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BUREAU OF INDIYIDUAL TAXES Pennsylvania lnheritance Tax � pennsylvan�a PO BOX 280601 HARRISBUR6 PA ��28-060� Information Notice DEPARTMENT OF REVENUE REV-1563 EX DocEXEC(�e-12) And Taxpayer Response FILE NO.2113-0989 ACN 13153973 DATE 10-11-2013 Type of Account Estate of ANNtE:G PATTISON Savings SSN Checking Date of Death 09-05-2013 � st BR'UCE �A WYRICK County CUMBERLAND � �, �ertificate 7 E WALNUT ST � � �:�., C"� LEBANON PA 17042-5476 p� ..,�� c� � � r'•' � c, ,�� , :v �„ r � �w� � � � � � :.� � .�. . ;� �, �, � � � � � � �� '� :� :� .. -� ��::�:'��k '�.,� �-" �...-_i �-»� �� "�'J °�i �`�`' �.�. !�°"{ �lnn:s;:- :: �..=�'�K.. .., ,.,aeMrw:yd.,.a.v.:.s^�...�.,.,�,,,�0±�1�.„,�€=.�.v:<!a .-�':a w":::.�:�... >:„; �:-.-4us��.�:-�u+.a.;., a.. .. �'�'ac�:.•;.�cd.�:..,�...;,.re�{-.s.a;v.._ _...c4a—�.. - .. � .. .�""=��• - .,- .....�. .s � � � .:. ,�f. . . w..0 ,. �._ '_ � ORRSTOWN BANK provided the department with the information below indicating that at the death of the above-named decedent ou were a joint owner or beneficia of the account rde�tified. Remit Payment and Forms to: Account No,-4000044279 Date Establist�d 07-11-2012 REGISTER OF WILLS Account Balance $124,759.73 1 COUR'TH4t�SE SQUARE Percent Taxable X 50 CARLISLE PA 1T013 Amount Subject to Tax $62,379.87 Tax Rate X 0.150 Potentia,l Tax Due $9,356.98 ��TE`: If tax payments are made within thcee montfis.of the decedent's date of death,deduct a 5 percent discount on the tax With 5%Di�count-(T�c x 0.95� $(see NOTE*) due. Any inheritance tax due witl become�elinquent nine months � after the date of death. PA� St�� 1: Please check the appropriate boxes below. � _ A ��tax is due. 1 am the spouse of the deceased or I am the parent of a decedent who was ' 21 years old or yQunger at-date of death. � ,, Proc.�eed fo Step 2 on reverse. Do noi check any vther boxes and disregard the amount shown abav�e as Potential Tax Due. �... �..�,� � . . _ ...�. . , . _ _ _ - _ - , s. _ _ -._ � -.+_��-:.n-'•-y.rerf...._..:':_`�bt..�u...�..;..s,.. ..�,,, �.« �.�, ,_.:k: -'s-+ --.y...:.. ,� .... .. ... . �._ . .. _ � ...__,..... . .� . .... ..,�.,.,._... .,.«--:Y. ..... -...-. ,.:�....-�.;. ::::... ..... «--: g � ;Tfi�`informabon is The above infr�rmation 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 oiher boxes. C ��'he tax.rate is incorrect. � 4.5% !ar�a lineal beneficiary(parent,child,grandchild,etc.)of the dece�sed. (Select correct tax�ate at right,and complete Part � ��/o 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 ihe back of this fprm. E �sset will be reported on Tfie above-identified asset has been or wi�l be reported and tax paid with the P,A-��nheritance Tax inheritar�ce tax'form Retum filed by the estate representative. � REV-�500. Proceed to Step 2 on r�verse. Do nof el�dc.arty oN�er boxes: Please sign and clate 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 31, p1e8S@ Obtaln a WI'I�f�fl COI'1`�ECtl�iil ii"OiTI tll�'�iiiai�Ci�I i��s�i�u�io�a�d a�tach��i�Yii��ii�iiiTi. 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 ditferent tax rate, please state ; '; ' ��}�� , ' ��;��; �. your relationship to the decedent: . �, � � ��.�� 1. Date Established 1 �� , � �;� � �� ,; ' � � �� . 2. Account Balance 2 $ � . � ��;� �'�� ` �:; �� `�� 3. Percent Taxable 3 X � . �, �� ;�� : � � . � � �. . �, 4. Amount Subject to Tax 4 $ � ;, ; _ .�.� . _�� . .,.. . . .; . � : � � �' , 5. Debts and Deductions 5 - �. � \ � 6. Amount Taxable 6 � � � �� 7. Tax Rate 7 X � _ _— -. �;�,�, `,. 8. Tax Due 8 $ � � � �° � ' ,.,.. , . . , . .':...: 9. With 5% Discount(Tax x .95) 9 X ;.. . .., .:..... .. . ... ..: . ......:. .. ....:.. 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 �c -Z.;�,- �` Taxpayer Signature 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