HomeMy WebLinkAbout03-11-14 (2) BUREAU OF INDIVIDUAL TAXES Penns �vania �nheritance Tax � Per111S�/�Va1118
PO BOX 280601 Y
HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE
REV-1543 E%DocE EL (OB-12)
And Taxpayer Response FILE NO.21 "'��- ��
ACN 14103965
DATE 01-23-2014
Type of Account
Estate of KARL D JACOBS Savings
Checking
Date of Death 10-22-2013 Trust
MARK P JACOBS County CUMBERLAND Certificate
1605 PRIMROSE LN �
DAUPHIN PA 17018-9594 ='
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PsECU 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. 187223564
Remit Payment and Forms to:
Date Established 08-17-1993 REGISTER OF WILLS
Account Balance $3,591.51 1 COURTHOUSE SGIUARE
Percent Taxable X 50 CARLISLE PA 17013
Amount Subject to Tax $1,795.76
Tax Rate X 0.045
Potential Tax Due $80.81 NOTE*: If tax payments are made within three months of the
decedenYs 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.
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 Sfep 2 on reverse. Do not check any other boxes.
C �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child,grandchild, etc.)of the deceased.
(Select correct tax rate at
right,and complete Part � 12% 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 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. �j�
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PART Debts and Deductions
2
Allowable debts and deductions must meet both of the following criteria:
A. The decedent was Iegaliy 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 $ '� 5
PART TaX CaICUIatIOCI
3 If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3),
pl�ase 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 decedenYs 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 ciaimed 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: .
1. Date Established 1 11 'LZ,���'�
2. Account Balance 2 $ ��� . ��
3. Percent Taxable 3 X �
4. Amount Subject to Tax 4 $ �1�'� • �V � -� � �
5. Debts and Deductions 5 - �s�`�� . u
6. Amount Taxable 6 $ —"��9� �� `
7. Tax Rate 7 X .C�-15
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 7��-°I21 �ZZ �'7
Taxpayer Signature � Telephone Number "�l�-�s.(,�yr� Date Z/ZZ Z�i�
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
10/29/2013 #3354 Milton Hershey Medical Center final bill#529564 $147.67
10/29/2013 #1167 Parthmore Funeral Home 1/2 dad's funeral expenses $2,166.34
11/24/2013 #3359 Health Network Labs(Humana) $20.02
11/25/2013 #3360 VA(final bill?) $1,249.10
1/7/2014 #3362 Health Network Labs(Humana) $11.92
$3,595.05
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PARTHEMORE Funer & Cremation Services, Inc.
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Mr.Kevin D.Jaco ��� 10l23/2013
44 Willow Way Dri e y
Enola,PA 17025 ��t
For the Services of Karl D.lacobs
1303 Bridge Street
P.O.Box 431
New Cumberland,PA 17070 We sincerely appreciate the confidence you have placed in us and wiil continue to assisc you in every way
we can. Please feel free to contact us if you have any questions in regazd t0 this statement. The following
PH:(717)774-7721 is an itemized statement of the services,facilities,automotive equipment and merchandise that you selected
FX:(717)7745546 when making the funeral arrangements.
wwvv.parthemore.com
Terms Due Date Account#
Net 30 11/22/20 t 3 6707.1
,, Description Amount
0.00
Direct Cremation 2,475.00
Gilbert W.Parthemore Visitation/Viewing 445.00
F�under Memorial Service 610.00
Catholic Jesus Stationery Set 165.00
Gilbert J.Parthemore
5�pervisor Total Services and Merchandise 3,695.00
Stephen K.Parthemore o.00
�resident,CFSP Death Notice,Harrisburg Patriot 330.67
15 Certified Copies of Death Certificate 90.00
Bruce R.Parthemore Clergy Honorarium 200.00
Pre-P�eed Coordinator,CPC Cumberland County Coroner Fee,Crema6on Authorization 30.00
Assorted Seasonal Flowers in Glass Vase 60.00
- - Total Cash Advances 710.67
Immediate Pay Discount-'Thank you! -74.00
Professional Memberships:
� .
