HomeMy WebLinkAbout09-17-13 9/9/2013
PA Dept of REV, Inheritance Tax Division:
My mother, LOIS M. HOLLER died on JULY 10 and was buried on JULY ]6, 2013. As a result of her
death, my sister and I each received checks from Ameriprise Financial. We received:
Amy S Fritzinger 8/28/13 Received a check for$3780.57
Roxanne C Morgan 8/28/13 Received a check for$3780.58
Both these checks were deposi[ed and used to pay for our mother's funeral expenses.
Receipts for these paid expenses are attached and are as follows �
Musselman's Funeral Home, 324 Hummel Avenue, Lemoyne, PA ]7043 (717-763-7440) ATT(�A,(' -ri1 ��/S "`
Rolling Green Cemetery, 181] Carlisle Rd, Camp Hill, PA 170I1 (717-76]-4055) AT'R'�'�er.'�'�5°i�'�'� "
The costs of my mother's funeral far exceeds the amount we received and thus we believe we are not
responsible to pay inheritance tax.
Thank vou.
� y..,_�. CiL,aL �`�. �'t'¢�-^�c�.
�! iJ
��R�� oF =�r�=a�^4 rA=�S Penns Ivania �nheritance Tax r Pennsylvania
Po @OX 28obUi Y( DEPARTMENTO�REVENUE
HARRFSBIlft6 PA 17128-OSPi � �ni�rm����n N�tI�.Q .- .. e¢v�izou cx p4�excc iea-tn
And Taxpayer Response F��E n�a.2i
ACN 13563293
DATE 68-23-20i 3
Type of Account
Estate of LOIS M HOLLER Security
SSN SEC Acct
Date af Death 07-14-2013 Stock
AMV S FRITZINGER CountyCUMBERLAND Bonds
1775 KECK.S RD
BREINIGSVILLE PA 18031-2219
� AMERIPRTSE provided fhe department with the information below indicating that at the cleath of Yhe
above-named decedent you were a joint owner or beneficiary af the acco�nt ideniified.
Account No.2448i270020d2 Remit Payment and Forms to:
Date Established REGISTER OF WILLS
Account Balance $7,702.61 1 COURTHOUSE SQUARE
Percent7axable X5Q '— �aRLISLE PA 17013
Amount SubjecY ta 7ax $3,&51.31 —
Tax RaTe X 0.045
Potentiai Tax Due g 77�,3� NOTE`: If tax payments are made within three months af the
decetienYS daTe of death,deduct a 5 percent discount on tfie tax
With 5%discount(Tax x 0.95) ${see NOTE`) due. Any inheritance tax due wiii become delinquent nine months i
after the daie of death.
PART �tep 1 : Please check the appropriate boxes below.
1
A �o tax is due. I am the spouse of the deceased or I am the parent of a �iscedettt wha was
21 years old or younger at daYe af death.
Proceed to StBp 2 on reverse. Do not check any other boxes and clisregard the amount
shown above as Potential Tax Due.
g �The informaiion is The above informa#ion is correct, no deductions are being taken, and payment wilf be sent
correct. with my response.
Procesd to Step 2 on reverse. Do not check any other boxes.
� �The taz rate is incorrecY. � 4.5°lo i am a iineal beneficiary(parent, chiid, grandchild, etc.) of the deceased.
(Select correcY tax rate ai
right,and complete Part � ��{o I am a sibiing of the deceased.
3 oa reverse.)
� i5°lo AII ather relationships (including none).
� Ghanges or deductions 7he inform bax i incarrect andJor debts and deductions were paid.
listed. _ omp/ete Aad 2�part 3 as appropriate on the back of ihis fprm.
E �Asset wiA be reported on The abave-identified asset has bean or wiii be reported and ta�paid with the PA Infieritance Tax
inheritance tax form Return filed by the estate representaiive.
REV•1500. Proceed to Step 2 on reverse. Da noY check any othar boxes.
Please sig� and date the back of the farm when finished.
PART Debts and Deductions
2
Allowable debts and deductions musf ineet both of the following criteria:
A. 7he decedent was legally responsible for 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.
(lf additional space is required,you may attach 8 112"x t 1"sheeis of paper.)
Date Paid Payee Descripiion Amount Paid
�/ 3. �Mar< k ��• 3 Se7muh �S fr,a+.-.�t f'�9�s - JS r°
7 fd r�i�'a��. �:r. otl. E�rec.� ('Prr.c -!er . _�7`7,�? "�' ..._.
� _� _ Total {Enter on Line 5 of Tax Calculatipn) $ �.3 .S°«Z.°'O
PART T1X Cd�GU1111011
3 if you are making a eorrection to the establishment date{I.ine 7)acoount balance{Une 2), or percent taxa6le(Line 3),
piease obtain a written correctipn f�om the finantiat instituiion ard attach 3t ta!his farrn.
