The URL can be used to link to this page

Home My WebLink About08-20-13 BUREAU oF INDIVIDUAL TAXES Pennsy�vania lnheritance Tax � Per11'1S�/LVa111a Po BOX 290601 DEPARTMENT OFREVENUE HARRISBURG PA ��2�8-060� � Information Notice � �� REV-I543 EX DocEXEL (08-12) And Taxpayer Response FILE Nro.21L� ACN 13138478� �1�� DATE 07-15-2013 Type of Account .{ ., ^ r- q_;.� n , _ ; � �� Estate of ELEANOR STUMBAUGH Savings SSN 159-24-7574 X Checking Date of Death 06-24-2013 Trust ** JOAN CLIPPINGER ' � CountyCUMBERLAND Certificate 200 ZEIGLER RD �..,- _ _. _ ., . DOVER PA 17315-213��}+�� , `�,� :_: 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.480894 Date Established 10-02-2012 REGISTER OF WILLS Account Balance $ 12,258.25 1 COURTHOUSE SQUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $6,129.13 Tax Rate X 0.045 Potential Tax Due $275.g1 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. Complete Part 2 and part 3 as appropriate on the back of this form. E Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax �nheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment, and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required, you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation) $ PART Tax Calculation 3 If ou are makin a correction to the establishment date Line 1 account balance Line 2 or ercent taxable Line 3 Y 9 � ) � ), P � ), 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 `,��\`�\' : �"�` s� �`"& ��`\ �\�\�\ ��o ��. our relationshi to the decedent: ��\\\�\� , ��\\\�� \ � �� v �� \�� A \`��V �� .�� Y P ��. �r�� `� � � �� "�'�"11# \��A\�A 1. Date Established 1 ��" `�� "��`V`�i �� s`°`��• �� :A.:A ��a�\�A, �� \��\�,,�� 2. Account Balance 2 $ ,� �� `��\\� ` � � � �� 3. Percent Taxable 3 X � V`� � � �� , �� s \\\ � A\�� \ V�� \�� \`��,� 4. Amount Subject to Tax 4 $ `�� o�� ,�� A \\��\� �� \�� \�� 5. DBbtS 3fld D2dUCtI0f1S 5 ' �V�.��`��\ �Ap� �� o�� A\\ �� \V�� \, �� \ � 6. Amount Taxable 6 � � \��\�\ �� , �, " "�� ' ��,�� \� �� \�� \\\\\�\ \\�\ �j ��\�� \,�� \ �� \\\�.\ \��\� 7. Tc�C Rdte � X `"`�h�� h \��`��V A�A A��,1� \�'a�V\�� A A� ApA�� V�V��a�� .� �� A\p �. � ��A��V��V�� A �� A�� 8. Tax Due 8 $ $�`�\V�\\�` ��V� �\V��A�� \��V��V�\\ �� \\ �� \�� 9. With 5% Discount(Tax x .95) 9 X ��.�� :��v��\��a��e\��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 �/7• ��b'�2v3� a.�� Home - /�� /� �Q/� payer Signature Telephone Number Da 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�/LVal11a Po BoX 280601 , DEPARTMENT OFREVENUE HARRISBURG PA 17128-0601 Information Notice " ��r REV-1543 EX DocEXEL (OB-12) And Taxpayer Response FILE NO.21 - �� p'7�j+� ACN 13138479 � DATE 07-15-2013 ,,:, .,.,, . __ . , p..,.,....,.. � �. , ' �� Type of Account " "� i r:� Estate of ELEANOR STUMBAUGH Savings ��t=� � ' ` " � � SSN 159-24-7574 X Checking Date of Death 06-24-2013 Trust ** J I LL E HARMON _. __ -.. - County CUMBERLAND Certificate 1895 MARY LN , CARLISLE PA 17013-1042�'"' ' ` �ii3i�i'u�. y,-.. _ - . ,_ 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.480894 Date Established 10-02-2012 REGISTER OF WILLS Account Balance $ 12,258.25 1 COURTHOUSE SQUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $6,129.13 Tax Rate X 0.045 Potential Tax Due $275.81 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 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 �� your relationship to the decedent: ��\�� `�\ � �� 1. Date Established 1 \\�`� � \� ��` `�� "� � \\� �\� �� \�\�Oo� �� \�\�\�� \��\��..\��`��\�� \ �. � �� 2. ACCOUfIt B8Iat1C@ 2 � ��,.'�� . � ��.•��`�.• �`•a ��' � e� X �� 3. Percent Taxable 3 �� \ \� �� 5�� 4. Amount Subject to Tax 4 $ � � �� ` � �� \\\��\\\\\�\��\�\��\�`��\\\\��\ \\ ��\\\ ��: � � � � ��\�� J. �BbtS 8f1C� �@C�UCtIOf1S �J ' �� A � � \��\\�A\\\��A`�� \� A\\ \\ � ��\�� \ �� \��`��\��\\ �\\ �� 6. AmountTaxable 6 $ ��°�� \\\\��\ �� \��\\\� �� \�� \\\��e��\��:�\�� \ �� 7. Tax Rate 7 X �� \� ��\�\ ��\\�\� \\`\�\��\\\��\\��\\\�\� \ \\� \\ � ��ti�� o��\�\\\\\`\�� \� �\��D��\��\\\\\\��\\\\�\��\��., ��`��o\��o 8. Tax Due $ $ ��\\\��\��\��\� � �� \� `�\�\\��`�\\�\ �l v \ \\ ��\��\� �\��\ ��`\ � s\ �,�\�\�� 9. With 5% Discount(Tax x .95) J ^ �\\��\��.a��\��\\��\\��\��\\��\��\�V��\\�\\�\V��\�i..:::: 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 -� �.3 -�/�-� �/ d�d xpayer Si ture 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 _ � e ., �.: :. � �._:�� , �� .. �� . .