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Home My WebLink About07-29-13 COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 017951 MITTEN BELL SHERRE 1504 LETCHWORTH RD CAMP HILL, PA 1701 1 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- fold 13139246 � $4.50 ESTATE INFORMATION: SS►v: � FILE NUMBER: 2113-0753 � DECEDENT NAME: MITTEN LEWIS K � DATE OF PAYMENT: 07/29/2013 ( POSTMARK DATE: 07/26/2013 � COUNTY: CUMBERLAND � DATE OF DEATH: 06/25/2013 � _ � ' TOTAL AMOUNT PAID: $4.50 REMARKS: CHECK# 4443 INITIALS: HMW SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH � REGISTER OF WILLS 3 ? ; f TAXPAYER s a � S � j BUREAU t�F INDIVIDUAL TAXES � �ennsylvan�a PO BOX 2806Q1 Pennsyivania lnheritance Tax HARRISBUR� PA 17i28—OSO1 It1fC?CC11�tlOCI NOtICG � DEPARTMENT OF REVENUE REY-2543 EX DocEXEC{�8-12) �- And Taxpayer Response �► � .7�..� FILE NO.21�"' .:/- ACN 13139246 DATE Q7-19-2013 Type of Account Es#ate of LEWIS K MITTEN Savings SSN X Checking Date of Death 0£-25-2013 Trust SHERRE G MITTENBELL Gounty CUMBERLAND Cerkificate 150�+ �ETCHWQRTH RD CAMP HILL PA 17011-7523 �� p� f..__a � �•�� !�! � w.�p ,��/�� l+�rv' r .. {'� }5 f '4`�/yr (ti�� ,Z �' - /�s ''w� q�n✓ p '., .�y • .� 4�,i� _ . .';i �^-r .._.' ry, �� . . -}. , , " , \..� " . _ , Ca� :�"7 ( _ �.Y , :� .,� f :��. . - .__. � �.:, �� . _ �;.-�; Y _ - --- -_ _ _ _ _ � ' :� . ��• �� ; rV �;;� � � o�RSTt�wM BANK provided the department with the information below indicating that at th��eat�i�Ya9�he above-named decedent yau were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: �-�� j Account No.1 p3009435 � Date Estabiished 07-U9-2C1'10 REGtSTER 4F W1LLS Account Balance ��.�� 1 COURTHOUSE SQUARE Percent Taxable X 16,6g7 �ARLtSIE PA 17013 Amaunt S�ubject to Tax $1 p5.39 Tax Rate X 0.150 �ypTE*: If tax payments�re made within three mt�nths of the Potential Tax Due $15.81 decedent's date of death,deduct a 5 percent discount on the tax With 5°f4 Discount�Tax x 0.95} ${see NC7TE*) due. Any inheritance tax due will become delinquent nine manths after the date of death. PART Step 1 : Please check the apprapriate boxes below. � A �No tax is c#ue. -I am the spouse af the deceased or 1 am the parent af a deceden#wha was - 21 years ald t�r ya►unger at date of death, Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amaunt showrr abQ�e as Potential Tax Due. g �The informatian is The above information is correct, no deductians are being taken,and payment will be sent carrect. with my response. Proceed to 5tep 2 on reverse. Do not check any other boxes. . c �The tax rate is incarrect. ,� 4.5°/a I am a lineal beneficiary (parent,child,grandchild,etc.)af the deceased. {Select correct tax rate at right, and complete Part � 12°/4 I am a sibling of the deceased. 3 on reverse.} � 15% All other relationships (including none). �y �Changes or deduc#ions The information above is incorrect andlor debts and deductions were paid. listed. Comp/e#e Part 2 and part 3 as appropriate on the back of this form. E �Asset will be reported an 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 ta S�ep 2 on reverse. Do not check any other boxes. Please sign and date the back of the farm 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 tit�ed as it existe�+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, div:de the dECedent's percentage owned by�he number of surviving owners or beneficia!�ies. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of an�debts and deductio�s 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 approp�iate tax rate from Step 1 based o�your relationship to the decedent. If indicating a different tax rate, please siat � ��j��r��,�� . your relationship to the decedent: -" � �,� ��..t�� ` 1 � P�;��p�a.�#m��t3� ��r�� 1. Date Established 1 2. Account Balance 2 � �� 3. Percent Taxable 3 X � � 4. Amo�nt Subject to Tax 4 $ � 5. Debts and Deductions 5 - � . 6. Amount Taxable 6 $ ��/ -�� 7. Tax Rate 7 X W �7 �' � {� 7 8. Tax Due 8 $ —1' � � 9. With 5% Discount (Tax x .95) 9 X <<j(� Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills, Agent." Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. � � Work ,- '`� Home ( � �S � Taxpayer Signature Telephone Number Date � /� IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA DEPARTMENT R VENUE 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 < m� ��'� � a . �, > �., a O �.. w � � � V � �. � �* ��r1 � �� L �� . �M�'M � �� MIM� � �f AY � i�MU �� wllra �IM �M • �� A 11lA Mf �M�11� + � ' � � � �!; � � . � � � ; , .... } :.�.�� ..�,.- -� �:�� . � � :�� - s� � --- : �, � 'k. ��+ w.. I.�;; � ...�._ >- �:R:; � ��:� ��`{ - �; � -� � ��:: � � �.�� ,.,.... �g � �� . "' l.�� , � ;� ,�,,,�` .�. � ��-� �. � � t�-� � � j }.rt� > L� ....�. {ar... t�i �� ., �� .. � "'V ir� � .. ��t - �� f {� �� , �,,.- 1„j �'�.� •r•t �� ;�� t++...� � �; i '� �.�v i v � �� j , ..�r� Qi��4f k�.��?�a''��J �' t� �* �� p''t� r.:^4� . , ,..; � 1�I`� 33 R� �' ... J /i�,i ,.1 � �� ' �.. � � u...� �� ,�� *��': /� �1 '� � �� : �.�":�.�.J��. • �.� „yM� .. . ' . .. .. .� i � t{,, ��2��.. ,. fi r,� . ._< . . . .. �� { , ' � � � „ *�--��\../