1. Enter the date the account was established or ttt�ed as it existed at the date of death.
2. Enter the total balance of the account inciuding any interesi accrued at the date oE death.
3. Enter the percentage af the account that is taxabte to you.
a. First,determi�e the percentage owned by#he decedent.
i. Accounts ihat are held "in trust far"another or others were 1 q4%owned by the decedent.
ii_ For}oint accounts established more than one ysar p�lor to the date of death,the percentage taxable is 1 DO%divided
by the total number of ow�ers including the decedent. (For exampie:2 owners= 50°l0, 3 owners=33.33°/0,4 owners
=25°l0, eta}
b. Next,divide ihe decedenPS percentage owned by tfie number of surviving owners or beneficiariss.
4. The amount subject to tax is determined by mulGplying Yhe accounY balance by the percent taxable.
5. Enter the total of any debts and deduotions 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 rela#ionship to the decedent.
If indicating a differenY tax rate,please s e ��' �yi ' � "'"'"a 'f# `� 5 i�, uc "
your re(aiionship to the decetlen#:__ ���� c�. �a�i{, �A� �' � f��t � q���� ���� �s�, ��
� � � ��
t. Date Estabiished i � � p�� � W� �f� ��
1 � .� rF ; .� �
2. Account Baiance 2 �
3. Percent Taxable 3 X ��
4. Amount Subject to Tax 4 $i^_,�,
5. Debts and Deductions 5 -
�`•'4€
B. Amount Taxable 6 $
——..—.— _
?. Tax Rats 7 X
tY i }
8. T� Due 8 $ � � — 4� i� wP4� .+, , a°
�—
_.���
9. With 5% Discount(Tax x.95} 9 X � g�� i.�'�� �• � ,�,.�,.;. ��-�. , �,�'.- �,
St'1..'� 2: Sign and da€e betow. Return TWO campteted and signed capies to ths Regisier of Wills listed an the frant of this form.
along with a check for any payment you are making. GheCks must be made payable to"Register of Wills,Agent." Do not send
payment directly to the Department of Revenue.
Under penaSty af perjury, !declare th�y�he faets l havs reported above are trus,correct and cnmplete to the best of my knowledge and
beUef. / �
�~ti ` Work G�.ro • ;c:� ��--G' �
� � � �>i
�=,,.-,�j .' _��' Lx. Home �c v -,�.�' .��-t� �y�_�� !� �t.;_
r�• Taxpayer Sig � Telephone Number Date
4F YOU NEED FURTNEft ASSISTANGE, CONTACT PENNSYLVANlA DEPARTMENT OF REVENUE
D{STRlGT 4FFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR
TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020
g��u oF �NOr��n�� rAxFS Pennsylvania lnheritance Tax � P�nnsylvania
PO BflX 280502
HARRI5BUR� PA 17128-psul infarmation Notice 6EPARTM'eNTOFREVEMUE
' � �� REY�i563A EF WcEYE[108-13)
And Taxpayer Response F��E No.21
AGN 73503293
pATE 08-23-20Y3
Type of Accpunt
Estate of LOIS M NOLLER Sec�rity
SSN SEG Acct
Date pf Death 07-10-2013 Stock
ANY S FRiTZINGER CountyCUMBERLAND Bonds
1775 KECKS RD
SREINI6SVIllE PA 18631-2214
� A!{ERIPRISE provided the department with the information below indicating that at the death af the
above-named decedent yau were a joint owner or beneficiary of the accounl identified.
Account Nv.2148127002UO2 Remit Paymbnt and Farms to:
Date Estabiished REGI$TER OF WILLS
Account Balance $7,702.61 1 COURTHOUSE SQUARE
Percent Taxable X 54 GARLISLE PA 17013
Amaunt Subject to 7ax $3,851.31
Tax Rate X D.045 NOTE': If iax paymenYs are made w!{�i�three months of the
PoTentiaf Tax Due $173.3i decedenYs date of death,deduct a 5 pert:ent discount on ihe tax
With 5°10 Discount(Tax x 0.95} $(see NOTE') due. Any inheritance tax due wi!!becomes delinquen#nine months
after the date of death.
PART St�p 1 : Ptease check the approprlate boxes below. �
1
A �No tax is due. 1 am the spause of fhe deceased or i am the pareni of a aiecedent who was
21 years oId or younger at date af death.
Proceed to Step 2 on reverse. Do not check any other baxes and disregard the amount
shown above as Potentiai Tax Due.
g �The information is The above information is oorrect, no deductians are being taken, and payment will be sent
correct. with my respanse.
Proceed to Step 2 on reverse. Da not check any other boxes.
C �The tax rate is incorrect. � 4.5°!0 1 am a lineai beneficiary(parent,child, grandchiid,etc.) of ihe deceased.
{Select correct tax rate at
right,and complete Part � 12°ln !am a sibiing ofi the deceased.
3 on reverse.)
