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Home My WebLink About12-10-14 COMMONWEALTH OF PENNSYLVANIA REV-1162 EX�11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 020014 BURKHOLDER MARY S 421 BRIAR LANE CHAMBERSBURG, PA 17202 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- fold _'___""' """" 14161591 � 528.71 ESTATE INFORMATION: ssrv: I FILE NUMBER: 2114-0996 I �ECE�EtvT NAME: HEBERLIG MILDRED C � DATE OF PAYMENT: 12/10/2014 I POSTMARK DATE: 1 2/09/2014 I COUNTY: CUMBERLAND � DATE OF DEATH: 1 O/01/201 4 I � TOTAL AMOUNT PAID: 528.71 REMARKS: CHECK# 3525 INITIALS: HMW SEAL RECEIVED BY: LISA M. GRAYSON, ESQ. REGISTER OF WILLS REGISTER OF WILLS BUREAU OF INDIVIDUAL TAXES Penns Ivania lnheritance Tax � el'11'1S lvania PO BOX 280601 y � p y HARRISBURG PA 17128-0601 IllfOrfllatlOf) NOtIC@ ' DEPARTMENT OF REVENUE And Taxpayer Response RE"-'S°'Ez°°`ExE` `°B-'2' FILE NO.2114-0996 ACN 14161591 DATE 11-12-2014 Type of Account Estate of MILDRED C HEBERLIG Savings SSN Checking Date of Death 10-01-2014 Trust MARY S BURKHOLDER County CUMBERLAND X Certificate 421 BRIAR LN CHAMBERSBURG PA 17202-3109 � C � � � � � _�._._._��.__._._.__. � � r� � 4 rn �- � c:� � � a� �> r- �, --� � !�� ;,,.� rr� � r'�n r`n ORRSTOWN BANK provided the department with the information below indicating that-at{�i'.e;:c�eath of th� � above-named decedent you were a joint owner or beneficiary of the account identifieti.�=? <;:, '� r-n -�, Account No.20040614 Remit Payment and Forms to: ,y�� ►—� � cs � __+ �v �"' rn Date Established 06-06-1991 REGISTER OF WILLS �:' crt c�n c� Account Balance $8,057.32 1 COURTHOUSE S�UARE --c ``� Percent Taxable X 8.333 CARLISLE PA 17013 Amount Subject to Tax $671.42 Tax Rate X 0.150 Potential Tax Due $ 1 pp.71 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 belo�nr. � � , . 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 iiate of death. Proceed to Step 2 on reverse. Do not c,heck any other boxes and disregard the amount shown above as Potentia/Tax pue. . g �The iniormatiun is i he above information is correct; no deductions are being taken, and payment will be sent correct. with my response. Proceed fo 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. 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 tnheritance 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 anii 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 forrn. 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 indicatin a different tax rate, pl e state ��`,��,��`�� ` �, ��s\��\"�� 9 ��\\\�\��\\�\"��\y.�\\� �� \��. ��\\\\ your relationship to the decedent: ��`,\�� "�� \��y, y\\��\��.\\\.\\�� \ ��s � �Z�� ,�� .�� \\� 1. Date Established � .,- .. l ��\\��\\��\��\\�\�� \°�� `��\ ��; ��,��,�\�\��\ �,��' � . \\��\�\�\� 2. ACCOUfIt B3�8f1C8 2 $ ��/i �� \\ �V�� p� ��\\� ��\� ��\ \\ � . �� \ \�� 3. Percent Taxable 3 X 3 3 ��`�� ` �� `� � � �\ � s�a � ' �� \ � �� A�� \ �� 4. AfilOUftt SUb�@Ct t0 T8X 4 $ ��-�� \�\�\��A�V�V\��V� �\ �� . � ��\��o��o:� �� ., � ��,: 5. D@btS lfld D@dUCtI0f1S 5 - �� V�`\V�VA��`V��A�AV�\��\V\�� `��. � \V`�A��A\�� \��V�\V��V��V�� \��; �� AA � �� A�� Fi. AfT10Unt T3X1bI8 Fi $ �� \V�� V�A��i� ��A�� \��A��o��\�� .��V�� VA V �V� � �� A� � � A� � �� A�� A\ 7. T� Rate �"T'��p 7 X � d�S � ��\��\�A��A��A��A0��\�`�.��\��\\� n� ��_�� ti��c�� \�`v�� . � �� ... 8. Tax Due 8 $ �C7,i�� VV`�A�� yo�V"`�� \ � � A�?�� A�\\y��A\��\��\��\�� A�� `��A�� `��` `` 9. With 5% Discount (Tax x .95) 9 X 7 ��\\�,�� ..�a��.��:��.,��.��:��.��.��..��. 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 — –.3 � � � Taxpaye 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 ��.��,��.� _. _ . � REC�R�ED fl��iCE 0� � N � F3EGISTc^ �'� �'lLLS �' �' � � � � = r � ��I� ��C 10 ?�i 12 5�i °° _ � v- CLE�;F: �� N 0 Qflt i�i e �� 'rtll�"'. N rir:7 is4v�� i W GUMBER� # "' ^�' �:: � ` ,� � i �.:. � •..� �^ L i•i w .. 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