HomeMy WebLinkAbout11-12-13 403 McCulloch Road
Shippensburg, PA 17257
PA Department of Revenue
Bureau of Individual Taxes
PO Box 280601
Harrisburg, PA 17128-0601
Attn: Joan,Post Assessment Review Unit
The purpose of this letter is to inform you that I have renounced my portion of the inheritance for
File No. 21 (the accounts listed below). The monies involved were moved to sole ownership of
Doreen E. Holtry, spouse of the deceased.
Acct Balance on
Correspondence
from PA Dept of Current
Account# Revenue Balance
303530137 $10,999.22 $11,010.48
10006332158 $18,526.01 $18,566.95
60002366007 $34,089.31 $34,105.75
60002366056 $18,795.04 $18,931.30
60002366098 $18,317.64 $18,376.88
60002366114 $18,317.64 $18,376.88
60002366247 $ 6,657.85 $ 6,669.09
Attached is a copy of my letter to Susquehanna Bank, a copy of the Bank's form removing my
name from all accounts,and a statement for each account from the Bank indicating the current
balance. This documentation is submitted as verification that all funds are owned solely by
Doreen Holtry. I have also returned the original"Tax Information Notices" sent to me.
Thank you. w :;0 rn
sri c�
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Barbara J. Fisher 7` -�
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Daughter of Richard and Doreen Holtry , ° rn
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icc: Register,of Wills.(Carlisle,PA)
a '
403 McCulloch Road
Shippensburg, PA 17257
Susquehanna Bank
Chambersburg Financial Center
801 Norland Avenue
Chambersburg,PA 17201
To Whom It May Concern:
The purpose of this letter is to inform you that I am renouncing my portion-of the
inheritance for the Certificate of Deposit accounts listed below as a result of the death of
Richard S. Holtry. The monies involved should be moved to Doreen E.Holtry,spouse of
the deceased.
Account# Account Balance
303530137 $10,999.22
10006332158 $18.526.01
60002366007 $34,089.31
60002366056 $18.765.04
60002366098 $18.317.64
60002366114 $18,317.64
60002366247 $ 6,657.85
Thank you,
Barbara J. Fisher
Daughter of Richard and Doreen Holtry
1bjf
Bank Name and# 01 Susquehanna Bank Branch# 347 _. ., Date,,.10123113. .,
Primary Customer Tax 10 Number 152.225313 User ID Lianne Gamer
Customer Special Request B10 Rev.1122013
Customer's Name [ {}RREEN E HOLTRY Wm CIF#(s) EH1J1895
1 ADDRESS CHANGE
❑ Primary(no account number needed) Q Include enclosures with duplicate statement copy
❑ Alternate Acd# _ (enclosures will not be included ineitary statement„ w _
❑ Statement acct# _ D Seasonal ..Acd#
❑ Duplicate statement-list address be!"f ee for service .... Start Date _�wStap pate e.. E
❑ Roll far next season
Change Mailing Address from: _ Char�p Mailing Address to:_ If P.O.pox list, sicla address hare:
Home Phone Home Phone
Business Phone .w_ Business Phone _... -�
2❑ADD NAME (POA note:Signatures are not required,but must be supported by POA documentation.)
2a.Acknowledgement of Account Owner(s) _ Acct# Tie Relation
By signing you are authorizing the person named Joint POA JU
below to added to the arxaunt(s)listed at right. Jointt wPOA
Joint POA
Person to be added: Joint 13 POA
TIN of added person _ Joint PDA
Joint Lj PDA
X 'P A ap pro ntments must be supported by a Power of Attorney
Signature (Ail existing account owners must sign,) Date document,either externally or Internally executed, POAs mygj
haveacompletedQu s omen raement and RM e C l P_
compliant ider)I,aHon. If an external POA is not supplied,
Signature (All existing account owners must sign.) Date customers may execute the 826 Internal bank PDA appointment,
2b.Acknowledgement of Added Person (A Customer Agreement must be completed if one is not on file,and proper ID must be provided.)
By signing you acknowledge that you are being added to the account(s)listed in the preceding secdon.