� 15°lo Ali other reiationships (including npne}.
a Changes or deductions The infar atierrabove-ts izacorrect andior debts and daductions were paid.
listed. � lefe Par12�part 3 as appropriats on the back ot thrs lorm.
� �Asset will be reported on The a6ove•identified asset has been or wilf be reported and ta�c paid wiih ihe PA inheritance Tax
inheritance tax form Retum filed by the estate representative.
REV-1500. Proceed(o Step 2 on reve�se. Do not check any other boxes.
Please sign and date ihe back of the form whert finished.
PART D�bts and Deductions
2
AI{owable dsbts and deductions must meet both of the following criteria:
A. The decedent was Iegaliy responsible for payment, a�d the estate is insufficient to pay the deductibie items.
B. You paid the dgbts 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 8 112"x 11"sheet5 ofi paper.}
Date Paid Payee �-- Descriptian Amount Paid
9 3. cr ' /+ T7'�I'L�� �1✓)S�t/.n;:n's -�i�}at'�aj f'�+.�wt'- 5'� f . °
..-1"��� �il, �or�zn �..�me {e'� . �?f�/ a" �'
<
Totai {Enter on Line 5 of Tax Calculation $ �3 ,5"'Z:2, °"
PART TaX CaICUIatIOn
3 If you are making a correction ta the establishment date(Line t)account baiance(Line 2),or percent taxable{Line 3),
pfease obtain a written correation flom the financiat institution and attach it to this form.
1. Enter the date the account was estabiished or titied as it existed at tha date of death.
2. Enter the tptal balanoe of the accouni including any interest accrued af the date of death.
3. Enter the percentage of the accaunt that is taxabie to you.
a. �irst,determine the percentage owned by the decedent.
i. Accounts that are hefd"in trust for"another or others were 104°10 owned by the decedent.
li_ For joint accaunts established mare tha�one year prior to the date af death,Ihe percentage ta�cable is 100%divided
by the total number of owners including the decedent. (For example�2 owners=50°!0, 3 owners=33.33%,4 owners
=25%,etc.}
b. Nexi,divide ihe decedenYS percentage owned by the number of surviving owners or beneficiaries.
4. The arnount sub}ect to tax is determined by multiplying the account balance by the percent taxable.
5. Enter the tptal of any debts and deductions ciaimed from Pert 2.
B. 7he amou�t taxable is determined by subtracting the debts and deductions from tfie 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 �' ' °""' ` �''fr '
your relationship ta the decedent:_ e�t•(.�. ^
1. Date Estabiished 1 ��
2. Account Balance 2 $
3. Perceni Taxable 3 X
4. Amount Subject to Tax 4 $ ��'
S. Debts and Deductions 5 - y'
6. Amount Taxabie 6 �
7. r�x Ra?e 7 X ��
$. Tax Due 8 $ --` °� �
9. With 5°/ Discount(Tax x .95) 9 X
'�Jt@p `t�: Sign and date below. Retum TW4 completed end signed wpies to the Register of Wills listed on the front of this torm,
along with a oheck 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 pe�alty of perjury, 1 declare that thg Eacts 1 have reportsd above are true,correct and complete to the best oi my knowledge and
belief. �'�
f'""_.,, �--_._. / Work Cn�v - :'c:�--O`/;��
/ ��.�1 �^,�.zrJ Home �ro -�3.5� �s�:s' r�S° �Mi
�:� Taxpayer Si'gnature Telephone Number Date
IF YQU NEED FURTHER ASSISTANGE, GONTAGT PENNSYLVANIA DEPARTMENT OF REVENUE
QISTRICT OFFlGE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERViCES FQR
TAXPAYERS WI7M SPECIAL HEARING AND/OR SPEAKiNG NEEDS ONLY: 1-$00-447-3020
$��U aF =NOt�ia�^� T^xes Pennsylvania lnheritance Tax � Pe���Y�����a
aD e�X 280sot DEPAftTMEN7'Of REVENUE
NARRISBURG PA 17128-�6Q1 Information Nofice
' � aEV��1541a E%OacIYE[ (�9�IJ1
And Taxpayer Response Fi�E tva.zi
ACN 13503254
DATE 08-23-2013
Type of Account
Estate of 1015 M HOLLER Secur'rty
SSN SEG Accf
date of Death 07-70-2013 fitock
RdXANNE C MORGAN County CUMBERLAND Bonds
2D3 E WALNUT ST
SNIREMANSTOWN PA 1�011-b768
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.27481270Q2002 Remit Payment end Forms to:
Date Estabiished REGISTER OF WILLS
Account Balance $7,7p2.g� l CdURTHOUSE S�UARE
PercentTaxable X5Q CARL(S�E PA 178'13
Amount 5ubject to Tax $3,851.37
Tax Rate X 0.045
Potsntiat Tax pue g 17S.g1 NOTE`: !f tax payments are made wiihin three monihs of the
decedenYS dafe of dsath,deduct a 5 percent discounT on the tax
With 5°fa Discount(Tax z�.95j $(see NOTE'} due. Any inheritance tax due wi!!become delinquent nine monfhs
after the date of death.
