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Home My WebLink About04-11-14 ;BURFAU OF INDIVIDUAL TAXES Pennsylvania lnheritance Tax • pennsylvania PO BOX 280601 DEPARTMENT OF REVENUE HARRISBURG PA 17128-0601 Information Notice � .- REV-154b EX DocEXEG (OB-12) And Taxpayer Response � FILE NO.21-I�` �J�� :`, '� �a �' . ntr ACN14116310 - ��'L �� DATE 03-26-2014 2014 AaR 11 P(� 1? ��$ Type of Account CLERK OF 2go3LORNER Savingsg Checkin 0 R P�i A N S� C 4�j� Date of Death 03-17-2014 Trust 6LENN I ORNER � CU�A,�ERLANC �� tCOUntyCUMBERLAND X CertifiCate 421 PAWNEE DR MECHANICSBURG PA 17050-2547 MEMBERS isr 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.229513 Date Established 07-28-2012 REGISTER OF WILLS Account Balance $1,150.99 1 COURTHOUSE SGIUARE CARLISLE PA 17013 Percent Taxable X 50 Amount Subject to Tax $575.50 Tax Rate X 0.120 NOTE*: If tax payments are made within three months of the Potential Tax Due $69.06 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 ul�he 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. i PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following cr'iferia: A. The decedent was legally responsible for payment,and the�es#ate 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 CaICUIatIOtl 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 finar�cial ins#itutiors and attach it to this f�rm. 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 taxabie 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 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 /7 � — d�� `/ a / 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 T,�ES Pennsylvania lnheritance Tax � pennsylvania PO BOX 280601 HARRISBURG PA 17128-0601 IC1fOCIT1at1OC1`ItIOtICe DEPARTMENT OF REVENUE REV-1543 EX DocEXEC (0E-12) And Taxpa er Response 2 RECORD Q OF�IC� 4� ACN N0.163114� J�`� f��!S� � ^F �I L L S DATE 03-26-2014 �� R �� Type of Account ��,��;{ i�� Estate of MERLE L ORNER Savings ORPHAtJS` COURT Checking -� Date of Death 03-17-2014 Trust GLENN I ORNER GUM6ERLAr�d Cp,� P/� CountyCUMBERLAND X Certificate 421 PAWNEE DR MECHANICSBURG PA 17050-2547 � MEMBERS isr 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.229513 Date Established 01-22-2009 REGISTER OF WILLS Account Balance $9,669.23 1 COURTHOUSE S�UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $4,834.62 Tax Rate X 0.120 Potential Tax Due $580.15 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 Step 2 on reverse. Do not check any other boxes. � �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 appropriafe 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 foliowing criteria: A. The decedent was legally responsible for payment,and the�state is insuffici'�nt.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"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 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 $ � 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 Hom � � 3 - /a 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 lnheritance Tax � pennsylvania PO BOX 280601 DEPARTMENT OFREVENUE HARRISBURG PA 17128-0601 Information Notice � REV-1543 E%DocE%EC (OB-12) And Taxpayer Response FILE NO.21--►�-�`�� RECORD D OFFICE OF ACN 14116312 �._ DATE 03-26-2014 zOly �?R 11 P�I 12 y$ Type of Account Estate of MERLE L ORNER Savings ' ��-��`:+� d� Checking ORPHA�aS' G�URT CountyCUMBERLAND14 X Certficate 6LENN I ORNER ~� 421 PAWNEE nR CUMBERGAF�D GO,, p/� MECHANICSBURG PA 17050-2547 MEMBERS isr 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.229513 Date Established 09-03-2010 REGISTER OF WILLS Account Balance $72,404.04 1 COURTHOUSE S�UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $36,202.02 Tax Rate X 0.120 Potential Tax Due $4,344.24 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 Step 2 on reverse. Do not check any other boxes. � �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. . .