of Account ,':'3 `'�'`_ �`? f� Es��ta�te of RHODA I TOMLINSON Savings r.,..}, ,. SSN 177-10-0804 Checking ��'-.E=��'� �� Date of Death 06-07-2013 X Trust RICHARD TOMLINSON �`;�0��.!1fi�.�� ;�µ;f�,�'�ountyCUMBERLAND Certificate 899 HAWTHORNE AVE MECHANICSBURG PA 17055-57��j4��s��,�?i'.iP ��%�., �'•�i 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.338008 Date Established 04-26-2012 REGISTER OF WILLS Account Balance $71,048.55 1 COURTHOUSE SGIUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $35,524.28 Tax Rate X 0.045 Potential Tax Due $1,598.59 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 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. Comp/ete Part 2 and part 3 as appropriate on the back of this forrn, 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 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 reiationship to the decedent. �� \�� \ �� '� � `� � `\\\\\�\ If indicating a different tax rate,please state \ � �� , �\\�� your relationship to the decedent: ��\��\ �` ` ��`�� `�� \� � \ � �� ., �� ! �� .. � �� ; \ � i. �ate Estabi�sned 1 �� 2. Account Balance 2 $ =`�� 3. Percent Taxable 3 > � X �� . � �� .. �. A 4. Amount Subject to Tax 4 $ � ,�� \�, �� \\\\ �� \� �: 5. Debts and Deductions 5 - �� . �____ . ..�A ,�... � 6. Amount Taxable 6 $ , A� �� \�� s � 7. T� Rate 7 X '� „ � �� A� A \::- � �� :�� .��.. �: ',. .. � . �� 8. Tax Due 8 $ � \ � � 9. With 5% Discount(Tax x .95) 9 X � �j� �� \�� \�� \o � � � �� ' � Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wilis 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 7/1-�37- �37(Pl Home � /(e /3 Taxpayer ignature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA 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 Penns Ivania lnheritance Tax � pennsylvania PO BOX 280601 y HARRISBURG PA 17128-0601 IC1fOCI11StIOC1 NOtIC@ DEPARTMENT OF REVENUE REV-1543 EX OocE%EL (OB-12) And Taxpayer Response FILE NO.21 ACN 13134202 �., 3,ro,;_ ,,�. DATE 06-25-2013 ,�_ .. ,. .._,_...- , . . _ .._ �li�� .,.; r ,. � ..� y,�I ��' .:� Type of Account �'i,i�� L�iJi_ �� 1� �s�t�of RHODA I TOMLINSON Savings SSN 177-10-0804 Checking ; ,,, r -- Date o f Deat h 06-07-2013 X Trust ANN L TIMASHENKA `°'�-`-`�`° '� " CountyCUMBERLAND Certificate 899 HAWTHORNE AVE i" ,',, �, ;i- ,' i MECHANICSBURG PA 17055-5732 � `t �� u��,"1`� �E � .`., s�•�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.338008 Date Established 08-28-2008 REGISTER OF WILLS Account Balance $37,671.74 1 COURTHOUSE S(�UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $ 18,835.87 Tax Rate X 0.045 NOTE�: If tax payments are made within three months of the Potential Tax Due $847.61 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 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 Pofential 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 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. \\\ �� .\ � �.��\� �\��'.�� ` �\� If indicating a different tax rate, please state �� ' � � � � A ��A��\ �� V` your relationship to the decedent: �� \��\: �\ 1. Date Established 1 �\��` � � 2. Account Balance 2 $ ;:� `� ` ` ` ` 3. Percent Taxable 3 X �' � � � �\� � �..� 4. AmOUflt SUbJ@Ct t0 T8x 4 $ �� "V� ' � '�� ' �"� s� �� \\� � \ \� \ � � \�� 5. Debts and Deductions 5 - �� e�� A �' " �� 'c\ . 6. Amount Taxable 6 $ ��\� \ �� ` ��\\\ 7. Tax Rate 7 X , �s�� \�. � y��.��e��`. � ,.a� \ . � \�\� 8. Tax Due 8 $ �. �, 9. With 5%Discount(Tax x .95) 9 X � �� o �� V�' ��' � � �� Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills,Agent." Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. work ��- �3�- 8�[� 1 Home 7 I(n / Taxpaye Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA 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 ,�.. � ��, �r � ��,,..� �..,� �...� �.�-. ti , �, .��,� BUREAU oF INDIVIDUAL TAXES Penns �vania �nheritance Tax � Per11'1S�/�Va1718 PO BOX 280601 � HARRISBUR6 PA 17128-0601 ICIfOCI11atIOC1 NOtICe ` DEPARTMENT OF REVENUE REV-1543 E%UocEXEC (OB-12) And Taxpayer Response FILE NO.21 ACN 13134201 � ,.�,�-, -,,.-., ;•^�°- ��- DATE 06-25-2013 r � r� !, w��1 _..� �:t . ...,._.5 �.� .� ? n� � R Type of Account �T�3 �'��_ '�Es t�of RHODA I TOMLINSON Savings SSN 177-10-0804 Checking ,,f;, ;; � �_` Date of Death 06-07-2013 X Trust R ICHARD TOML I NSON ,.,,. �„,�, ,.-.,.-Gpunty CUMBERLAND Certificate 899 HAWTHORNE AVE �',ts';�E-;Co� t:'.:='s;•,t MECHANICSBURG PA 17055-573 r; � � €��, f`;�1 r' �U,.