PART gtep 1 : piease check the appropriate baxes below.
t
A �tax is due. + i am the spouse of fhe deceased or I am the parent of a decedent who was
� 21 years oId or younger at date of death. �
Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amoernt
shown above as Potential Tax Due.
g �The infarmation is The above inlormaYion is correct,no deductions are being taken,and payment will be sent
correct. with my respoose.
Prqceed to Step 2 nn reverse. Da not cheak any other baxes.
C [�The tax rate is incorrect. � 4.5°lo I am a lineai beneficiary(parent,chikl,grandchild,efc.j of tfie deceased.
(Select correcT tax rate aY
right,and complete Part � �2 fo !am e sibling af the deceased.
3 an reverse.)
� 15°ta Ait other relationships (including nonej.
d �anges ar deductions The informaSO�is incarrect andtor debts and deductions were paid.
listed. �Comple2e PaR 2 a�d parf 3 as apprapriate on the back qf thrs form.
��
E �Asset wlil be reported on The above-idantified asset has been or will be reported and iae paid with the PA inheritance Tax
inheritance tax Porm Retum filed by the estate representative.
REV-1500. Proceed to Step 2 on reverse. Da not check any other boxes.
Please sign and daie the back ot the form when finished.
PART Debts and Deductions
2
Allowable debts and deductions must meet both of the foliowing criteria:
A. The decedeM was legaily responsible fior payment, and the estate is insufficient ta pay the deductible items.
B. You paid the debts after the death of the decedent and can furnish proof ot payment if requesfed by the department.
(if additionak space is required, you may attach 8 112"x 71"sheets ai papecj
Date Paid Payee Qescriptian Amount Paid
� �lh.t c x,, f��:,�.r_ ' !livs 5{fix�x v �.�z�,t.r l�,.�.r. �"�� ,r' rz
7 f 1 1l3 �� f,3 z ,�,^> '._71 r �'e cr� C��'nt� 1zr !S�7�` 7. " --
� � � Total (Enter on Line 5 of Tax Calculation $ 3 a ,�, �v �
PART Tax Calculation
� It you ere making a correction to the establishment date(I.ine 7)account balance(Line 2j,or percent taxabie(Line 3},
piease ob#ain a written correction from the financial institution and attacb if to this tarm.
1. Enter the date the account was estabiishad or titied as ii existed at the date of death.
2. Enter the total balance of the account inc(uding any'snterest aocrued at the date ot death.
3. Enier the percentaga of the account that is taxable to yau.
a. First,determ+ne the percentage owned by Fhe decedenL
i. Accounts thaf are held'7n trust for"another or others were 100%owned by the decedent.
ii. For joint accounts established mare than one year prior to the date of death,ihe percentage taxable is 100%divided
by the total number of owners including the decedenf. (For axampie:2 owners=5d%, 3 owners=33.33°l0,4 awners
=25%, etc.}
b. Next,divide the decedent's percentage owned by the number of surviving pwners or beneficiaries.
4. The amount subject to tax is determined by multiplying the account balance by the percent taxabie.
5. Enter ihe[otal of any debts and deductions claimzd from Part 2.
6. The amourt taxabie is determined by subtracting the debts and deductions from the amount subjecf to tax.
7. Enter the appropriate tax rate from Step t based on your reiationship fo the decedeM.
If indicating a different tax rate,piease statg.�� ` �Y`'"`���jf�m "'i� r��,�F " �4?' � + �°
your relationship to the decedent: �� __ t ��� ��-��� �
1. 6ateEstabeshed 1 -------- ��� t '. � � � # ` ,� a¢ �y
2. Aecount Baiance 2 � '
3. Percent Taxabie 3 X v�'——�
4. Amount Subject to Tax 4 $ �
5. Debts and Deductions 5
6. Amount Taxabie 6 $ � '
7. Tax Rete 7 X
8. Tax Due 8 $ � —"" � �
9. With 5% Discount(Tax x .95} 9 X �.. � ,� {
�Jt@�'! 2: Sign and date below. Return TW4 compfeted and signed copies to ihe Register af Wills listed on the front of this form,
along with a check for any payment you are making. Checks must be made payable ta"Register of Wilis, Agent:' Do not send
payment directly to the Department of Revenue.
Under penalty of perjury, !declare that the facts I have reported above are true, correct and complete to the best ot my knowledge and
belief.