X CIF#of added person: ( _
Signature Date
3 REMOVE NAME (Signatures required in this section)
Person to be removed: LffA—RSA1kK-j-0f SHER— From 303830137 10006332158 60002366007
Tax ID Number .6001 � Account(s); 60002366056 60002366098 60002366114 AND
60002366247
3a.Acknowtedgemant of Removed Person(s): By signing I Other considerations:
acknowledge that I wish to have my name removed from the Removing a name from an account may affect other services,such
account(s)listed above, as ATM or Visa Check Cards,electronic payments or debits,direct
i, deposits,sweeps to lines of credit or other accounts,or combined
X�
'41 i; 't j:3 , �) +'�_ '` " ,z statements. Checks should be nh-ordered.If applicable.
Signature Date
3b.Acknowledgement of Remaining Owner(s): Itwe acknowledge that the person listed above is being removed from the account listed
above,and that Uwe will remain on the account. Itwe authorize any checks issued before this date to be paid for any of the then authorized
owners t signors.
'2e>+ i X
Signature&Printed Name Date §Ignature 8 Printed Name Date
i
i
4 0 OTHER BARBARA J FISHER IS RENOUNCING HER PORTION OF THESE CDS.
i
X X
Signatum&Printed Nome Hate Signature&Printed Name Date
BANK USE ONLY Q Exoeptton Signature; X
Printed Name and Title: Date
BUREAU INDIVIDUAL TAXES
28 PO BOX 280601 y Penns lvania Inheritance Tax ■ ennsyLvania
HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE
„--__ REV-1543 EX D-EXEC (08-12)
And Taxpayer Response FILE N0.21
ACN 13150507
DATE 09-27-2013
Type of Account
Estate of RICHARD S HOLTRY Savings
SSN Checking
Date of Death 08-07-2013 Trust
BARBARA J FISHER County CUMBERLAND X Certificate
111 SPRINGHOUSE RD
SHIPPENSBURG PA 17257-1120
SUSQUEHANNA BANK 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.303530137
Remit Payment and Forms to:
Date Established 11-30-2000 REGISTER OF WILLS
Account Balance $10,999.22 1 COURTHOUSE SQUARE
Percent Taxable X 16.667
CARLISLE PA 17013
Amount Subject to Tax $1,833.24
Tax Rate $2774.94.9 9
Potential Tax Due $ NOTE*: If tax payments are made within three months of the
decedent's date of death,deduct a 5 percent discount on the tax
With 5%Discount(Tax x 0.95) $ (see NOTE*) due. Any inheritance tax due will become delinquent nine months
after the date of death.
PART Step 1 : Please check the appropriate boxes below. iaee q shed Jccuf'1-en�n�071
1
A [-]No taxis due. I am the spouse of the deceased or I am the parent of a decedent who was
21 years old or younger at date of death.
Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount
shown above as Potential Tax Due.
B ❑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 F]The tax rate is incorrect. F—] 4.5% 1 am a lineal beneficiary(parent,child,grandchild, etc.)of the deceased.
(Select correct tax rate at
right,and complete Part ❑ 12% 1 am a sibling of the deceased.
3 on reverse.)
15% All other relationships (including none).
D ❑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 the back of this form.
E [—]Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax
inheritance tax form Return filed by the estate representative.
REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes.
Please 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 81/2"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 3),
please obtain a written correction from the financial institution and attach it to this form.
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"intrust 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 0%,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 Official Use Only p AAF
your relationship to the decedent: PA Department of Revenue
1. Date Established 1
2. Account Balance 2 $ PAD
3. Percent Taxable 3 X 1
2
4. Amount Subject to Tax 4 $
3
5. Debts and Deductions 5 - 4
6. Amount Taxable 6 $ 5
7. Tax Rate - 7 X 6
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.