�L�'r-:l_.-'� . ._ ., E'ra 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.338008 Remit Payment and Forms to: Date Established 08-28-2008 REGISTER OF WILLS Account Balance $37,671.74 1 COURTHOUSE SQUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $18,835.87 Tax Rate X 0.045 Potential Tax Due $847.61 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 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% 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. Comp/ete 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 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 �� \�� ` �� `'� � �`� �� \�\ our relationshi to the decedent: �� `�� ` `�� `� �� 1. Date Established 1 ��;��\,. \ � ` �� "� ��` � ��\ ``�� \�\��\�� \\\� \ 2. Account Balance 2 $ � `� s"� �` � `� � `�� :�� 3. Percent Taxable 3 X `�� \. . ,.� 4. Amount Subject to Tax 4 $ � �� e �� \ \ \ �\\ \� �\ ��\� �. \ \� 5, Debts and Deductions 5 - +�� y�� \ �� 6. Amount Taxable 6 $ ��V�� 7. Tax Rate 7 \\� ' �\ :\ \\ � \ \�\ � X ��\ � S��o��;�� ' � ..� �:. 8. Tax Due 8 $ � �\\\ � � � � 9. With 5% Discount(Tax x .95) 9 X ��a��\�� s�o�� o�� oo �� O��\ \ �� `��s O� 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 717- 7.37-��(o/ Home 7 / / Taxpayer Signatur Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA 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 B�R�� oF INDIVIDUAL TAXES Pennsylvania lnheritance Tax � pennS�/LVa111a Po BoX 280601 = DEPARTMENT OFREVENUE HARRISBURG PA 17128-0601 Information Notice � � - REV-1543 EX OocEXEC (08-121 And Taxpayer Response FILE NO.2113-0667 �,�`,�j�' � r + sy, 4�.�`�.�: ��i ACN 13136206 3 .. DATE 07-01-2013 ;�l'�,� u�Ui. �7 �� 1� Type of Account .,�state of RHODA I TOMLINSON Savings �..�i_�_�`�'e'�, k-�SSN 177-10-0804 Checking � r �� ,flate��f Death 06-07-2013 X Trust ANN L TIMASHENKA �� ' ""�"J `� �ounty.,C�UMBERLAND Certificate 899 HAWTHORNE AVE ��,.,�y�iEL,li'.i� t. ,�., � MECHANICSBURG PA 17055-5732 PNC BANK NA provided the department with the information below ir.dicating 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.5140064519 Date Established 05-06-2009 REGISTER OF WILLS Account Balance $3,979.00 1 COURTHOUSE SQUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $1,989.50 Tax Rate X 0.045 Potential Tax Due $89.53 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 belovk. 1 A �No tax is due. I am the spouse of the deceased or t am the parEr�#of a decedent who was 21 years old or younger at date of dea#h. Proceed fo Step 2 on reverse. Do not ch�ck 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% I am a lineal beneficiary(parent,child,grandchild, etc.)of the deceased. (Select correct tax rate at right, and complete Part � 12�/a 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. Comp/ete Part 2 and part 3 as appropriate on the back of fhis 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 fo 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 ovuners 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. V�V��A�V A A�� `� • � , • `�� If indicating a different tax rate, please state `��\��ti��`�� ` �� V .. ��,� �� o o� . \ ` �� your relationship to the decedent: �� ` �`�` ��:� ��`�\� � � 1. Date Established 1 �� `�`� �� s��. .Y�� :.. ��S 2. Account Balance 2 $ ` � ��'"`�� ` ` � 3. Percent Taxable 3 X � �� 4. Amount Sub'ect to Tax 4 � �� ' � „ , � � 1 �\�� ' � �� .. 5. Debts and Deductions 5 - �� `��;` ��`V �'� ��'� �. � .,. ��, � � 0 �a , 6. Amount Taxable 6 $ ��' ��'��, �` ��`� �� `'° �� ' `� ' �� \� � �'. �\ 7. Tax Rate 7 X ��` \` �\\��\�\.�.� �� , \ . 8. Tax Due 8 $ �� ' ' . � � �� `�A �A�� ` �� 9. With 5% Discount(Tax x .95) 9 X `a� �\�;��v� �� s��ti� ��\��v��\�\s�� s�� 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 �17-73�- $7lnl _ Home 7 /(o /J Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA 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 SURfAU OF INDSVIDt1A� TAXES pennsylvania inheritance Tax � ' �ennsylvan�a PO BOX 280601 HARRISBURG PA 17128-0601 IllfOrCTlr�t1011 NOtICO : DEPARTMENT OF REVENUE And Taxpayer Respanse ' aEV-isas ex na�EZec cos-iz> FILE NO.2113-0667 - ��t�: ��' � ACN 13136205 �� ,.;;�- i ;�` , �'�_ DATE 07-01-2013 ,��. ��.. . ,. v� ., . .w -,^ �s f� �� '��- j'i ,� 1� TYPe of Account (ii j,j �}tJt. Estate of RHODA 1 TOMLINSQN Savings , � °�°,•u, � SSN 177-10-0804 Checking �'� �" Date of Death p6-07-2Q13 X Trust RICNARD W TDMLTNSON Q�.s�iit` s�,.