�Q work /Crull �'9!- `���'
7�-�^f r:n.r.�. C- l'u�..�-' — — Nome 73 '1- .YBS'� �. �" � �� -
,
Taxpayer Signature Teiephone Number Dats
IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA DEPARTMENT OF REVENUE
DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISIdN AT 717-787-8327. SERVICES FOR
TAXPAYERS WITH SPECIAL HEARWG ANd/OR SFEAKING NEEDS ONLY: 1-$00-447-3020
s��� oF �NO:YZOUA� TAXES penns ivania lnheri#ance Tax � ����S�C�Vc'#CtiB
Pp BoX 28v601 y DEPAPTME:NT OF REVENUE
NARRI59URG PA 17128-O6UI �nfQr[�t�t��n N�t�G�e . . . . REy,i„a�a eK m�c�c <ea-�x�
And Taxpayer Response Fi�e No.2t ,
ACN 13503294
DATE OS-23-2013
Type o(Account
EstaTe of IOIS M HO�IER Security
SSN SEG Acct
Date o(Death 0?•10-2013 Stock
ROXANNE C MORGAN Caunty CUMBERLAND Bonds
2Q3 E WALNUT ST
SHTREMAN5TOWN PA 17U11-6768
nnetztPezsE providsd the department with the informatian below indicating ihat at the death af the
above-named decedent yau were a joint owner or beneficiary of the account identified.
Remit Payment end Forms to:
Account No.2148127002002
Date Estabiished REG15TER OF WILLS
Account Balance g 7,7q2.g1 1 CQURTHQUSE S{}UARE
Percent Taxable X 50 —"` CARLISLE PA 77013
Amount Subject to Tax $3,65f.37 ~ L___� �,
Tex Rate X 0.045
Potential Tax Due $ 173.31 NOTE': If T2x payments are made within three months of the
decedenYs date of death,deduct a 5 percent discou�t an the tax
With 5°la Discount;Tax x 0.95) $(see NOTE') due. Any inheri#ance tax due will become delinquent nine manths
� after the date of death.
PART StB 1 : Piease check the a �
� p ppropriate boxes beEaw.
� No tax is due. i am the spouse of the deceased or I am the pareni of a decedent wha was
21 years old or yaunger at date of death.
Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount
shown ahove as Potenfiat 7ex Due.
g �'ihe information is The above information is correcf, no deducfions are being taken,and pavment wiil t�e sent
correct. with my response.
Proceed to Step 2 on reverse. Do noi check any other boxes.
� �The tax rate is incorrect. � a.5°io I am a lineal beneficiary {parent,child,grandchild,ete.)of ihe deceased.
{Selecf correct tax rate at
right, and complete Part � 7 p�o I am a sibling of the deceased.
3 on reverse.y
� 15/o All other relationships{includiog none}.
p �Changes or deductions The iniorrr�ationabove is incorrect and/or debts and deductions were peid.
listed. �'omplete Part�part 3 as appropriate on!he back of this fonn.
E �Asset wili be reported on Tfie abave-ide�f'rfied asset has been or wiit be reported and tax paid with the PA Inheritance Tax
inheritance tau form Return filed by the estate representative.
REV-i 540. Proceed fo Sfep 2 on reverse. Do not check any olher boxes.
Please sign and date the back of the form when finished.
PART pebts and Deductions
2
Ailowabke debts and deduciians must meei bath oF the fiailowing criteria:
A. The decedent was legally responsible for payment, and the estate is insufficient to pay the deductible items.
B. You paid the de6ts aRer the death of the deceder.t and can fumish proof of payment if requested by the depaRmenY.
(If additional space is required,you may attach 8 1/2"x 1 i"sheets of paper.)
Date Paid Papee Desoription Amaunt Paid
� � or f� h'�Ca� r� U�S.:Im.n's /"i,t[a.t/ {Lar� /,f u-"
Y /3 f Zi�_ r� i)i,..� .� lcCn C�2r�+e-(-PT �{7S"'7�'"° '
.---. � �_�_ � ""__.__
_�_ Totai (Enier on Line 5 af Tax Gaicutation} $ j3 �'�-� ?.�—�
PART Tax Calcuiation
3 If you are making a correction to the establishment date{Line 1}acconni balance{�ine 2),or percent taxable(Line 3),
please pbtain a writlen correctioa from the financiai institutioa and attach it to this form.
1. Enter the date the accpunt was established ar ti!led 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 taxabie to you.
a. First,determine the percentage owned by the decedent.
i. Accaunts that are held"in trust for"another or others were 1p0%owned by the decedent.
ii. For joint accaunts estabiished more than one year prior to the date of death,the percenYage taxable is 104%divided
by the total number of owners including the decedent. (For example:2 owners= 50%,3 owners=33.33%, 4 owners
=26°i,etc.)
b. Next, divide the decedenYs percentage owned by the number of surviving owners or beneficiaries.
4. The amount sub}ect io tax is determined by muitiplying the account balanee by ihe percent taxabie.
5. Enter ihe total of any debts and deductions claimed from Part 2.
6. Ths amourt taxable is determined by subtracting the debts and deductions from the amount subject ta tax.
7. Enter the appropriate tax rate from Step 7 based on ypur relationship to the decedent.
If indicating a different tax rate, please siate '` �,` ' ° " y" �`b�.y °` '+ "
your relationship to the decedenk:_ C��.f d, �� �� � � � ��� ` � -�
1. Date Established 1 _� �"^ ,�� ���� �s,�
2. Account Salance 2 � � ��
3_ PercenT Tarabie 3 X �
4. Amount 9ubject to Tax A $_� � � �
5. Debts and Deductions 5 - -?
6. Amount Taxa6ie 6 � �
?. Tax Ra!e 7 X �� �.