11 (} Work
Home r//2-5.3a -Sono //�7�•�/3
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
41
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PREVIOUS < SUBMIT > BUT
SPECIAL MESSAGES.�
CUSTOMER INFORMATION ACCOUNT INFORMATION
111 SPRINGHOUSE ROAD Current balance 11,010.48
SHIPPENSOM PA 17257-1120 Current cash value 10,936,83
Original balance 10,000.00
Certificate number
CID term 36 M
CIF number H1J18% Maturity date 6/30/16
Tax ID number 162-22-5313 Issue date 11/30/00
CID type IJ 36-47 MONTH <100,000 Hold amount 100
Account number 303530137 Penalty amount 49.47
Birth date 12/10/1927 Deposit AccountfType
Phone(H) (717) 532-5182 (B) t) - Date redeemed 0/00/00
INTEREST INFORMATION PAYMENT INFORMATION
Accrued interest .82 Last payment date 10/30/13
Interest rate .450000: Next payment 11/30/13 .00
APY .45? Value after next pmt .00
M-T-D interest .54297 RENEWAL INFORMATION
M T-D Agg Days 4 Renewable yes
Y-T-0 Interest 73'97 Last renewal date 6/30/13
Per diem .13574 Last renewal balance 10,993.93
Interest payment frequency 1 M
Rw;• Interest disposition Add to balance
BUREAU OF INDIVIDUAL TAXES Pennsylvania Inheritance Tax pennsytvanla
PO BOX 280601 Y
HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE
---"" REV-3543 E%DocEXEG (03-12)
And Taxpayer Response FILE N0.21
ACN 13150509
DATE 09-27-2013
Type of Account
Estate of RICHARD S HOLTRY Savings
SSN Checking
Date of Death 08-07-2013 Trust
BARBARA J FISHER County CUMBERLAND X Certificate
111 SPRINGHOUSE RD
SHIPPENSBURG PA 17257-1120
SUSQUEHANNA BANK 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.10006332158 Remit Payment and Forms to:
Date Established 01-05-2009 REGISTER OF WILLS
Account Balance $18,526.01 1 COURTHOUSE SQUARE
Percent Taxable X 16.667
CARLISLE PA 17013
Amount Subject to Tax $3,087.73
Tax Rate X 0.150
Potential Tax Due $ 0.150 NOTE*: If tax payments are made within three months of the
decedent's date of death,deduct a 5 percent discount on the tax
With 5%Discount(Tax x 0.95) $(see NOTE*) due. Any inheritance tax due will become delinquent nine months
after the date of death.
PART Step 1 : Please check the appropriate boxes below.
A F-]No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was
21 years old or younger at date of death.
Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount
shown above as Potential Tax Due.
B ❑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 tax rate is incorrect. ❑ 4.5% 1 am a lineal beneficiary(parent,child,grandchild, etc.)of the deceased.
(Select correct tax rate at
right, and complete Part F-] 12% 1 am a sibling of the deceased.
3 on reverse.)
❑ 15% All other relationships (including none).
D ❑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 the back of this form.
E ❑Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax
inheritance tax form Return filed by the estate representative.
REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes.
Please sign and date the back of the form when finished.
fDebts and Deductions
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 3),
please obtain a written correction from the financial institution and attach it to this form.
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"intrust for"another or others were 100%owned by the decedent.
if. 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=3133 0f6,4 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 Official Use Only ❑AAF
your relationship to the decedent: PA Department of Revenue
1. Date Established 1
2. Account Balance 2 $ PAD
3. Percent Taxable 3 X 1
4. Amount Subject to Tax 4 $ 2
5. Debts and Deductions 5 '4
6. Amount Taxable 6 $ 5
7. Tax Rate 7 X 8
7
8. Tax Due 8 $
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 -)/7-5,3a-6000
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
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PREVIOUS
PREVIOUS R SUBMIT EXIT
SPECIAL MESSAGES.>
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CUSTOMER INFORMATION ACCOUNT INFORMATION
