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BUREAU OF INDIVIDUAL TAXES Pennsylvania inheritance Tax � pennsylvan�a
PO BOX 280601 DEPARTMENT OF REVENUE
HARRISBUR6 PA i�i28-o6oi Information Notice
REY-1543 EX DocEXEC(�6-12)
And Taxpayer Response FILE NO.2113-0690
ACN 13145248
��r;��5�y :-�� ��° �.�- • DATE 08-26-2013
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� ` �' : t �,-=;Est�te+o��tiZABE'�H E V1IAT�'$. � Savings
Checking
� ,Date of Death 06-04-2013 Trust
. � �- .. ,. n#y CUMBERLAND Certificate
__....R.OB�R.T '� .�ATTS . _
834 GRANTHAM RD ������� ���t
GRANTH7RM PA� 17027 __._ �`i��B���..���.� �`s�.. .,,,�s
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CITIZENS BANK,`OF PEFtNSYLVANIA provided the dep�rtment with the inf�rma��pn b�low indicating that at
the death of the above-named decedent you were a j�pint owner or beneficia; Qf the account identified.
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;. �. . . d Forn�s to:�
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Account�No.�1 t�?Sfi382 R�m t� a ment an
Date Establtshed 12-17-1982 REGtSTER OF WILLS
Account Balance � , $3,814.18 , . 1 CUURTMOU�SGlUARE j � : :
. : . CARLI�LE PA 17013 • ;� � .
Percent Taxable X 50
. ,. .,.
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Amount Subject to Tax $1,907.09 ' � �
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Tax Rate X 0.150 . . . .. � : •. ..... � �r
� �JOTE*: 1f t�c payments are mad�v�i"'�tfh���#hr��nont�s of the
W�tF�5�D`�ount`�(T�x'x O:SS �,2$�.� ;_:,.. .,. , . _ decedent's date of death,deduct�a 5�p�en�,�}sc�unt an the ta�c
.
. � .,
° ) ,;�f�ee`�1��`) due. Any inheritance tax due will becom�de"linquent�rnne�on#hs
i after the date ofdeath. °
PART ,., , ,
� S�tE�-�.; Please�t�k the appropriat� boxes below.
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A Q No tax is d�e. 'i am the sp�se Qf the decieased or 1 am the parent of a decedent who was
21��/ears t�ld ar yaunger at date of death. - �
Pro�ed ta Ste�v,�on r.ev�rse. Qa not cher:k any other boxes and disregard the amount
. ; . ; . : shown�ove a�Potential Tax Due.
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g �-3'he inforrt�ti'on is - The above inft�rmation is correct,no deductions are being taken,and payment will be ser�t
correct. with my response. ,
` Proceed ro Step 2 on reverse. Do not check any other boxes.
C �The tax rate�incbrrect. � 4.5°I'o 1 am a lineal beneficiary(parent,child,grandch'rld,etc.�of the deceased:���� �
(Selec#co Jrre�t t�x rate at� '� � �
right,and complete Part � 12% I am a sibling of the deceased. �
3 on reverse.)
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a 15%o All other relationshi s(including none).
.
�Changes or deductions The information above is�ncor�ect and/or debts and deductions were paid.
� listed. , _v _ Cpmplet�P�rt.2����art:.3. a�.apPropriate on th�_back af fhis fnrm..:,-.� . ;': ' � �
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�s'��;�vm b�re�aar��;pn "��,�bo��;=�d�n��d�as��t h�s be�t��r witt.b�r$p�fe���a�a:�'C��_p�i�d�rri�t�,t1i�P�;'�����i�ce.'T�c<
'� � ��r�ne�t�x:fdt�h�° �i�t�ir�t"�i1.�d by th��ie'sfa�e repr�s��i�ative. .
� �� �V-`�5n0:� " ��- � � Pro�eed�'�'o'�Step�2�:on caeverse.�D�r`not el�ieck��a�ry ot�r�boz�'s.� , �;
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_ Ple�se,s.ign and,�ate the back of;the form9wt�en finist��d..�._. ..
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PART
2 : Debts and Deductions
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Allowable debts and deductions must meet both of the foliowing criteria:
A. The decedent was legally responsible for payment,and the estate is insufficient to pay the deductible item
B. You pard the c�b#s after the death of the decedent and can furnish proof of payment if r ue ` S
(If add�idr�al space is required,you�iay attach 81/2^x 11"sheets of papes��by the department.
; Da�e�R�+ti Payee , � -
Description �
Amount Paid
Total Enter on Line 5 of Tax Calculation $
PART
3 Tax Calculation
If you are.making a correction to_xhe.establishment date(Line 1)account balance(Line 2),or rcent t
— P�ease otitain a written cornection from the ffnancial institutioe and attach it to ih�s form. � �able(Llne 3),
1. Enter the,date the account was e�tablished 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 d �
3. Enter the percentage of the account that is taxable to you. eath.
a. First,determine tne percentage owned by the decedent. a
- i•' Accounts that are held"in i�ust for"�another or�ottaers were 100%awned by tMe decedent.
ii. For joint accounts estab�ished more thar�one year prior to the date of death,the rcenta e
by the total number of owners including the decedent. (For example:2 owners 50%,3 ow�e�ble is 100%divided
=25%,etc.) 33.33�0,4 owners
b. Next,divide the decedeni's percent�ge awned by the number of surviving owners or ben'fi� '
::,
•� e ciaries.
. �' , pY►�9 .. _
he amount subject to 3ax is determm�c� mutfi f i the account balance by the percent taxable.
5: Enter the�total ofi any debts and deductions claimed from Part 2. '
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6. Th�a�riount fazable is determined by subtracting the debts and deductions from#he amaunt sub'
7. Enter the a ro , . �ect to tax.
RP p�ate�au rate from Step 1 based on yaur relationship to the decedent. `
_. .
Ifi indicating a differe.�t'taic`rate,piease state �
,
your relationship�to tlie decedent: `
1. Date Established � �
2. Account Balance 2 $
3. Percent Taxable 3 X -
4. Amount Subject to Tax 4 $
,.., �
5• De6ts and�e�uctions 5 - : ,
6. Amount Taxable 6, $, .
7. Tax Rate � X
8. Tax�ue �: a ,$�
9• With 5%Discount(Tax x.95) 9 X
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Ste� 2;,Siqn a►�ddate betow, ,Return TWO compl�ted and si ned co ies
along with a check for any payment you are making. Checks mus9be made to the Register of Wills listed o�the front of#his form, —
payment directly to the Department of Revenue. PaYable to Register of�lls,Agent. Do not send =
Under penalty of perjury, I declare that the facts I have reported above are true,correct and com I
befief. - p ete to the best of my knowledge and
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Taxpayer Si ature Tele hone N -
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YOU NEED �FU�R`I�HE1� A ' :. . , . . —
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,; .j t j Date
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S�ISTaNCE �ONTAC�' t��NIV�Y . . . ; � ,.
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DISTRICT OFFICE, ' ' �� � =
OR� TH� ,IIV�HE�lTAIVCE TAX DIVt��C�t;:;�AN�,�-.���PAI�"�Il'�i��` �� ���{��UE
TAXPAYERS WITH SPECtAL HEARING AND/OR SPEAKING NEE S� �1� ����832�. 5����S .F17R =
ONLY. 1-800-447-3020