� , PART Debts and Deductions 2 Allowable debts and deductions must meet both of the foilowing criteria: A. The decedent was legaliy 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 cQrrection 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 tau 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 I8. 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 � � - Taxpayer Signature Telephone Number ate IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA DEPARTMENT OF RE�ENUE 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 -� . _.. r,... � ...:��.,,-.�.w.,.�,..,�. � - --��,�.�>�.�.. `. BURFAU OF INDIVIDUAL TAXES Pennsylvania lnheritance Tax � pennsylvania PO BOX 280601 HARRISBURG PA 17128-0601 II1fOrI71at1011 NOtIC@ DEPARTMENT OF REVENUE `:qit+YY d� �� +k'. REV-1543 EX DocEXEC <OB-12) .-• - `� f�hd�Taxpayer Response FILE NO.21 `��}-,�j�� R�C Q�,�},�j�,�� Q.� ACN 14116313 � � �; DATE 03-26-2014 ZOl� R�R 1� t � �2 �� Type of Account ��. Estate of MERLE L ORNER Savings �� 4� ��°'�� Checking 0 R P N A.S�S' C 0 U RT Date of Death 03-17-2014 T�ust 421NPAWNEENDR ��MaEf��.A�� Q., PA CountyCUMBERLAND X Certificate MECHANICSBURG PA 17050=`2547 -- MEMBERS isr 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.229513 Date Established 01-11-2007 REGISTER OF WILLS Account Balance $9,876.21 1 COURTHOUSE S�UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $4,938.11 Tax Rate X 0.120 Potential Tax Due $592.57 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. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legaliy responsible for payment,and the estate is insuf#icient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of paymenYifi 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 T$X C�IICUIat10n 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3), please obtain awritten carrection from*.hs t�inancial ins#it�tion�nd a�tach it#Q 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 totai 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 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 �' Taxp yer 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 � B�R�o oF INDIVIDUAL TAXES Pennsylvania lnheritance Tax � PennS�/�Val11a PO BOX 280601 DEPARTMENT OFREVENUE HARRISBURG PA ��28-060� .. Information Notice REV-1543 EX DocE%EC (08-12) And Taxpayer Response FILE NO.21—r(�-7�I y RECORDEQ OFFICE 4F ACN 14116342 � �(��c�� DATE 03-27-2014 �p�y fla� 11 �� 12 `18 Type of Account C��,� �F, Estate of MERLE L ORNER Savings Checking � Q�P�j Q��' ��R� Date of Death 03-17-2014 Trust ** GLENN I ORNER ��BE��a� �Q.� PA CountyCUMBERLAND X CertifiCate 421 PAWNEE DR MECHANICSBURG PA 17050-2547 MEMBERS isr 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.229513 Date Established 07-03-2013 REGISTER OF WILLS Account Balance $2,257.22 1 COURTHOUSE S(�UARE CARLISLE PA 17013 Percent Taxable X 100 Amount Subject to Tax $2,257.22 Tax Rate X 0.120 Potential Tax Due $270.87 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 Potentia/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. e PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legaily 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), ` piease obtain a writ�en correction from the financiai 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 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. T� Rate 7 X ��. _ o .. �� s .��A��.�� <. ,. �; `�`�.�`. � �� '°: �. .� �v �:.��..�� .�� 8. Tax Due 8 $ ��\\\ � � � ��d_ � �\\ � 9. With 5% Discount(Tax x .95) 9 X ��V� �, �� \� e„�� ,�, ��:�� 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 "�l �o Taxpayer Signature Telephone Number Da e 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 ;. ,. ; �.�. ., ., -� � < :�w � ',� ;o . - �. .. . . ° � � � O �. - a� - � _ � � � _ �,�, �. M � � O U � '—' � '� n�, ti� ..n � � '��' � -- t�� ?�� UOU �" .,.., l:::� ;�. :,.., `�d ''4� Q��1��9Wt1� 1�f10a .SN�Hd�O �; o �0 ',y:�3la � °� � �' s� z t c�d r T �c� htoa w � ¢ � � a �s � on � .� .� Sl�l�� :; ��1Sf�3� .� � �� .�0 3�i.��a Q30�Oa3a �. - � �� s .c � � � v fx � r