111 SPRINGHOUSE RORD Current balance 16,566.95
SHIPPENSBURG PA 17257-1128 Current cash value 16,313.74
Original balance 16,715.87
Certificate number
CID term 36 N
CIF number H131895 Maturity date 7/85/14
Tax ID number 162-22-5313 Issue date 1/85/09
CIO type 13 36-47 MONTH <10,099 Hold amount All
Account number 10086332158 Penalty amount 258.13
Birth date 12/10/1927 Deposit Account/Type
Phone(H) (717) 532-5182 (B) () - Date redeemed 8/08/80
INTEREST INFORMATION PAYMENT INFORMATION
Accrued interest 21.92 Lest payment date 18/85/13
Interest rate 11390809% Next payment 11/85/13 .89
APY 1.40 Value after next pmt 88
M-T-D interest 2.82828 RENEWAL INFORMATION
M•T-D Agg Days 4
Renewable Yea
Y T-D interest 213.53
70757 Last renewal date 7/85/11
Per diem
}. r .8
I
Last renewal balance 17,9957
nterest payment frequency 1 n
Interest disposition Rdd to balance
BUREAU INDIVIDUAL TAXES
28
PO BOX 280601 J Pennsylvania Inheritance Tax ': pennsytvanla
HARRISBURG PA 17128-0601 Information Notice ;' DEPARTMENT OF REVENUE
REV-1543 E%D..EXEC (08-12)
And Taxpayer Response FILE N0.21
ACN 13150511
DATE 09-27-2013
Type of Account
Estate of RICHARD S HOLTRY Savings
SSN Checking
Date of Death 08-07-2013 Trust
BARBARA J FISHER County CUMBERLAND X Certificate
111 SPRINGHOUSE RD
SHIPPENSBURG PA 17257-1120
SUSQUEHANNA BANK 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.60002366007
Remit Payment and Forms to:
Date Established 10-04-2006 REGISTER OF WILLS
Account Balance $34,089.31 1 COURTHOUSE SQUARE
Percent Taxable X 16.667
CARLISLE PA 17013
Amount Subject to Tax $5,681.67
Tax Rate X 0.150
Potential Tax Due $852.25 NOTE*: If tax payments are made within three months of the
decedent's date of death, deduct a 5 percent discount on the tax
With 5%Discount(Tax x 0.95) $(see NOTE*) due. Any inheritance tax due will become delinquent nine months
after the date of death. n
PART Step 1 : Please check the appropriate boxes below. "3f�'_ r CA 4a<, ee� G✓1
A F-]No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was
21 years old or younger at date of death.
Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount
shown above as Potential Tax Due.
B EI 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 F\7/ The tax rate is incorrect. ❑ 4.5% 1 am a lineal beneficiary(parent,child,grandchild, etc.) of the deceased.
(Select correct tax rate at
right,and complete Part ❑ 12% 1 am a sibling of the deceased.
3 on reverse.)
15% All other relationships (including none).
D F-]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 the back of this form.
E F-]Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax
inheritance tax form Return filed by the estate representative.
REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes.
Please sign and date the back of the form when finished.
P Debts and Deductions
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 81/2"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 3),
please obtain a written correction from the financial Institution and attach it to this form. ..�
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 0%,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 Official Use Only ❑AAF
your relationship to the decedent: I PA Department of Revenue
1. Date Established 1
2. Account Balance 2 $ PAD
3. Percent Taxable 3 X 1
4. Amount Subject to Tax 4 $ 3
5. Debts and Deductions 5 - 14
6. Amount Taxable 6 $ 5
7. Tax Rate 7 X 8
8. Tax Due 8 $ 7
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, 1 declare that the facts I have reported above are true,correct and complete to the best of my knowledge and
belief.
Work
Home ?/7-S3,;2 15'Gbo 11,6:L60,13
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
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`* PREVIOUS SUBMIT > EXIT 1V
r. SPECIAL MESSAGES.>
37L"::t.•."'1.'.i— .t;...t=:=•: •i 'v t"i;i.:.?MlL'":.'Y::R•a aa: ._ �'. •. - _ ..+n::t"`*� ••Mt.,.. � .. _ ... .
