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Home My WebLink About12-08-14 REV-1162 EX111-961 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD OZOOOH KHAN HASAN K 407 MERCURY DR MECHANICSBURG, PA 17050 ACN ASSESSMENT AMOUNT CONTROL NUMBER ---------- -------- fold 14124791 � $64.42 ESTATE INFORMATION: SSN: � FILE NUMBER: 21 14-0441 � �ECE�ENT NAME: KHAN KHALIL AHMAD I DATE OF PAYMENT: 1 2/09/2014 � POSTMARK DATE: 1 2/06/2014 � CouNTY: CUMBERLAND � DATE OF DEATH: 05/02/2014 � � TOTAL AMOUNT PAID: 564.42 REMARKS: CHECK# 197 INITIALS: HMW SEAL RECEIVED BY: LISA M. GRAYSON, ESQ. REGISTER OF WILLS REGISTER OF WILLS BUREAU oF INDIYIDUAL TAXES Penns Ivania lnheritance Tax � � enr1S Lvania PO BOX 280601 Y . . � Y HARRISBURG PA 17128-0601 IIIfOCfllatlOC1 NOtIC@ DEPARTMENT OF REVENUE And Taxpayer Response RE�-`5`3 EX°°`EX` <°B-'Z' FILE NO.21 -/�- � I ACN 14124791 DATE 05-13-2014 Type of Account Estate of KHALIL A KHAN Savings SSN 419-02-6797 X Checking Date of Death 05-02-2014 Trust HASAN K KHAN County CUMBERLAND Certificate 407 MERCURY DR r-v MECHANICSBURG PA 17050-5273 � � � � C � � � � �7 � � C.? r� � c-� c�' cn � =�' :v �" --� ;.,. " � � � � C.(�) .�"."7 »'.".� . ,, . (,'> C:7 C.':;l � � �L7 "�'� �'Yl "� L-- �7 � �" C� ;--�� --�t---� ----_ T � � � � �- � 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. Account No.484977 Remit Payment and Forms to: Date Established 11-17-2012 REGISTER OF WILLS Account Balance $8,589.75 1 COURTHOUSE S�UARE Percent Taxable X 16.667 CARLISLE PA 17013 Amount Subject to Tax $1,431.65 Tax Rate X 0.045 Potential Tax Due $64.42 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. � �i ha i�fc;matien is 7he a�ove informatior is ccrreci, r�o deductions are being iaken,and payment will be seni correct. with my response. Proceed to Step 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. Comp/ete 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), piease obtain a written 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 ,�,`�;`� `�` L�j � � "y�� `��,�\\;��`,�; s �\�\��\�� \o��t��+��\ $�.��3��\\\\��p��y�� \ your relationship to the decedent: ,�� , ��o��\��,�� \��\��`��\��'\��°�� , �� \�� a::c��\\�\\\��\ 1. Date Established 1 �\�\�\��` ��`�� `,�,��\��\�\��\��\��\\��\ �� . ��, �� \��,�� 2. Account Balance 2 $ � � � �� A\��V\��\�o` �`��\��\\�V��\�A��\\��VA�� X \�� o �� o� � 3. Percent Taxable 3 �� @ � � ��A �� .��A��\�� . �� AA�� \V��V��A��A .A�� 4. 14111OUllt.SUb @Ct t0 T3X 4 W � A�V �� A�\ �� A� �V ��A `VAVA�:��'�A�� \�� 1 ` � ��\�� \��.��\�� \\\�.,`\\��\��\\��::;° �J. �@btS 1f1C� �@C'�UCtI0f1S rJ - � ��\y� A�o�A��A� �o�� A�A\\�� \�� A� ��A\�Ay� A��A�� ` �� A��\V�VA��A� �� p��.��\�� \� 6. Amount Taxable 6 $ ��` �` �� v�� A\�VA��\��A V�\V�� `�� A��V��A�\\�� \�VV\\�A��\�� \ � '��5��A0��\��AVA��\��A - 7. T3X f38t2 7 X � ��o� � � \�� A��\��\��`��y�� ;�V� �� r�� A�.�A��"�� : �� `. 8. T3X �l.l @ 8 � \V��A��\\�-��A A�\VA A �VA��V��"�V��A�� A ��- � ��A��,�� V�� AA��A� Ap��\\�\��Aj��A��AV�� V � �A�� AAA�AA��A 9. With 5%Discount(Tax x .95) 9 ^ ��\� ....:� o��..�:..�� .�.,a.;:�\\\\\\�.�\ �\�\��\\\��a��\\��jp\�\\�...\�\\��.aa\� Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wilis 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 �`5 y - ;Z�- -cj 4'�(�� ('�'�'� Home ° � 1 '-�5- 1� Taxpayer ignature Telephone Number Date } � '��' � +.4 IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. 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