8. Tax Due $ $ ���� ��`� �'`
s. with 5/o Diseaunt(Tax x .95} g x � ��R � x.., �,.�
�'Jt8�3 `Z: Sign and date beiow. Return TWO completed and signed copies to the Register of Wiits tisted on the front oE this form,
along wiih a check fpr any payment you are making. Checks must be made payable to"Register of Wills, Agent" Do not send
payment directly to the 6epartment ot Revenue.
Under penaity ot perjury, i dsc4are ihat the facts i have raparted abave are true,correet and compiete to the best of my know(edge and
belief.
7 Work ��ty ��'1- YS" YJ'
_��.,��C—��— Iiome 7 3 J. s �vG 1 - 9 ._ f 3 �
�--- —
Taxpayer Signature Telephane tVumber date
tF YOIS NEED FURTHER ASSISTANCE, GONTACT PENNSYLVANIA DEPARTMENT OF REVENUE
DISTRICT OFFICE, OR 7HE INHERITANCE TAX DIVISION AT 717-7$7-8327. SERVICES FOR
TAXPAYERS WITH SPECIA� HEARING ANDIQR SPEAKING NEEDS ONLY: 1-800-447-3020
- _. .._ _ . _ ._ __
t��1�� f� ��� _
Musselman Funeral Home and Cremation Services
324 Hummel Avenue
Lemoyne, PA 17043
Tel: 717-763-7440 Fax: '717-730-9798
Brian C. Musselman, Supervisor
Clifford D. Forester Sr. Funeral Direetor
Mr. Gerald L.Holler
18 Scazsdale Drive
Camp Hill, PA 17011
Thank you for selecting our funeral home to provide services for your family during your time of bereavement. I liope that you found
our services,so far,to be of the highest standards that we always try to achieve. The following is a summary of the service charges as
prcviously explained and provided in written fortn on the services for:
LOIS M.HOLLER
PROFESSIONALSERVICES
$Included
Embalming $Included
Other Prepazation of Body $Included
Funeral Package B $5495.00
Total Funeral Service Selected
TOTAL PROFESSIONAL SERVICES $5,495.00
Use of Facilities&Staff for Visitazion $Included
Use of Facilides&Staff for Ceremony at Funeral Home $Included
Use of Staff'&Fquipment for Graveside Service $lnciuded
7'ransfer of Remains W Funeral Home $Included
Hearse/Funerel Coach $Included
OTHER MERCHANDISE SELECTED
Casket: Coleman $1,400.00
Outer Buriai Container Sentinal in Silver $1,295.00
Acknowledgement Cards S Included
Register Book Roscs $Included
Memorial Folders Roses $Included
TOTAL OTHER MERCHA]VDISE SELECTED $2,695,Up
CASH ADVANCES
Certified Copies of Death Certificate $IncWded
Clergy}tonorarium $�pp,pp
. NewspaperNo4ice HarrisburgPatriotNews $ �7p.pp
Flowers:Pink Rose Casket Spray $225.00
Vault Inspection Fce $30.00
CASH ADVANCE TOTAL �525.00
TOTAL OF SERVICES $8,715.00
BALANCE DUE $8,�15.iD0
If there aze any questions or concems that remain unanswered,please call me.
Sin erely, �
\�� � -J �—
� �-�-/ i
Musselman Funeral Home and Cremation Services
324 Hummel Avenue
Lemoyne, PA 17043
Te1: 717-763-7440 Fax: 717-730-9798
Brian C. Musselman, Supervisor
Clifford D. Forester Sr. Funeral Director
Monday, September 9,2013
Mr. Gerald L. Holter
18 Scarsdale Drive
Camp Hill,PA 1701 I
Dear Gerald,
Thaok you for selecting our funeral home to provide services for your family during your time of bereav�nent. I hope that you fo�nd
our services,so far,to be of the highest standards that we always hy to achicve. The following is a summary of the service charges as
previously explaincd and provided in writteo form on the services foc
LOIS M. HOLLER
PROFESSIONAL SERVICES
Embalming $Included
Other Preparation of Body $Included
Funera]Package B S Included
Total Funeral Service Selected $5495.00
TOTAI,PROFESSIONAL SERVICES $5,495A0
Use of Facilities&Staff for Visitation $Incl�ded
Use of Facilities&Staff for Ceremony at Funeral Home $Included
Use of S[aff&Equipment for Graveside Service $Included
Trensfer of Remains to Funeral Home $Included
Hearse/Fu�eral Coach $Incl�ded
OTHER MERCHANDISE SELECTED
Casket: Coleman $1,400.00
Outer Burial Container Senti�al in Silver $1,295.00
Acknowledgement Cazds . $Included
Register Book Roses $Included
Memorial Folders Roses $Included
TOTAL O"IHER MERCAANDISE SELECTED $2,695.00
CASH ADVANCES
Certified Copies of Death Certificate $Included
Clergy Honorarium $ 100.00
Newspaper Notice Harrisburg Patriot News $ 170.00
Flowers:Pink Rose Casket Spray $225.00
Vault Inspection Fee $30.00
LESS: Credits granted CASH AllVANCE TOTAI. $525.00
Ck#8593,2855,2145,2854 �fi,715.00
$8,7I5.00
'COTAL OF SERVICES
so.00
PAID IN FOLL $0.00
If there aze any questions or concems[hat�emain unanswered,please call me.