CUSTOMER INFORMATION ACCOUNT INFORMATION
111 SPRINGHOUSE ROAD Current balance 34,185.75
SHIPPENSBURG PA 17257-1128 Current cash value 34,812.66
Original balance 25,969a56
Certificate number
CrD term 18 N
CIF number "171895 Maturity date 5/04/14
Tax ID number 162-22-5313 Issue date 18/84/06
C/O type 1G 16-23 MONTH <100.898 Hold amount +88
Account number 60802365007 Penalty amount 6e.08
Birth date 12/10/1927 Deposit Accountlfype
Phone(H) (717) 532-5182 (B) () - Date redeemed 8/88/00
INTEREST INFORMATION PAYMENT INFORMATION
Accrued interest .19 Lest payment date 11/04113
Interest rate .200009% Next payment 12/84/13 .00
APY .282 Value after next pmt .00
MT—D,interest .74742 RENEWAL INFORMATION
M•T-D Agg Days 4
Renewable Yea
Y•T-0 interest 62.54
Last renewal date 11/04/12
Per diem 18688
I Last renewal balance 84,837.62
Interest payment frequency 1 M
, —',' Intere st disposition Rdd to balance
BUREAU INDIVIDUAL TAXES
28
PO OX 280601 Pennsylvania Inheritance Tax pennsytvanld
B
HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE
REV-1543 EX RoeEXEC (08-12)
And Taxpayer Response FILE No.21
ACN 13150513
DATE 09-27-2013
Type of Account
Estate of RICHARD S HOLTRY Savings
SSN Checking
Date of Death 08-07-2013 Trust
BARBARA J FISHER County CUMBERLAND X Certificate
111 SPRINGHOUSE RD
SHIPPENSBURG PA 17257-1120
SUSQUEHANNA BANK 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.60002366056 Remit Payment and Forms to:
Date Established 10-04-2006 REGISTER OF WILLS
Account Balance $18,795.04 1 COURTHOUSE SQUARE
Percent Taxable X 16.667
CARLISLE PA 17013
Amount Subject to Tax $3,132.57
Tax Rate X 0.150
Potential Tax Due $ 0.150 NOTE*: If tax payments are made within three months of the
decedent's date of death,deduct a 5 percent discount on the tax
With 5%Discount(Tax x 0.95) $(see NOTE*) due. Any inheritance tax due will become delinquent nine months
after the date of death.
PART Ste 1 : Please check the appropriate boxes below.��e
cr e c amen
A ❑No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was
21 years old or younger at date of death.
Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount
shown above as Potential Tax Due.
B ❑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 F�The tax rate is incorrect. ❑ 4.5% 1 am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased.
(Select correct tax rate at
right, and complete Part 12% 1 am a sibling of the deceased.
3 on reverse.)
15% All other relationships (including none).
D [_1 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 the back of this form.
E F]Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax
inheritance tax form Return filed by the estate representative.
REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes.
Please sign and date the back of the form when finished.
tDebts and Deductions
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 3),
please obtain a written correction from the financial institution and attach it to this form.
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.
1 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"intrust 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 Official Use Only 0 AAF
your relationship to the decedent: PA Department of Revenue
1. Date Established 1 `
2. Account Balance 2 $ IPAO
3. Percent Taxable 3 X 1
4. Amount Subject to Tax 4 $ 2
3
5. Debts and Deductions 5 4
6. Amount Taxable 6 $ 5
7. Tax Rate 7 X 6
8, Tax Due 8 $ 17
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 1 have reported above are true,correct and complete to the best of my knowledge and
belief.
Work
Home 7�7 s3a �sOop fir/ I73
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
+ "Poitid I NeeiFomrn !'Website )'Help Desk 1-Home
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PREVIOUS < SUBMIT > EXIT M.4 4
SPECIAL MESSAGES.>
7. � , :•a' re
CUSTOMER INFORMATION ACCOUNT INFORMATION
311 SPRINGHOUSE ROAD Current balance 18,931.30
SHIPPENSBURG PR 17257-1128 Current cash value 18,363.57
Original balance 15,880.88
Certificate number
CA)term 36 N