. . , _ --�._ ��`� . , �l
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� Pennsylvania�neral ���
Directors Association
1! i. At F; t�. Ei
Order�f�he
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Golden Rule
' 'r0�� $4,331.67
; Payments/Credits -$a,331.67
� Balance Due $�.��
Page 1 of 1
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TAMMY L JACOBS aa,i�r�»
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LEBANON VA MEDICAL CENTER (595) +� TTc
� 170Q 5 LINCOLN AVE V.U. Department
� LEBANOp► pA 1 7042-7597 of Veterans A,ffairs
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� STATEMENT QUESTIO(�IS OR ADDRESS CHANGE?
Zoz 2867548 00 0000301 0001201 ca>> i-866-408-2657
�IIII�'lll�1',P��1'�I�I��ul���6��l�l�y���'���II���I�+�I�Ilyl Methods of payment
KARL D JACOBS ���E Ww1M•DeY.pOV
22 GAIE rtD 8Y MAIL: to the address bebw
CAMP HILL PA 17011-2619 M) PERSOflt at the VA Medicai Center
PAY BY PHONE: 1-888-$27-4817
Statement reflects payments received by �0�1o/2oia
PATIENT NAME: KARL D JACOBS LOCAL VA'S MESSAGE.
ACCOUNT NUMBER 59r� 0000 0000 7573g JACOB
STATEINENT DATE 10/14/2013
ACCOUNT •-��5.� PAYMENTS RECEIdED NEW (�1AI�ES ro ev0�� ;aTE gq�q�y�F
SUMM/+�,RY � ��f 1� 26 CHARGES PAY BALANCE
.00 114.84 BY 11/08/2013 1.225.10
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COPAY RK#3675444 FlLL DATE: 06/14/2013 8.00 595-K30EMKK
DRUG: INSULIN,GLAR6INE,HUMAN )00 UN1T/ML INJ
DAYS:30 QTY:1 PHY:YOURSHAW,JEFFREY P
CHG:$8.00
COPAY RX�3675442 FILL DATE: 06/14/2013 8.00 ,595-K30EMKK
DRUG:FLUCONAZUIE 50MG TAB DAYS:S QTY:S
PHY:YOURSHAW,JEFFREY P CHG:$8.00
COPAY RX�3675450 FIL! DATE: 06/14/2013 8.00 595-K30EMKK
DRUG:PREDNISONE 5MG TAB DAYS:30 QTY:30
PHY:YOURSHAW,JEFFREY P CHG:$8.00
COPAY RX�367�448 FILL DATE: 06/14�2013 8.d0 595-K30EMKK
DRUG:PANTOPRAZOLE NA 40MG EC TAB DAYS:30
QTY:44 PHY:YOURSHAW,JEFFREY P CHG:$8.00
COPAY RX#3675443 FILL DATE: 06/14/2013 8.00 595-K30EMKK
DRUG:FUROSEMIDE ZOMG TAB DAYS:30 QTY:45
PHY:YOURSHAW,JEFFREY P CHG:$8.00
COPAY RX�3675440 FiLL DATE: 06/14/Z013 8.00 595'K30EMKK
ORUG:COLLA6ENASE 250 UNT/GM TOP 0lNT DAYS:30
QTY:90 PHY:YQURSHAW,JEFFREY P CHG:$8.00
C�PAY 4��3575bk; ffi.L ^uATfi: Obii4J�^viy $.00 595-K30E�iKK
DRUG:NYSTATIN 100000 UNT/ML SllSP DAY5:7
QTY:480 PHY:YOURSHAW,JEFFREY P CHG:$8.00
.......PAYII�#�BY,MAII.�OR�IN�PERSONY DET �.1'F�E t�pN BEL011. pp WpT INCLUDE pNY t�pRRESPpNbENCE y2TH PAYMENT.
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0000 0000 JACOB 10/14/201
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MAIL TO:
BALANCE DtJE BY ANIOUI�tT pUE �'pAYMENT AI�IA�IT ����/j�C 'I�i�Itll��h�,���IhIIIIIi'III��u����h��I�hn1I'IIu�lnl��{� .
11/OS/2013 1,225.10 $ �a y� ,� ��`�U DEPARTMENT OF VETERANS AFFAIRS �
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PO BOX 530269
KARL D JAC08S ATLANTA GA 30383-0269
22 6ALE RD
CAMP HILL PA 17011-2619
y f0� Pay Br Check. Money Order or Credit Cerd PeyObIC t0 °YA". (nClud@ ACCOURt j
,� 2ois 10-o2as Veteran PAtient Statetnent Number. *If p in b Credit Card corn lete fiefds marked with an asterisk(+►).
