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Home My WebLink About05-12-14 (4) COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(71-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 ' HARRISBURG,PA 1]128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT N0. CD 019140 DACHEUX E EVANGELINE 92 N WANUT ST SPRING GROVE, PA 17362-1026 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- ---------- -------- 14122484 $309.04 ESTATE INFORMATION: SSN: FILE NUMBER: 2114-0447 DECEDENT NAME: LAY JOSEPHINE J DATE OF PAYMENT: 05/12/2014 POSTMARK DATE: 05/08/2014 COUNTY: CUMBERLAND DATE OF DEATH: 01/20/2013 TOTAL AMOUNT PAID: $309.04 REMARKS: CHECK# 2327 INITIALS: DB1 SEAL RECEIVED BY: LISA M. GRAYSON, ESQ. REGISTER OF WILLS REGISTER OF WILLS BUREAU OF INDIVIDUAL TAXES Pennsylvania Inheritance Tax pennsylvania PO BOX 280601 DEPARTMENT OF REVENUE HARRISBURG PA 17126-0601 Information Notice xev-isaa ex noocxec (aeaz) And Taxpayer Response FILE 2 1 —NO. —jy—Lfq1 ACN 14122484 DATE 05-02-2014 Type of Account Estate of JOSEPHINE J LAY Savings SSN Checking Date of Death 01-20-2013 Trust E E DACHEUX County CUMBERLAND X Certificate 92 N WALNUT ST SPRING GROVE PA 17362-1026 - N M C o Cc a aR r~vo (n 77 3C C7 C3 Q C r J C' FA m on o SUSQUEHANNA BANK provided the department with the information below indicating that at tt* deatWbf the above-named decedent you were a joint owner or beneficiary of the account identified. Account No.10004657655 Remit Payment and Forms to: Date Established 03-26-2009 REGISTER OF WILLS Account Balance $5,067.76 1 COURTHOUSE SQUARE X Percent Taxable 50 CARLISLE PA 17013 Amount Subject to Tax $2,533.88 Tax Rate X 0.150 Potential Tax Due $380.08 NOTE If tax payments are made within three months 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 `J The information is The above information is correct, no deductions are being taken, and payment will be sent LLl1 correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. C ZThe 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 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 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. 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"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. It 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 $ .75 .9 3 . 3 5. Debts and Deductions 5 - 4 6. Amount Taxable 6 $ 8 7. Tax Rate 7 X IR ~/Q 6 8. Tax Due 8 $ .10 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 / — o! TaxpayeT 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 4 �J ' s , { , i •�at(i �1 I/� M ra CV 111 i M m a o } N a LAW W� Q C t a