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Home My WebLink About02-25-14 COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OFREVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 77128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 018807 CALABRO LINDA J 2459 ST AUGUSTINE BLVD HAINES CITY, FL 33844 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- fold 14106241 � 5378.19 ESTATE INFORMATION: SSN: I FILE NUMBER: 21 1 3- 1 268 � DECEDENT NAME: SIMOKAT PATRICIA A � DATE OF PAYMENT: 02/25/2014 � POSTMARK DATE: 02/21/201 4 I CoUNTY: CUMBERLAND � DATE OF DEATH: 09/09/2013 I � TOTAL AMOUNT PAID: 5378.19 REMARKS: CHECK# 7517 INITIALS: CJ SEAL RECEIVED BY: LISA M. GRAYSON, ESQ. REGISTER OF WILLS TAXPAYER � pennsylvania BUREAU OF INDIVIDUAL TAXES Pennsylvania lnheritance Tax DEPARTMENT OF REVENUE Po BoX zso6o� Information Notice HARRISBURG PA 17128-0601 REV-1543 EX DocEXEC cos-iz� And Taxpayer Response FILE NO.2113-1268 ACN 14106241 DATE 02-05-2014 Type of Account Estate of PATRICIA A SIMOKAT Savings SSN 200- 2013 Trust LINDA J CALABRO County CUMBERLAND Certificate 2459 SAINT AU6USTINE BL HAINES CITY FL 33844-2420 n _ ; T _�� _ . �--. - - �-_� . , ;_� ; ,._.; _._., _ �., -,:: - "'. � . ��-.: r_•_� _ 1 .., — i__ '_ .�-^. _.. i �,.�,.. __.:. .. - _..." ',._.✓�....... - ---J �`:=', __Y �.'`> � C..'" AMERICHOICE Fcu 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.36225 REGISTER OF WILLS Date Established 06-04-2004 1 COURTHOUSE SC�UARE Account Balance $6,303.10 CARLISLE PA 17013 Percent Taxable X 50 Amount Subject to Tax $3,151.55 Tax Rate X 0.120 NOTE*: If tax payments are made within three months of the Potential Tax Due $378.19 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 uThe information is The above information is correct, no deductions are being taken, and payment wili be sent correct. with my response. Proceed to Step 2 on reverse. Do no t c h e c k a n y o t h e r b o x e s. 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 inf Complete Part 2 and part 3 as appropriate o nthe back of th s forlm. listed. 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�roceed t Step 2 onPeverseatiDo not check any other boxes. REV-1500. 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), Qlease 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 your relationship to the decedent: � 1. Date Established 1 2. Account Balance 2 $ 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 $ \ 5. Debts and Deductions 5 - 6. Amount Taxable 6 $ 7. Tax Rate 7 X . ,. ._ � ., „ .. _ 8. Tax Due 8 $ �� 9. With 5%Discount(Tax x .95) 9 X � �� Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills,Agent." Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. Work �� Home b3- a a • 35S 9 � � � 2�0 axpa er ' natur _ 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 , ..a._ �+ N ("� � � � � rSF . �� '. I�Ir- (�/� � � �..; , �� _;_�� n y 7d � � � � � - _ , ._ �.� �, � �. ' W � w co t �� - - ,' , �' � � {,�._- _ . _ -.., ._. .,,�, f�;� � � � � 1 � ~ °� . 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