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STATEMENT OF PHYSICUIN SERYtCES
P�1�t!����.�� 1-1���G I �GA D RDCOBS �►oe 2 � 2
��1�1.��DII �. Hershey CAMP HILL PA 1T011-2619 �Te-. 0 26/73
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ACCOUNT# 5��4 nu►rE: 08J22i13
IF ANY QUESTIONS PLEA.SE CONTACT M$ � R
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rBALAt�ICE St�MARY RESPd�lS�LE PfRTY pp�„I�y � ��
m �eeE 6UARANiDR RESP�6IHILITY � 147.67
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STATEMfNT DATE: GUARANTOR RESPOMSIBILITY: MINIMUM PAYMENT
8� 09/26/13 � 147.67 S 147.67
MSHMC PHYSICIANS GROUP
BIWNG SERVICES
P O BOX 8.54
HERSHEY PA 17�4 U0000529564 uP OOODOOOD00014767092613
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PO BOX 643313 CAMP HILL PA 1701I-2619
PITTSBUR6H PA 15264-3313
OFflCE USf OIVLY CH�K ONE �R CREDR CARD PAYMENT,PLFASE FlLL IN IMADRNIATI�N BEUDI! -=--_--_>- --_
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M/C CARD NUMBER IXP DATE ---= - __ --`— =-
STATEMENT OF PHYSiC1AN SERVICES
PAOE
'ENN�TATE HERSHEY �RL D JACOBS � � 2
22 GAIL RD STATEI�ENT
���Un S. Hershey CAMP HfLL PA 1T011-�19 opr�: pg/2y13
LAST STATEMENT
�Mf�)-C� �e�l'�I pCCOUNT# 5�� �TE: 07/25113
IF ANY QU�TIONS PLEASE CONiACT MSHMC PATIENT FiNANC1AL SERVICES PED TAX iD# ����
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18782873
PERFDIlF�D BY: FAISAL dZIZ F� V�CULAR �RY
PLI�E �F SVC: OR PHYSICIiW
02I13/13 4420� +�59.9 alTPdTIENT VISIT t�i 437.�
03/13/13 APPLIED TC DEDtJCTI 0.�
03J13I13 F�DICARE ADY ADJ 275.3{t-
06/24�I13 CNARITY ADJUSTFIEM' 40.42- 121.24
186�43564
PERFOI�D BY: FAISAL lIZ� !N VIL"UlLAR SUR6ERY
PLII�E OF SVC: OP PNIYSICIIW
D3l06113 49215 �43.9 OtJrPATTENf VISIT EST 284.OD
o�o�i3 APPLIED TO �DUCTI o.o0
04r/04/13 lffDICARE pDN dDJ 183.Y8-
�t/a8/13 A�IVVdLIDlMISSIi�G CO O.DO
0�/Ib113 APPLIED TO DEDUCTI D.�
0�122/13 CHARITY AQ.Jl�STl�NT 79.29- 2b.43
BALANCE: KARL D JA�.S �147.b7
QI'FER CNAR6ES BItLED 1D Y�! Tt�URAt�E C�IPANY. 761.00
i� HAVE t�Qf' RECEIVED Y�t PAYFEM. TD dVDID ftAtT'I�R
COLLECTI�1 EFFDRTS, P'YMt� IFI FULL MtJ.ST 8E RECEIVED IMl�ffDIATELY.
IF PAYF�NT HlLS BEEFI MAOE, THlWC YQI IIF� DISRE6ARD T�RS BILL.
THIS STdTEF�tdT IS �R PHYSICIAN SERVICES a1LY. IN DR�R TO
�, KEEP YQAt A�T d�tRENI', �t POLICY IS TO APRLY YQJR PAYl�t�(�
N Tp TIIE OLDEST QlfSTAt�II� BALIWCE. YdJ MI�Y ALSO RfCEIVE A
STATEl�J�T F�t iDSPITAL FEES. THANC YOU FOR t�SIN6 PSH
f�DICAL 6'RGU� F�! YaAt PFKSICIAN SERYlCES.