Sincereiy,, ; ��` �/ "
_./r;. _ . ` � .
����—��-''_ }— . . '--'_,
Net due 30 days. l�t�e charge of 1.5°l0/mont '18%per annum
Late charge on any amount unpaid past the due date.
_ � _DONALD S FRITZINGER _ . S�j�? �
AtJIY S FR�TZINGER 3-50/310908fi
r 7 7�3 KEGN:S RD 1 000905 63034 9
FFFiW(iSVILIE,PA 18031 ('�_ �j _ /�
7
� oaTE
� P �J �tii p , � � �� �� �� �',
ono a oF �,���5��, ���n S ,.c OS�C-� p�w I�$ � ��j _
`\,` ^ 1 ��
,
I �� 1 _'��`k���'�.i.'��..t� �:�1�sl\\1 a1+PU�"���U=__�LLARS Qi .
� wensFa9oeankHw � :�/
PmnsyNan a �
iw211sMgp[o
< �,i,�'Erzr�< ��-��-�'� .._� ,'
F�F� L.a 1S 1^loc'.L6� _ ��f'-'--- '' �-'�'
" �e03i�0005D3�: i000305630349��°088�3 �i
�,�; ,. d-- �-__ ---- :
,.�-s- _-__a.a.�_-�, __ _..-�-� P5 t;
_--- - -_ __ __ _ �___�
�� �-
� ¢
-.— W
�
W
-� w
o '
� � M � ❑ �� W
f' �0 il1 � w W W
Q J f�0 m W h �y � Y �
� tL1 W f� � N J a 1-! Q F- 2 �
d' n z^ • . F �p m � �y � . N = 6 j �:
o CC
Z�nQ� o V.-� pp � � F- u m o �' Q � U !4 r�.
�u'"y a f�m u o Q o z H G �,. J a . Q � � '�
V � " QN L7 a9 2 \ ��O p W
N y � Z Qf �Z E � ~ F
o i LL H� . `� � � O
e Z o z �w � -- w
3 ° � a c°� =rc ��� ` " [�.1 LL 1 �
pO Z �» � s � \ \.
� o W a � c� �,
o � < x= _> W , U o � ,
Z Z � O 1"�W V . ' �l � r� � J �
W \
Q O a aQ O< � Q ��� W Z
tr g ° o w � '�/J � N 7
o-y a �i H W EL vi '. " ��•.�\ pQ V •
1 ❑ Y w� t�9 N a (' ` �„ m '�r ^' Ill W
`� � � � Nt _ C� � o a W
N
� w�� = W e � � ��`,� ° ui w a N z
U
� =n� i u O � � o _ `ei = V
!1 W U W E >� U Q
� NNU � N ��c � �� p
W
❑ a O Z I�' � °( x
tu ' � �' � O
� o U 5 Z
a
J m Q � IL N
CI J O� w C� I-
N LL N Z �� C�
r
Q1 I 6 ¢
W -1
.2 0 0 . Zc " a , ,' ,. w
CI ; N �p � - �� �2 Y
N o "' ,y LL . - W m
C °Y,�n f, ,. Z
NR u,y � Q
EN=aN � 1 � y LL
y�n� 20W W .J � ❑ W W
y �N Na'J X N �
�p�N 1-N wr W .. ,_ !- 2 S
H41rS 2�UN X .-. _. � �V� W N V W
' C6�Q LLWC9 Q � � � U j U
� YH F y F Q a m o
��o N O
�y = Z W �o
C _°'"�„q >n W a � � O F' W o
W ya°cOW Q.ym � � � � O W W m
G O�z N F- � W �` 0 t� U F- Z
CW
u N W u W U � W 2 Q ¢ O �
•t � ¢ r
y CayNfr p
E ����-+ U
qg3�coo . .. �� ... ..