�� ` �``�_CauntyCUMBERLAND Certificate 899 HAWTNORNE AVE �� t. ''`' "'�? � MECHANTCSBUFCG PA 17055-57�3�L'"��' °` `��'�� '� �� •�'�� pNC BANK NA pravided the departmen#with the information below indicating that at the death af the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No.514�64519 Date Established 05-06-2009 REGISTER OF WILLS Account Bafance $g,g7g,pp � 1 COURTHOUSE S�UARE Percent Taxable X�� CARLIS�E PA 17013 Amount Subject ta Tax $1,989.50 Tax Rate X 0.150 NC1TE*: If tax payments are made within three manths of the Potential Tax Due $298.43 decedent's date of death,deduct a 5 percent discouni on tne tax With 5%Discount{Tax x 0.95) ${see NOTE�) due. Any inheritance tax due wil!became delinquent nine rrtanfhs after the date of death. PART St�p 1 : Please check the appropriate baxes belaw. 1 A �No tax is due. ! am the spause of the deceased or I am the parent of a decedent who was 21 years ald ar younger at date of death. Proceed to Step 2 on reverse. Da not check any other boxes and disregard the amaunt shown above as Potentiat Tax Due, g �The information is The abave infarmation is carrect, no deductions are being taken,and payment will be sent correct. with my response. Proceed ta Step 2 on reverss. Do nof check any ofher bvxes. � �The tax rate is incorrect. � 4.5°1a f am a linea!beneficiary{parent,chifd,grandchild,etc.�of the deceassd. {Select correct tax rate at right, and complete Part � 12% I am a sibling of the deceased. 3 an reverse.} � 15% All other relationships (including none). p �Changes or deductions The informatian above is incorrect and/or debts and deductions were paid. listed.` Complefe Part 2 and parf 3 as appropriafe on fhe back of this form. a � �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 nqt check any other boxes. �� Please sign and date the back of the form when finishecf. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsibie far 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. (ff additional space is required,yau may attach 8 1/2"x 11"sheets of paper.) Date Faid Payse Description Amount Paid Total {Enter on Line 5 ofi Ta�c Calculatian $ �A�T Tax Calculation 3 If you are making a correction to the establishment da#e(Line 1)accaunt balance(Line 2),or percent taxable(Line 3), please obtain a written correction from the financiai institutian 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 inciuding any interest accrued at the date of death. 3. Enter the percentage of the accaunt that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held"in trust#ar"anathar ar others were 100°/a awned by the decedent. ii. Far 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 dscedent. {For exampls:2 owners=50°l�,3 owners=33.33%,4 owners =25%,etc.} b. Next,divide the decedent's percentage awned by the number of surviving pwners or beneficiaries. 4. The amount suhject ta tax is determined by multiplying the accaunt 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#he debts and deductions#rom the amount subject ta tax. 7. Enter the appropriate tax rate fram Step 1 based on your relationship to the decedent. � �z� �� .� ��`,�, �� '�" � �� If indicating a different tax rate,please state �'�� , �� ti�� your relationship to the decedent: �� ` �� ` ,�� `�" � �\� � �� , � ^ � �`� 1. Date Established 1 ,�� ; s, � \� �� 2. Account Balance 2 $ �� ;�� . � �� a V` `\ 3. Percent T�able 3 X ` � �, `� `� ` � �� 4. Amount Subject to Tax 4 $ � �� .� � �� °�� , �� ° �� \ �`� \ �� z e \ ��; 5, Debts and Deductions 5 - �' � �" � �� , �� '� ��..�: . �s � . .> , > >? 6. Amount Taxable 6 � ��A � `, s"�� " � 7. Tax Rate 7 X �� A � a �,� �° � "� �� r�� ' , � 8. Tax Due 8 $ �� \ \ �� : � �� o ��\� �� . y „� � , � i�� . 9. With 5/o Discount{Tax x.95} 9 X ��?�• �� ,��;� ��' StG� 2: Sign and date below. Return TW4 complstsd and signed copies ta the Register of Wills listed on the front of this farm, alang with a check for any payment yau are making. Checks must be made payable#o"Register of Wills,Agent" Da not send payment directly to the Department of Revenue. Under penalty of perjury, i deciare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. Work 'T 17- ?3?-�7j�►/ Home 7 /� 13 Tax ayer Signat r Telephane Number Date IF YOU NEED FURTHER ASSISTANCE, C(�NTACT PENNSYLVANIA DEPARTMENT OF REVENUE D1STRlCT OFFIGE, OR THE 4NHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS W1TH SPECIAL HEARING ANDIOR SPEAKING NEEDS ON�Y: 1-800-44?-3020