- - _ ._ _ _ _ FII�tAt�IAL ASSISTIWCE IS AVAILAHLE_TD_PATIEN�S i�D CAN�T_AfFORD-__._ ______ ___ _
TO PAY TFEIR t'�DIGAL BILLS.IF YOU iIAYE QI�STI0I�LS REGIIRDIN6 YOUR
BILL CI[LL jee�00-254-2619 OR 717-531-5�i9�eeE �t YISIT US AT
TI� bCADEF�C SUPPORT BlD6., (OFf IDPE DRIVE), ilOOM 2106. tqJJRS
ARE Fqd 8AM-8PMs TtJES & MffD 8AM-5:30PM, THJRS � FRI 8AM-4:30PF1.
❑CHECK BOX AND ENTER ANY ADDRE55 OR INSURANCE CORRECfiONS ON BACK
Health Network �•�""°�""�''"�°"°"°°'"a`.F"'°"T�°""'
L A B O R A T O R I E S �Nan� I�u�e�x�� �oieoove��
� 2024 LEHIGH STREET `�"'� °'"°`
ALLENTOWN, PA 18103 �,u� ,,,,s„�,�
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STATEMENT DA'iE PAY THlS AMOUNT ACCOUNT NO.
Piease contact your insurance company
for an explanation of your biil. 11/O6/2013 s20.02 248L109397-0
CNRRGES AvD CREDI7S E.3AOE AF('ER S7ATE't,fiEMT SHOW AMOUNT�
6:,TE LVILL APPEAR ON ttEXT STATEtAEtiT. PAID NERE
Patient Name: KARL D JACOBS
��MAKE CHECKS PAYABLE/REMIT T0:�
II�III�'I"'�I'I�I'�1���1"II�I�'IIII�'lll'I���I�IlII��I��Ilil�l' °40°$ HEALTH NETWORK LABORATORIES
KARL JACOBS PO 80X 85DO,LOCKBOX # 9581
� � C/0 MARIA JACOBS PHILADELPHIA, PA 19178-9581
22 GALE RD
CAMP HILL PA 17U11-2619
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mformadon has changed,and H�cate d�ange(s)on reverse side. Y011R PAYMENT IN ENIX.OSED BdVQ.OPE
Physician: BAXTER DREW WL�LLMON Diagnasis Code: 285.2g,v58.�
Date ' Desc�iption Amount
Procedure
Code
08/15/13 36915 PHLEBOTOMY CHARGE 8.32
OQ115/"13 80098 BASIC METABOLIC PANEL 22.51
Ot3/15/13 E34550 URIC ACID 13.87
Of3/15/13 85025 CBC WITH DIFF 23.23
Ut3/15/13 P9604 NURSE HM TI2AVLrL F'LAT 1.26
08/15/13 PIMC NOT APPROVED (11/06/2013,PIMC,1,92,00 -5.32
08/15/13 PIMC NOT APPROVED {11/06/2013,PIMC,1,43,00 -10.88
08/15/13 PIMC PAYMENT (11/06/2013,PIMC,1,93,0003350 -2.22
08/15/13 PIMC NOT APPROVED (11/06J2013,PIMC,1,99,00 -5.80
OB/15/13 PIMC PAYMENT (11/06/2013,PIMC,1,49,0003350 -4.35
08/15/13 PIMC NOT APPROYED {11/06/2013,PIMC,1,45,00 -12.54
08/15/13 PZMC PAYMENT (11/06/2013,PZMC,1,45,0003350 -7.18
08/15/13 PIMC PAYMENT (11/06/2013,PIMC,1,96,0003350 -0.88
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Current 31-60 Da s 61-90 Da s 91-12�Da s 727-180 Da s Over 180 Days Amount Due: i20.02
$20.02 $0.00 $0.00 $0.00 $0.00 $0.00
HEALTH NETWORK LABORATORIES
PO BOX 8500,LOCKBOX#9581
PHILADELPHIA,PA 19178-9581
If you have provided insurance information,the Amount Due Tax ID: 23-2948774
represents your insu�ance co-pay, deductible or non-cove�ed &���9 q��ons cau:610-402-8170
services. PIMC DEDUCTIBLE$11.46 Toll free 877�402a1221
Fau 610-+l02 7681
Account Number:248L109397-0
STATE�AENT Patient Name:KARL D JACOBS
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