CIF number HlJ1895 Maturity date 6/04/14
Tax ID number 162-22-5313 Issue date 18/84/86
C/D type 14 36 MONTH 123 CD {188 Hold amount .88
Account number 60002366056 Penalty amount 544.29
Birth date 12/10/1927 Deposit Account/Type
Phone(H) (717) 532-5182 (B) O - Date redeemed 0/80/00
INitN1:51 INFORMATION PAYMENT INFORMATION
Accrued interest 1.56 Last payment date 11/04/13
Interest rate 3.008000: Next payment 12/84/13 .08
APY 2.02: Value after next pmt .09
M T 0 interost 6.21211 RENEWAL INFORMATION
M-TD Agg Days 4
Y T•O interest 421.56 Renewable Yea
Per diem 1.55599 Last renewal date 6/04/11
Interest payment frequency i M last renewal balance 18,143.16
` r >.: . < Interest disposition Add to balance
BUREAU OF INDIVIDUAL TAXES Pennsylvania Inheritance Tax pennsyLVanla
PD BOX 280601 Y
HARRISBURG PA 17128-0601 Information Notice % DEPARTMENT OF REVENUE
-- -' REV-1543 E%DooEXEC (OB-12)
And Taxpayer Response FILE N0.21
ACN 13150515
DATE 09-27-2013
Type of Account
Estate of RICHARD S HOLTRY Savings
SSN Checking
Date of Death 08-07-2013 Trust
BARBARA J FISHER County CUMBERLAND X Certificate
111 SPRINGHOUSE RD
SHIPPENSBURG PA 17257-1120
SUSQUEHANNA BANK 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.60002366098 Remit Payment and Forms to:
Date Established 10-04-2006 REGISTER OF WILLS
Account Balance $ 18,317.64 1 COURTHOUSE SQUARE
Percent Taxable X 16.667 CARLISLE PA 17013
Amount Subject to Tax $3,053.00
Tax Rate X 0.150
Potential Tax Due $ 0.150 NOTE': If tax payments are made within three months of the
decedent's date of death,deduct a 5 percent discount on the tax
With 5%Discount(Tax x 0.95) $(see NOTE') due. Any inheritance tax due will become delinquent nine months
after the date of death.
P;RT Step 1 : Please check the appropriate boxes below. cr
A ❑No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was
21 years old or younger at date of death.
Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount
shown above as Potential Tax Due.
B 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 tax rate is incorrect. F-] 4.5% 1 am a lineal beneficiary(parent,child,grandchild, etc.)of the deceased.
(Select correct tax rate at
right, and complete Part ❑ 12% 1 am a sibling of the deceased.
3 on reverse.)
15% All other relationships (including none).
D ❑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 the back of this form.
E F�Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax
inheritance tax form Return filed by the estate representative.
REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes.
Please 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 61/2"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 3),
please obtain a written correction from the financial institution and attach it to this form.
t. 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"intrust 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 Official Use Only ❑AAF
your relationship to the decedent: PA Department of Revenue
1. Date Established 1
2, Account Balance 2 $ PAD
3. Percent Taxable 3 X 1
2
4. Amount Subject to Tax 4 $
3 �
5. Debts and Deductions 5 4
6. Amount Taxable 6 $ 5 i
7. Tax Rate 7 X 8
8. Tax Due 8 $ 7
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, 1 declare that the facts I have reported above are true,correct and complete to the best of my knowledge and
belief.
za)Qn 1/n Work
V Home 7/7-5JO•.5"000
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
2
f PREVIOUS < SUW11T EXIT l,N 1
PC
iorm�7G runJ CUS tF_t0.JER tyCt;.OURT lW CAt';tAIMDR
111 SPRINGHOUSE RURD Current ttalance 16,376,30
wwcnie _
SHIPP NS6URG PH 17257-1120 Current cash value 18,112.27
-`-,s: —r .r Qriginal @glance 15,000m
im
Certificate number
n CAD term 36 r
f _ CIF nua7rber hi131845 Maturity date 1(04(15
Tax ID number 162-22-5313 Issue date 18/94/86
type 13 36.47 MONTH <100.068 Hold amount .00
Account number 50002366040 Density amQUnt 240,26
Birth date 12l10f1427 DepositAccaint/Type
Phone(Hj (717) 532-5182 t @; () - Date redeemed 0/00/00
€a d:" 3a aL14 a st s i rt
4i'TEREST 44FORIZATIOU PW iENT lip @FORr,7ATtOR
- - - - Accrued interest .67 Last payment date 11!04113
interest rate t 340000: Pleat pDytnent 12f04f13 ®Q
---- ---- -- -- -
AP Y 1,35% Value after pert pmt .00
----_-_._.--.---_._--.-------__.-__ WT-D interest 2.54632 RENE?l tAL Ir3FORFIATIOrl
--- — ---- --- WJ,D Agg Days 4
Rene%z,mble Yea
-------.-------------- Y-T-D interest 224 45
Last renewal date 1104/12
Per diem .67,'6;
Interest payment frequency 1 r
Cast rener ml halance 17,431.27
- interest disposition Udd ;a t:atance
BUREAU OF INDIVIDUAL TAXES Penns Ivania Inheritance Tax pennsyLVania
PO BOX 280601 Y
NARRISBUR6 PA 17128-0601 Information Notice DEPARTMENT OF REVENUE
REV-1543 EX UotEXEC(08.12)
And Taxpayer Response FILE NO.21
ACN 13150517
DATE 09-27-2013
Type of Account
Estate of RICHARD S HOLTRY Savings
SSN Checking
Date of Death 08-07-2013 Trust
BARBARA J FISHER County CUMBERLAND X Certificate
111 SPRINGHOUSE RD
SHIPPENSBURG PA 17257-1120
SUSQUEHANNA BANK 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.60002366114 Remit Payment and Forms to:
Date Established 10-04-2006 REGISTER OF WILLS
Account Balance $18,317.64 1 COURTHOUSE SQUARE
Percent Taxable X 16.667
CARLISLE PA 17013
Amount Subject to Tax $3,053.00
Tax Rate X 0.150
Potential Tax Due $ 0.150 NOTE*: If tax payments are made within three months of the
decedent's date of death,deduct a 5 percent discount on the tax
With 5%Discount(Tax x 0.95) $(see NOTE*) due. Any inheritance tax due will become delinquent nine months
after the date of death.
PART Ste 1 : Please check the appropriate boxes below._ 5ee a�c kA (3 c e�m��4_Jr,0
A No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was
21 years old or younger at date of death.
Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount
shown above as Potential Tax Due.
B E 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 tax rate is incorrect. ❑ 4.5% 1 am a lineal beneficiary(parent,child, grandchild,etc.) of the deceased.
(Select correct tax rate at
right,and complete Part F—] 12% 1 am a sibling of the deceased.
3 on reverse.)
15% All other relationships (including none).
D 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 the back of this form.
E [—]Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax
inheritance tax form Return filed by the estate representative.
REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes.
Please 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$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 3),
please obtain a written correction from the financial Institution and attach it to this form.
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 Official Use Only ❑AAF
your relationship to the decedent: PA Department of Revenue
1. Date Established 1
2. Account Balance 2 $ PAD
3. Percent Taxable 3 x 1
2
4. Amount Subject to Tax 4 $
3 j
5. Debts and Deductions 5 4
6. Amount Taxable 6 $ 5
7. Tax Rate 7 X 6
6. Tax Due 6 $ 7
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 I>-$3� v�000 17/> 0J&
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
.�� •��''i��?.4r`:.�"n,; :�Y';��'t�an���:�ifd3ic��o - i Ne�€Foru+m:i•YUebsite i Heip t7esk 11#ome
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�- PREVIOUS { SUBMIT > ' EXIT
SPECIAL MESSAGES.>
••;,�. ..,a lLM:.'.;.w.;— ,.•. ....-,..,.q•� ... '.. ••'r ,b_ u' ».. em,-6'.•::Y.R!N•.....•!iP.. . -tAdh.'."1tRVw•` •'_-Y#x '.;>:•R-.r. '•K: . •r C'i�u3
CUSTOMER INFORK44TION ACCOUNT INFORMATION
111 SPRINGHOUSE ROAD Current balance 18,376.88
SHIPPENSBURG PA 17257-1120 Current cash value 16,112.27
Original balance 15,880,00
Certificate number
C/D term 36 M
CIF number H171895 Maturity date 1/84/15
Tax ID number 162-22-5313 Issue date 18/84/06
C/D type 13 36-47 MONTH <100,900 Hold amount .08
Account number 60082366114 Penalty amount 240.28
Birth date 12/18/1927 Deposit Aceounttfype
Phone(H) (717) 532-5182 (B) () - Date redeemed 8/80/08
INTEREST INFORMATION PAYMENT INFORMATION
Accrued interest .67 Last payment date 11/04/13
Interest rate 1.3468002 Next payment 12/84/13 All
APY 1.352 Value after next pmt .88