. . .. _ . _ .. --
American Enterprise Investment Services, Inc. CONFIRMATION
Minneapolis, Minnesota 55474 c�s�v
WEHAVERECO0.DEDYOURTRANSHCilONASFOLlOWS: FULL REDEMPTION 19765L850
TRANSACTION DATE CLA55 GRICE SHARES AMOUNT
8/28/2013 A S13. 120 287. 185- S:S ,767. 87
SOLICITED ACCRUED DIVIDEND 512 .71
�� �-----
- --_
i�CHECK AMOUNT � S'�$�
, ____ _— �
ROXANNE C MOR6AN (, Y937/ TOTA�SHA0.ESOW17ED ACCOUNT�NUMBER
203 E WALNUT ST ,,�'�+'' 3� .000 0201-5628,530-4
SHIREMANSTOWN PA 17011-6768
NON-NEGOTIABLE
COLUMBIA TAX-EXEMPT FUND
PLE45E REAO IMPORTANT E%PL4NATIONS NND D�SCLOSURES
ON TNE BACK OF TNIS CONFIRNIP.TION
GAIN/lOSS INFORMATION MILL BE
SENT AFTER YEAR END
KEEP THIS STU6 i0R VOUR RECORDS. OGL i00�80 b2R008�F]27
� a � m � Oa� -f D-� iF
� d \ � O N
� �' 7. H .-r cn w c� o �
� s " ., a> > o m
c m m° m �' 3�-r C Cv"O
c A� 3 r�-F 41
m m .'c J' w, O E O
a � e m � Cn � C � �
O rt3 CAC]
E. 'm N a o t�D N�N =
� .i o �°c � c) � N= �
c � y m ? � �F n A O �
y i N y�rA-� /�\
» � � � � � t� . Q�N Co 1 /
X L�Z�A �
3 '� m° m m � �. , O'00 C]�
� �° c� � a
e � ° .. m rn^ �
�
� 6 �� N q � � � 5 3 J� 0
o v S v � v m� +�
m y .mi m N O X � ~ G
m +. � .�i � X \ �
c � m .s O m X �wl �
O X.
� o N O T �'
� (D� \.
� �� �
� �
V
:�r �`- Fa.:�.,sx ✓��.._zs3Fm�su.EU,cns'd. ,._ .
- .._`.,3T .�s�.,.,.a,�C?-�`�R",,,�'±"„ �- x"�9 ,-,�" f ea�di �, .
_` '--�i_3—.�:--��... y - ' - _
STEVEN P.MORGAN �� "'–` — -'
ROXANNE NOLLEp MORGAN 2854
717-737•5840 60d1]3/313
203 E WALNUTST. -- , l �/ ,3 . taa
SHIREMANSTOWN,PA 77011
n.,��
Pay to ihe uS���n
O,dc,�o£ rn _ 5 ���eru /J-owt cr
[� ._ � �9 �ap,•-�
br7 iNK ( OJ
�PNCBANK �a�� `;
PNC Baot,NA. Oqp
c��_ �.6�s � � 22� �, ��(��
____. .. ..�te!tk�-Vk-/� rr
�:03 i3 i 2738�: 500448009 i��'
2854
ROXANNE NOLL R MORCipN T' —'_ �"_- ` .2855
717-737-6840 611-02]3/313
203 E wAwlJ�$�'. � 143
SHIHEMANSTOWN,PA 170Y1 , h/ 3
Datr
Pac to d:e
o��<i�,��r m�s Sz�.�� � s � .A /-L� � � � 3 7��,s�-
%6..�..,_ se,-, !-(, � .�,t �5[r,, l� �r � �"' �
QPNCBANK —��"ars "
, �
PNC Bmk,NA 01p
7
io� L°,-s l�Ik � _
�:0 3 i 3 1 2 7 3B�: r � . �`2`-�,.,-i_��-� rl�v r�� .__:•-
500448009i�i 855
Balance due Musselman's for LOIS HOLLER'S FUNERAI,:
$8715.00
Checks enclosed to pay this bill:
#2145 from Gerald Holler $1053.85
#8893 from Amy Fritzinger $3780.57
#2855 from Roxanne Morgan $3780.58
#2854 from Roxanne Morgan $ 100.00
TOTAL PAID: $8715.00
BALANCE DUE: �.00
PAID IN FULL
We need paid receipts ASAP. Please call 737-5840 or 991-9545
when ready.
�;t! ., , .�v_�
li"
I1 %�
„ �.
:.
f _
j';
� R ,
, ';�
t; �
,;
� �,
� r.
h�
--- ;�;)
�, .
;::; , ,-� ,,�,,.
�
�
�; � �r
. . �:�.. ��
,
U �_ �
,:M �: r.
�� c,
� ,.
_ ,� ��
—, �-� �
�� �_ ,
r'
_ ` '_` �-',
-ti. _ _' ''� '�`�`"�_
t . f. .. .. ".,��i
V
- O
�
_ �
_ �'.:.
- i: Stkrs
; s ,
t .
— . . �,x��r��
�- . ., ' -,�.., �,: -
�` �.���,;,,„.
":4 �K i � �:�s�,
s� _ �_ .
: /ry
-.t
�
;�
,��: