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HomeMy WebLinkAbout03-14-14 (3) BUREAU OF INDIVIDUAL TAXES Pennsylvania Inheritance Tax pennsylvania PO BOX 280601 DEPARTMENT OF REVENUE HARRISBURG PA 17128-0601 Information Notice Tr And Taxpayer Response REV-0543A EX OocE%EL (08-12) FILE NO.2113-0678 ACN 13503568 DATE 09-05-2013 Type of Account Estate of JOHN R BURGOON Security SSN X SEC Acct Date of Death 06-15-2013 Stock CHARLES D BURGOON County CUMBERLAND Bonds PO BOX 1345 MONTAGUE NJ 07827-0345 .C> a :Dz' CX?-1„7 Tti C -D may_ Cn 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.640507711133 Remit Payment and Forms to: Date Established REGISTER OF WILLS Account Balance $1 3,302.38 1 COURTHOUSE SQUARE Percent Taxable X 33.333 CARLISLE PA 17013 Amount Subject to Tax $4,434.08 Tax Rate X 0.045 Potential Tax Due $ 199.53 0.0 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. 1 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 F1 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 F-1 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. S. 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.) , i 5 Date Paid Payee Description Amount Paid, r- 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. 1. 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 4, Amount Subject to Tax 4 $ 2 3 5. Debts and Deductions 5 4 6. Amount Taxable 6 $ 5 7. Tax Rule 7 8. Tax Due 8 $$ 7 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, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. Work :Home 973-2G2'. or.JS 9/9/Z015 Taxpayer Signa ure 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 BUREAU OF INDIVIDUAL TAXES Penns Ivania Inheritance Tax ` � ��; pennsytvania PO BOX 280601 y HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE Jr REV-1543A EX OocEXEC (08-12) And Taxpayer Response FILE NO 2113-0678 ACN 13503569 DATE 09-05-2013 Type of Account Estate of JOHN R BURGOON Security SSN X SEC Acct Date of Death 06-15-2013 Stock SCOTT R BURGOON County CUMBERLAND Bonds 1749 KEEL .DR ELDERSBURG MD 21784-6577 ("> ...... CU Fr-1 r>i CD C._a __ 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. Remit Payment and Forms to: Account No.640507711133 Date Established REGISTER OF WILLS Account Balance $13,302.38 1 COURTHOUSE SQUARE Percent Taxable X 33.333 CARLISLE PA 17013 Amount Subject to Tax $4,434.08 Tax Rate X 0.045 Potential Tax Due $ 199.53 0.0 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. 1 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 F1 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-1 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. 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 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 dale 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=500%,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 El AAF your relationship to the decedent: PA Department of Revenue 1. Date Established 1 2. Account Balance 2 $ PAD 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 $ 2 3 5. Debts and Deductions 5 4 B. Amount Taxable 6 $ 5 7, Tax Rate 7 X 6 S. Tax Due - 8 $ _- ... 8 9. With 51Y6 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'��N=1i3-1$3K Y�llt-j Home /�1C�- 5-5/t/� I/1�(��J" 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 BUREAU OF INDIVIDUAL TAXES Pennsylvania Inheritance Taxi pennsylvania PO BOX 280601 DEPARTMENT OF REVENUE HARRISBURG PA 17128-0601 Information Notice ________,7 And TaXpayer Response REV-1543A EX DocEXEL (08-12) FILE NO.2113-0678 ACN 13503570 DATE 09-05-2013 Type of Account Estate of JOHN R BURGOON Security SSN X SEC Acct Date of Death 06-15-2013 Stock DEBORAH A DONOHUE County CUMBERLAND Bonds 246 NAUGATUCK DR GREENSBURG PA 15601-6009 r..� 0 rn *i 1 AMERIPRISE provided the department with the information below indicating that at the d@ath of the- above-named decedent you were a joint owner or beneficiary of the account identified. Account No.640507711133 Remit Payment and Forms to: Date Established REGISTER OF WILLS Account Balance $ 13,302.38 1 COURTHOUSE SQUARE Percent Taxable X 33.333 CARLISLE PA 17013 Amount Subject to Tax $4,434.08 Tax Rate X 0.045 Potential Tax Due $ 199.53 0.0 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. 1 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 DThe 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 F-1 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 Minheritance 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 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 t account balance Line 2 ,or y g { } ( } 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 ©AAF your relationship to the decedent: PA Department of Revenue 1. Date Established 1 2. Account Balance 2 $ PAD 1 Percent Taxable 3 X 1 4. Amount Subject to Tax 4 $ 2 3 S. 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 8 r 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 1Zt4- 4to9-8000 Home - tt4- Z79-30G8 4�t0�f 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 BUREAU OF INDIVIDUAL TAXES Pennsylvania Inheritance Tax a.e...,s pennSytiranla PO BOX 280601 DEPARTMENT OF REVENUE HARRISBURG PA 17128-0601 Information Notice i — REV-1543A EX UocE EL (OB-12) And Taxpayer Response FILE NO.2113-0678 ACN 13503571 DATE 09-05-2013 Type of Account Estate of JOHN R BURGOON Security SSN SEC Acct Date of Death 06-15-2013 n `= Stock CHARLES D BURGOON . County CUMBERLAND Q Bones,i PO BOX `1345 ts MONTAGUE NJ 07827-0345 ��' t' 4 CD 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. Remit Payment and Forms to: Account No.640502589133 Date Established REGISTER OF WILLS ' Account Balance $20,896.67 1 COURTHOUSE SQUARE Percent Taxable X 33.333 CARLISLE PA 17013 Amount Subject to Tax $6,965.49 Tax Rate X 0.045 Potential Tax Due $313.45 0.04 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. w PART Step 1 : Please check the appropriate boxes below. j 1 A [--]No tax is due. I 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. i g FThe 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 I right,and complete Part F—] 12% 1 am a sibling of the deceased. 3 on reverse.) i 15% All other relationships (including none). Changes or deductions The information above is incorrect and/or debts and deductions were paid. n D 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. f 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 8 1/2"x 11"sheets of paper.) Date Paid r Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 It 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°k divided by the total number of owners including the decedent. (For example:2 owners=500%,3 owners=3333 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 $ 3 5. Debts and Deductions 5 4 6, Amount Taxable 6 $ 5 7. Tax Rate 7 X 6 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, I declare that the facts 1 have reported above are true,correct and complete to the best of my knowledge and belief. A QD Work N� rJn1 Home 975. 21o2- 0648 4 4 to r3 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 BUREAU OF INDIVIDUAL TAXES Pennsylvania Inheritance Tax I pennsytvan18 PO BOX 280601 DEPARTMENT OF REVENUE HARRISBURG PA 17128-0601 Information Notice REV-1543A E%OocE%EL (08-12) And Taxpayer Response FILE NO.2113-0678 ACN 13503572 DATE 09-05-2013 Type of Account Estate of JOHN R BURGOON Security SSN X SEC Acct Date of Death 06-15-2013 Stock SCOTT R BURGOON County CUMBERLAND Bonds 1749 KEEL DR ELDERSBURG MD 21784-6577 fix.+ T G�J 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.640502589133 Remit Payment and Forms to: Date Established REGISTER OF WILLS Account Balance $20,896.67 1 COURTHOUSE SQUARE Percent Taxable X 33.333 CARLISLE PA 17013 Amount Subject to Tax $6,965.49 Tax Rate X 0.045 Potential Tax Due $313.45 0.04 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. PA 1 RT 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 0 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 F_� 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 [XAsset 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. ._ . . _ .. .. .. .. ... � +. ._ tf ...--w-..... ter.. .. 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 depart ment.' (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 Y 9 ( ) ( ), 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. r 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 4. Amount Subject to Tax 4 $ 2. 5. Debts and Deductions 5 - 4 6. Amount Taxable 6 $ 5 7. Tax Rate 7 x 16 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 I have reported above are true,correct and complete to the best of my knowledge and belief. Work 30-713— FS3 X 17y Home VLf&' Taxpayer Signature Telephone Number Date 9 ICS / 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 BUREAU OF INDIVIDUAL TAXES Pennsylvania Inheritance Tax pennsylvania PO BOX 280601 DEPARTMENT OF REVENUE HARRISBURG PA 17128-0601 Information Notice And Taxpayer Response T- r REV-1543A Ex oo`ExE`<0e-12' FILE NO.2113-0678 ACN 13503573 DATE 09-05-2013 Type of Account Estate of JOHN R BURGOON Security SSN X SEC Acct Date of Death 06-15-2013 Stock DEBORAH A DONOHUE County CUMBERLAND Bonds 246 NAUGATUCK DR GREENSBURG PA 15601-6009 C7 ' --0 C::� I CO CD C. AMERIPRISE provided the department with the information below indicating that at the d*:h--of the 1_0 CD above-named decedent you were a joint owner or beneficiary of the account identified. ' Account No.640502589133 Remit Payment and Forms to: Date Established REGISTER OF WILLS Account Balance $20,896.67 1 COURTHOUSE SQUARE Percent Taxable X 33.333 CARLISLE PA 17013 Amount Subject to Tax $6,965.49 Tax Rate X 0.045 Potential Tax Due $313.45 0.04 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. 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 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 F—] 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. \ 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 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. y 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 5. Debts and Deductions 5 4 6. Amount Taxable 6 $ 5 7. Tax Rate 7 X 6 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 1 have reported above are true,correct and complete to the best of my knowledge and belief. Work -77,LJ-408-8000 Dtana� Home 7Z,�{ - Zfq 3868 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