M T-D interest 2.69632 RENEWAL INFORMATION
M-T-D Agg Days 4
Renewable Yea
Y-TD interest 224.45
Last renewal date 1/84/12
Per diem 67465
i Last renewal balance 17,931,27
Interest payment frequency i M
`"` "" ''°M� :• Interest disposition Add to balance
I
i
BUREAU 28 INDIVIDUAL TAXES Pennsylvania Inheritance Tax ennS lvania
PO BOX 280601 Y �. P Y
HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE
'-- r REV-1543 EX DocEXEG (OB-12)
And Taxpayer Response FILE N0.21
ACN 13150519
DATE 09-27-2013
Type of Account
Estate of RICHARD S HOLTRY Savings
SSN Checking
Date of Death 08-07-2013 Trust
BARBARA J FISHER County CUMBERLAND X Certificate
111 SPRINGHOUSE RD
SHIPPENSBURG PA 17257-1120
SUSQUEHANNA BANK 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.60002366247 Remit Payment and Forms to:
Date Established 10-04-2006 REGISTER OF WILLS
Account Balance $6,657.85 1 COURTHOUSE SQUARE
Percent Taxable X 16.667
CARLISLE PA 17013
Amount Subject to Tax $1,109.66
Tax Rate X 0.150
Potential Tax Due $ 0.150 NOTE': If tax payments are made within three months of the
decedent's date of death,deduct a 5 percent discount on the tax
With 5%Discount(Tax x 0.95) $(see NOTE) due. Any inheritance tax due will become delinquent nine months
after the date of death.
PART Step 1 : Please check the appropriate boxes below.
A F-]No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was
21 years old or younger at date of death.
Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount
shown above as Potential Tax Due.
B El 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 tax rate is incorrect. F—] 4.5% 1 am a lineal beneficiary(parent,child,grandchild, etc.) of the deceased.
(Select correct tax rate at
right, and complete Part 12% 1 am a sibling of the deceased.
3 on reverse.)
15% All other relationships(including none).
D F—]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 the back of this form.
E ❑Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax
inheritance tax form Return filed by the estate representative.
REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes.
Please sign and date the back of the form when finished.
t
PART Debts and Deductions
2
Allowable debts and deductions must meet troth 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 3),
please obtain a written correction from the financial institution and attach It to this form.
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"intrust 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 Official Use Only [I AAF
your relationship to the decedent: PA Department of Revenue
1. Date Established 1
2. Account Balance 2 $ PAD
1 Percent Taxable 3 X I1
4. Amount Subject to Tax 4 $ 3
5. Debts and Deductions 5 4
6. Amount Taxable 6 $ 5
7. Tax Rate 7 X 6
8. Tax Due 8 $ 7
8 f
9. With 50%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.
QQ Work
K� CtY1 Home?530 -SOrso /71?Iii3
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
y
'46i et Cue".(?b#�tal 1 Net�arum Webs Ii'Help Desk I Nome
IMXr—M VON
poll
040 101'.
. ..... -Ono
PREVIOUS < SUBMIT EXIT M_I 1 (tea L?
SPECIAL MESSAGES.a
CUSTOMER INFORMATION ACCOUNT INFORMATION
111 SPRINGHOUSE RORO Current balance 6,669.09
SHIPPENSBURG PR 17257-1128 Current cash value 6,590,08
Original balance 5,488.98
Certificate number
C!D term 24 M
CIF number Hldle95 Maturity date 6/84/14
Tax ID number 162-22-5313 Issue date 18/04/06
CtD type IN 24-35 MONTH <100,088 Hold amount .08
Account number 60002366247 Penalty amount 46.22
Birth date 12/18/1927 Deposit Accountlrype
Phone(H) (717) 532-5182 (I3) O - Date redeemed 0/88/80
INTEREST INFORMATION PAYMENT INFORMATION
Accrued interest .13 Last payment date 11/84/13
Interest rate ,708080% Next payment 12/04/13 ,80
APY .70% Value after next pmt .00
M T-D interest .51137 RENEWAL INFORMATION
M•T-O Agg Days 4
Y•T-D interest 42,69 Renewable Yes
Per diem ,12790 Last renewal date 6/e4/12
{ Interest payment frequency 1 M Last renewal balance 6,683,19
� .- '..
Interest disposition Rdd to balance
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