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Home My WebLink About10-07-13 (2) . BUREAU OF INDIVIDWL TAXES Pennsylvania lnheritance Tax � pennsylvan�a PO BOX 280601 DEPARTMENT OF REVENUE HARRIS3l�6 PA ��Zg-o6o� Information Notice REV-1563A EX DocEXEC(�6-1 ) � ' And Taxpayer Response FILE NO.21 a--'� ACN 13503� ' DATE OS-23-2013 TYPe-of Accpur�t ,` Estate af L01�M HOLLER : Securiry SEC Acct Date of Death 07-10-2013 ; Stt�ck AMY S FRITZINGER County CUMBERLAND � �onds 1775 KECKS RD HREINIGSVILLE PA 18031-2219 ` - , . � r .�'.�� ..+ �5-. .. '- ' :-.' ' . . _+ AMER I PR I SE provided the department with the inforr�a#ion below indicating,that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Acc�unt Na��244&127002002 �m�Payment and Forms ta Date Establish�d REGISTER OF WILLS Account Balance $7,742.61 � ��1�OlJSE Sf��kRE Percent Taxable X 50 CARLIS,LE PA 17013;, Amount Subject to Tax $3,851.31 ' ' � ` " "``' . +�'� �. .`. � �"t Tax Rate X 0.045 NOTE*: If tax payments ar�rl�"td�nrith'm f�:mt� f the Potentia(Tax pue $173.31 d��ent's date of death, �5 percer�i tF�e tax With 5%Discount(Tax x 0.95) $(see NOTE*) due. Any inheritance tax d�t��,t e deTi�q�u��months after the date of death. � �y�.�r r� � �.� .�- C-i"t �1 '� �.;� � PART . � �` � � � � � Step 1�Pl+ease check the appropriate boxes below. � �, � � ,,,,�, c�a .,� c� c: A �No tax is du�. I am the spou�of the deceased or 1 am the par�t�if a decede�v�o was 21 years old ar younger at date of death. � ° "'"' Proaeed to Step 2 on reverse. Do not check any other boxes and disregard the amounf shown above as Pofential 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 t�uc rate is incorrect. � 4.5% I am a IineaF beneficiary(parent,child,grandchild,etc:)of the deceased. (Select correct tax rate at - right,and complete Part � ��o I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(includrng none). � p Changes or deductions The infor ' correct and/or debts and deducti�is were�paid., listed. lete P part 3 as appropriate on the badc pf thfs forr�. �. E �Asset witl be re�orted on The above-identified asset has been or wili be reported and tax paid with the PA tnherits�nce Tax � inheritanae tax form Retum filed bythe estate representative. REV-150d. Proceed to Step 2 on reverse. Do not cl�eck eny other boxes. � � � P{ease 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 q3. /1'1Grs- � �f-2r �., ��'�Se/�'►►;:n 'j l�►:7p�'P� (-�+°:x� �� / . � . �-��-z, ¢�' �j1� �ore-en C`�r►�e {er �'7�'I. °�'' Total (Enter on Line 5 of Tax Calculation) $ �-3 �Sl��, ��' 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 t��ar�c�al insti#u#ior�and att.ch it#o this#orrn. 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 decedent's 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 . ��\�,��;,��, ��,��,��,��,�;��; � �\ �� \`\ \\�� . �\��\ �\�\�\\�\�\��\��. your relationship to the decedent: �h-� c�. `�� ^ �� \\�\.\� \\\ \ � � ��\\��\��\� � \ \ ��.��3��\�\ \� ��\�� 1. Date Established 1 <��,�;�„�;�� :, .�� \��\�`,� ��o�� .� � \ �� \� ��\��\\\��\�\\��\\�� \: \\\��" `�� : \`�` ��a� ��\\��•��\��\\�� 2. Account Balance 2 $ � �� °, � � , �� ,�� \ � � �� \ . \\\\\�� \ �\\ \\��\��\�\Q\\� \��\�. �\�\�� \ ��\�� .� ��\�� \\�\��\��\��\�\ X ��\�� \ \\\ �\�� 3. Percent Taxable 3 - "�� \.�� .��.\�� . ��`�� \��\�\�\��\\`��\��\\\�� " �� \�� \ �� \ �� \�\\\\�\ \�� j �� .� \ \\�\q�� \\ �\�\��\ � �� . 4. Amount Subject to Tax 4 $ " � ``��° ; , � � '� �� -� ��\\��\\�O� �� \�A�� A� ��\ �� A�� 5. Debts and Deductions 5 - ..�-.��` �'� \ \ \ \ \�\\\\� \\ `� ��„ �\� � \� : � \� �: �-\�� \�\ ��\\ � Ca ��\ ��\ �� \ . � \�\\ \\\� \\ �\. �.�o �� \�� \� � � � � � � �� \�� \ �\ 6. Amount Taxable 6 � ` �� ` ��`�� A��A�� . ., �� \� �� \ \ \ � \ � \� \ � � � �� . � � � \� � \ \ ��\\ \\�� \\\ � �\��\�: �� \� �� \� 7. T1?C �2t� 7 X �� .�A�� A�� \ V��`��\�� :\�� `��\ � �� . � �� 8. Tax Due 8 $ ":��`� � � � '� �� __ �� V� ��V� ��`�A��V� `\� �� V��\ ��A�o��V��A\ �� ' � � � \\ \� �� \\\�\�� . � � �� \��p\��\\ �\.\��\ �\ ��\\�� \�� \� : �� 9. With 5°/ Discount(Tax x .95) 9 ` 0 .,��\��.��...�\�...��.�a��...� �..��\\�... .:.,��.,..�.�.`�\...� .�.:.��..��\�\\�\�� ....�� 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 C��v -t ; �::`�-�-v�f��'� � � � f\ - _ . = Home Cc�v ��%�°��. �� 7�� /�� , Taxpayer Sig 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