HomeMy WebLinkAbout07-16-13 (2) BUREAU OF z�,v�W,,� T,�E� penns Ivania tnheritance Tax � Pennsylvania
PO EOX 28060] Y �.f� DEPARTMENi OF REVENUE
HARRISCIIRC PA 17128-06tl1 Infarmation Notice xEV��sFa u oa�e�c oa-izr
And Ta7cpayer Response ^a�l�J �� �/
FILE N0.21 � g
ACN 13134434
DATE OB-25-2013
�ECisr�� o� ��ri��s
Type of Accourrt
,.'Q 13 JUl. 18 F'I� 12 36 est�ce of E�.iNa��uvE��E Savings
SSN Checking
���R QateofDeath{I4-11-2013 Trust
THQMAS DOUVILLE � �� CountyCUMBERLANd Certificate
srE aoi pRPHANS' COURT
5225 WILSON �r� ��U��RLAND CO., pq
MECHANICSBURG PA 1705
PSECU provided the department with the information below indicating that at ihe death of the
above-namect decedent you were a'oint owner ar bene6ciary of the account identified.
Remit Payment and Farma to:
Account No.8106782721
Date Fatablished 02-0$-1983 REGISTEH OF WlLIS
Account Balance $2,t28.35 � �QUR7HOUSE SQUARE
Percent Taxable X 16.667
CARLISIE PA 1�073
Amount Subject to T� $354.d0
Tax Rate X 0.045
Pofe�tiai Tau Due g f S.g� NOTE': !f tar payments are made within three months of the
decedenPs date of death, deduct a 5 percent discount on the tax
With 5°/a Discount(T�x 0.95) $(see NOTE`) due. Any inheritance tax due will become delinquent nine months
after the date of death.
PART St�(J 1 : please check the appropriate boxes below.
y
A �No tax 1s due. i am the spouse of the dec�aased or! am the parent at a decedent who was
21 years old or younger at date of death.
Procaed to Step 2 an reverse. Do not check any other boxes and disregard the amount
shown above as Potential Tar Due.
g �The information is The above intormatipn is correct, no deductions are being taken, and payment will be sent
correct, with my response.
I Proceed fo Step 2 an reverse. Do not check any ather boxes.
� ❑The tax rate is incorrect. � 4.5°/, I am a Iineal beneficiary(parent,child,grandchild,etc.) of the deceased.
{Select correct tau rate at
right,and complete Part � 12�/, I am a sibling of the deaeased.
3 on reverse.)
� 15°/a All other relationships (including none).
p �Changes or deductions The information above is incorrect and/ar debts and deduations were paid.
Iisted. Comptete Part 2 and part 3 as appropriate an the back of this 1orm.
E �Asset will be reported on The ahove-identified asset has been or will be reported and ta�c paid with the PA Inheritance Tau
i�her4tance tax tarm Return filed by the estate representative.
REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. �
Piease sign and date the back of the form when finished. �
PART Debts and Deductions
2
Allowa6ie debts and deductions must meet both af the following ori#eria:
A. The decedent was fegaiiy responsible for payment,arrd the estate is insuffioient to pay the deductible items.
B. You paid the debts after the death of the decedent and can furniah proof of payment if requested by the department.
{if additlanai space is required,you may attach 8 t12"x 11"sheets of paper.)
Date Paid Payee Description Amount Raid
_ -` �
v �
, m
Total Errter on Line 5 o a�c Iculation $
PA�T Tax Calculation
� N you are�I�a correctlon ta the estabiishm�t date{I.Ine 1}accaunt balance{lirie 2),ar percent ta�bie(i.lr�e 3},
pl�aw.abt�in a-wdtta�correcZion.from ihe financ�d inatiUrtion and,,tq�ctt�ta:lhia.�rm.
1. Enter the date the account was established or titled as it existed at the date of death.
2. Enter the totai balance of the accaunt including any iMerest accnaed at the dete ot death.
3. Enter the percerrtage af the accwunt that is tattabie ta you.
a. First,determine tMe percentage owned by the decedent.
i. Accounts that are held"in trust for"another or athers were 1009'0 owned by the decedent.
ii. For jant accaunis ee#abiiSh4d rtroi'e#�srs ona year prior to the date of death,the percenta�e t�aGIB is 100°lo divided
by the total number of owners including the decedent. (Far exampie;2 owners=5Q%a,3 a�mers=33.33%,4 oroaners
=25%,etcJ
b. Next,divide the dece,deM's pa�centage owned by the number of surviving owners or beneficiaries.