� � ,e � .�„� BUREAU pF INDIVIDUAL TAXES Pennsylvania inheritance Tax � pennsylvania PO BuX 280601 ' DEPARTMENT OFREVENUE •HARRISBURG PA 17128-0601 Information Notice � ' �� REV-1543 EX DocEXEL (08-12) And Taxpayer Response FILE NO.21�f�-(�� ACN 13138480 �;�-f..• - - DATE 07-15-2013 ^ � C� Type of Account �;;.v ; ,r ,�`1 �' ', / �� Estate of ELEANOR STUMBAUGH Savings SSN 159-24-7574 Checking Date of Death 06-24-2013 Trust JILL E HARMON , - CountyCUMBERLAND Certificate 1895 MARY LN �' �': -', `° " CARLISLE PA 17013-]�0��+ , `'�': '�.,+ ;�;�� 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.480894 Date Established 10-02-2012 REGISTER OF WILLS Account Balance $4,109.67 1 COURTHOUSE SGIUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $2,054.84 Tax Rate X 0.045 Potential Tax Due $92.47 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 form. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax nheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment, and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation) $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%,3 owners=33.33%,4 owners =25%, etc.) b. Next,divide the decedenYs percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicatin a different tax rate, lease state ��`��"`� ` � � °`�� ' ` � � �°�� 9 p �� ` \� �\ \\ your relationship to the decedent: ��\, ,� `� `�� o � � �� \ ��\��\��\��\ � `� � � �\a� �� `�.��r�� a�,�O � ��\� �, � 1. Date Established 1 �\�� \��\\\\� �� \�� , � 2. Account Balance 2 $ �� A' � �� 3. Percent Taxable 3 X ` � � � � � � � �� .�`�� o��\ � �� 4. Amount Subject to Tax 4 $ `�� \ �� ;��\��\��\\�� \\\ �\�� 5. Debts and Deductions 5 - ��,� �� s��`� �\�� ,. ��.. .�� .. �� V��\�oo� �� 6. Amount Taxable 6 � \ � � � ��e��,��\�� `\ \�� \�� \\ \ \� � � \\ X �� \�a� � \��\�� \\ � �� 7. Tax Rate 7 �� ,��\ ��A �� O � �A�o ��\� �A\ �� \��`�`�\ � �A��A��p �A � �\\o A\�� 8. Tax Due 8 $ ��\ ��\\��\��A\\��A�� `� � \ �A 9. With 5% :\�\��\��a\\\��\��.\.\\��.��\�\\��o��\\a��\\�\��\�`��\�.\��\��\\a\\��\ Discount(Tax x .95) 9 X �� ,�� ,�.. 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 f Home � .�//�-� % /��o /� axpayer ature 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�/LVat11d PO BOX 280601 ' DEPARTMENT OF REVENUE HARRISBURG PA 17128-0601 Information Notice � r �� REV-1543 EX OocE%EG (OB-12) And Taxpayer Response FILE NO.21-1?,Gl�� r F ^ . . _ �, ACN 13138481 _ , , DATE 07-15-2013 �� i , ,�, r�,� � r� Type of Account y� � F i � Estate of ELEANOR STUMBAUGH Savings __ SSN 159-24-7574 Checking Date of Death 06-24-2013 Trust JOAN CLIPPINGER �' � � =, , CountyCUMBERLAND Certificate . 200 ZEIGLER RD CL��;� � ��. � , DOVER PA 17315-2137 ' � ° �`•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.480894 Date Established 10-02-2012 REGISTER OF WILLS Account Balance $4,109.67 1 COURTHOUSE S(�UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $2,054.84 Tax Rate X 0.045 Potential Tax Due $92.47 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 St@p 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other 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 nof check any other boxes. C �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child, grandchild, etc.) of the deceased. (Select correct tax rate at right, and complete Part � 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 ��;\\��`\�\�s� �� ` � �\ our relationshi to the decedent: ��`��"`V�� `�� `�` °��"`�� ; `\��,�`�� 1. Date Established 1 � ��\ \�� \ \�ll�`\\�`��\�\ \ ��k= � ��, ��\ \�� . �A \\ \\�� \.. � \�� \� 2. Account Balance 2 $ \ \\ \ � O�\� �� \� � � ' �� 3. Percent Taxable 3 X \ \ �. � �� ' � 4. Amount Sub ect to Tax 4 $ �� 1 ��.s�� V �� \ .� V� `� �� \ \��. s\ ��\\�� \\ �. �\ �\� �� : 6. A otunt TaxDablections 6 � ��\\\\ s��,��\��\\.��\��\ �� 7. Tax Rate 7 X �� ,�� \\ �� s�� . :�� A` 8. T� Due 8 $ \ � \\ V ��`��AA �� ' ��\��\ \\��\�`� ��\\��\ �� \ � �/ . 9. W ith 5��0 D i sco u nt(Tax x .95) 9 ^ ��\��s��\��\��\��\\��\��.\\0.\�� \��\�� \\ 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 / -��- a�� Home _ 5�� - /� �' / a�/.3 T payer Signa ure Telephon Number ate 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