4. The amaunt subject to tau is detarmined by muKi�ying the account balance by the peresM ta�cable.
5. Entar the rotai of any debts and deductions claimed from Part 2.
6. The amount taxable is determined by subtraoHng the d�bts and deductions ftom the emowt subject to tax.
7. Enter the appropriate tsu rafe from Step 1 based on your relakio�ship to the decedent.
If indicatinga different tax rate,pleasfl state
yaur relationship to the decedent:
t. Date Established 1
r
2. Account Balance 2 $ a )�/./��„�_
3. Percent Taxable 3 X f�I.Q lp�
4. AmountSubjecttoTax 4 $ ��i�i��-. �-Mf
5. Debts and Deductions 5 - +� �ff��d 1 .
6. Amount Taxabls 6 $ -- a�,� �. � �
7. Ta�c Rate 7 X , �t'�i
8. Ta.�Due 8 $ —�"
' 9. With 5°/,Discount(Tax x .95) 9 X
��@(} �: Sign and da#e bebw. Refurn TVrt}campi�ed and signed capies to th�Registsr af Wilis IisY�d 4rs the ftoni of this twm,
along with a check for any payment you are making. Checks must be made payable to"Register o(WiNs,Rgent" Do rwt sern!
payment directly to the Department of Revenue.
Under penalty af perjury, 1 dectare that ihe facts i have reported above are irue,correct and compleke to the best of my knowiedge and
belief.
WOrk
. Hame / —
T payer Signature Telephane Number Date
!F Y4U NEED FtJFt'{'HER ASSiSTANGE, G4NTACT PEi+i#+tSYLVkNFA DEPARI'ME{+fi' OF REVENUE
DISTRICT OFFICE, OR THE INHERITANCE TAX DiV1SION AT 717-787-8327. SERVIGES FOR
TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-80Q-447-3020
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Catering Special Function Porm Page 1 of 1
Event DessripUon: Douville Mertarial DayiDate: Friday,April 19
Contact NametPhane: Tom Oau»Iie 51A-6622 I.ocatian; Springt�eid
Departmem: ti$HOilyDriveMechanicsburg,PA StadTime: 11:06AM
Guest Count: 75 Total: $589.58
P�ans Price Tatai
i Buffet Style
�. Push 14t11 toGefher doi�aru!skirfed
75 Assorted Sandwiches with Lefluce&Tomata $2.640 $198.Op
Ham,Turkey,Roast 8eef on kaiser,pretze!mlis,cros4,and wraps
� 35 Pasta Saiad,Gourmet $1.561 $54.83
Italian Pasta Salad
35 Potaro Salad $Q.784 $27.32
Red�iss Pata�Sa1ad �
75 Chips,Homemade $0.345 $25.86
75 ChocWate Chip Cookies(Two per persqn� E0.528 $39.60
_ Asst.of Ghoc.Chip.Su9ar.and Oa!Raisin
75 AssoRed Beverages $1,634 5122.51
Bevera�es will be severed
Have bowis of mayo and must.On the buffe�
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LaborCosC $93.58 7az: $28.08
STATEMENT OF ACCOUNT
��� arN�cute�a oF r�ussw
88908 3NOWDRIFT RD
ALLENTOWN,PA 18108 PAGE: 2 of 2
� ACCOUNT NO: 7001.154
� RETURN SERVICE REQUESTED 341ae � INVOICE NO: PH971121
DX NO: KOPDX
INUOICE DATE: 03l31/13
ooa+oo oioz phone: 877-670�6323 FACILITYf 7001 BETHANY VILLAGE ASSISTE
PA7IENT NO: 154
You may also view/pay your bills at: PATIENT NAME: DOUVILLE,ELINOR
https://myomntview.omnicare.com AMOUNT DUE: 352.32
dP,p��"�I�Ili�hl�lnrudh,�,�q��,p���u�h�lulllnhh TAx: o.00
ELINOR DOWILLE
C/0 TOM DOUVILLE ouEwre: 04/25/2013
HOLLY DRIVE ��J/ ��
MECHNICSBURG, PA 17055 nrourrroue: 352.32
� � .� : . � � � � ��� . / �( 34286•TR709TFiND07828 � .
. . . . �6 � �✓ . 9R70A0188:2.2 � .. .
�KEEP TOP PORTpN FOR YOlqt qECORp3-HETURN BOT70MSTU8 WITH PAYMENT�. .��� �. � �. ININH���I��HN��. �.
DOWILLE, ELINOR 700i BETMANYVILLACaEASSISTEDLVG
7001.154 03/31/13
�.��.DATE ��AX IW. TkAItS �-:.dE9CRIPtION �.'� PNYSICIAN� NDC NQ. OUANT.� AMOIINT.� TYPE �:'
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� 03/19/t3 �R21idiEE CNAkGE C1PROfLOXACIN MCL 250NG TAYLE �� :�:: ptISNNAN ':� 55111-0126-01 -�14 '4.00 Rlf���
� 03/19/13 R21 CWYtGE LOPERAMIDE 2MG CAPLET f�� �. . KRISHMAN . 00404•7725-72 12 7.18 OTC �
03/19/13 R213l.167 CIWlfiE LEVOtNYR00fINE SODI(M 0.0 � KRtSNYAN �� OOS7E-tE05-Oi �30 4.00 RX '�
03l20/17 R213aS0'I CNAR� I�TWROLOL TIYRTRATE �� �� ISHMIIN � 00378-0018-OS 180 �4.00 Rlf �
.� �� 03/20/13,-�.$273838� � CiU1RGE .�FCIAROCORTI8d1E�..�ACETATE� �. T�(RP. ISHNNF �-�. �00115-7033'02 ���'�15 . �...7.42 .RX� ..
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� -�03l20/13� R213838.� ClURGE�� P11NTaPRA20lE SODIUI 40MG�... ... KR[SNMAN��� 00378-6689-W � . 30 �.�12.00 RX ���.
. . ._ (CCRAY) � � .. . .
� 03/20/13 R213838 �.CIURGE� �FEtqFlBRATE f/C�760MG'TA6LEi .- KRI9HNAN-` 00115-5522•10 � � �� 30 .�.72.00 RX�'..�
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-,. _.�. .._____ __-._ . . __.._ Fkrncs�Ctw�e�m�'be enw�ed at a MONTHLV PERI00 RATE OF.: . . .
. ___ . . ____ .
. . .. _. . . . � . . . . .... 1.Sf1%�(ANNUK RATE OE.18J11�%%I ha�ed N�an�n uiq�d-b��nce -_._ _._.
. . . . . � � . . � � .: ouhtendkp 90 deys�or more. . . � .
- � PREYIWS�BALANCE � � ��CHARGES � FINANCE CNARGE � �' TDTAL CHARGES ��� � �PAYMENTS 8 CRED[.TS � � �AMOUNT DUE
� � � � 134.02 � � �218.30 � �0.00� � � � : � 35232�� � � � 0.00 � � � � � �35232 �
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STATEMENT OF ACCOUNT
� . /a�� OMNICARE KMIO OF PRUSSIA . . . . . . . .
�89Y08 SNOWDRIFT RD�
�� ,4��errrowri,pn�e�os PAGE: 1 of 2
ACCOUNT NO: 700&195
� � RE7URN 3ERVICE REQUESTED sa2s5 INVOICE NO: PH98B930 � �
DX NO: KOPDX
INVOICE DATE: 04/30H 3
aoseas ozos phone:877-670-8323 FACILITY: 7003 BEfHANY VILLAGE THE OAK
PATIENT NO: 195
You may also vlew/pay your bills at: PATIENT NAME: DOUVILLE,EuNOR
https://myomnNiew.omnicare.com AMOUNT DUE: 89:13
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ELINOR DOWILLE
C/OTHOMASDOWILLE oueoare: 05/25/2013
118 HpLLY DRIVE
MECHANICSBURG, PA 17055-5527 � r n A�,�ouNroue: 89.13
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DOWILLE;EUNOR 7003 BETHANY VILLAGE tHEDAKS
7003-195 04/30/13
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PREVIq1S BALANCE � CXIIRGES . . �� fINANCE CNIUtCE � � TOTAL CHARGES � . �PAYNENTS i CREDITS � AMOUNT DUE �
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