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Home My WebLink About12-17-14 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 020035 SZOLLOSY HELEN MARIE 13 HAZEL CIRCLE MECHANICSBURG, PA 17050 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- fold 14163472 $7.85 ESTATE INFORMATION: SSN: FILE NUMBER: 2114-1185 DECEDENT NAME: KING DOLORES M DATE OF PAYMENT: 12/17/2014 POSTMARK DATE: 12/16/2014 COUNTY: CUMBERLAND DATE OF DEATH: 11/06/2014 TOTAL AMOUNT PAID: $7.85 REMARKS: CHECK# 5626 INITIALS: DMB SEAL RECEIVED BY: LISA M. GRAYSON, ESQ. REGISTER OF WILLS REGISTER OF WILLS BUREAU OF INDIVIDUAL TAXESPenns Ivania Inheritance Tax pennSyLVanid PO BOX 280601 Y HARRISBURG PA 17128-0601. Information Notice DEPARTMENT OF REVENUE REV-1543 EX D..EXEC (88-12) And Taxayer Response q-I lv"� FILE N0.21 I RECORDED OFFICE OF ACN 14163472 REGISTER OF MILLS DATE 11-25-2014 2014 DEC 17 Pm 1 U5 Type of Account CLEgs(atq�f DOLORES M KING Savings 0RP ��jN X Checking AtE�df De%Th 11-06-2014 Trust HELEN M SZOLLOSY CUMBERL)CPY9ty;6UM#6ERLAND Certificate 13 HAZEL CIR MECHANICSBURG PA 17050-3637 PSECU 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.8455880982 Remit Payment and Forms to: Date Established 02-25-2009 REGISTER OF WILLS Account Balance $1,483.83 1 COURTHOUSE SQUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $741.92 Tax Rate X 0.120 Potential Tax Due $89.03 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. B0 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. C [*]The tax rate is incorrect. ❑ 4.5% 1 am a lineal beneficiary(parent,child, grandchild,etc.) of the deceased. (Select correct tax rate at right, and complete Part FX_J 12% 1 am a sibling of the deceased. 3 on reverse.) 15% All other relationships(including none). FDF]=Changes or deductions The information above is incorrect and/or debts and deductions were paid.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 7' Allowable,debts and deductions mustmeet 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' // /7 .2oly �'sreen e Ep, Vi'/la c, 0CWdEQ2oef 8i(l "ecs S�Zv ;:(,9;r 17-112, ge,fq aide V;16-1-c, i/ /'1t 1114 P,,N4t,f 13,10 qv, 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.'F 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"intrust 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 indicatinga different tax rate, lease state re i0e_a o% \\o" \'\ `\�` "Q° \\ p � - �\may \ fi''icla� your relationship to the decedent: 1. Date Established 1 I /2 07 yam\ 2. Account Balance 2 $ 3. Percent Taxable 3 X a.50 \\ \ \ \\\o \\\\ 4. Amount Subject to Tax 4 $ -7 yy L1� 1 120V�� 5. Debts and Deductions 5 T,h v 6. Amount Taxable 6 $ 66, V ` V`�A \vv Avy`°vyvv�1012,w A \ ems a� _ 7. Tax Rate. 7 X _ 0, /20 as? \\\V��\\\\\VA\\��v�\v`\\\Ay� - � � .`.�\`�; Va �M� vy.� vvvAy�\o�y A vvv�r1MAl mac.y 8. Tax Due 8 $ 9• 7_ 6 vy v vv v vvv�v y vvv v v 9. With 5%Discount(Taxx .95) 9 X 7, 1B.5 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. WorkQC Home Ta Payer Signature Telephone Number Date `f11910r4l' 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 M X d' CL .\ 014-1-1`217- 01. 4 4516006368 a 494 .jBOS-4I cp e n`•p�tee`„t yM'sR» etM.:i•4w•:/.rY.• ,E a cu c • >011000138< Ln CR PAYEE ACCT v C3� LACE ENV GTD a � v BANE OF AMERICA � J l V t �(�j 4 U 'arFe3E:•� rszt:`..•.::fs f:rF:.a.`:+ «. Lc) co LN 7 / si.".is . . `.G:•:t7:'- : — :. :t. 00 •—" � g W. K II M•f � •C+f..:t`.aE+44 7':S':".•°::'•i•E! ,l.; . .�i V 0 RESIDENT STATEMENT FROM GREEN RIDGE VILLAGE . ..... Statement Date Due Date Account Number Statement 1 0 210 BIG SPRING ROAD 1 1/30/2014 Upon Receipt 167 NEWVILLE PA 17241 $6.41 (717)776-8200 AMOUNT I MOUNT PAID$ Please m ake check payable to GREEN RIDGE VILLAGE Plea Remit To: Dolores King Presbyterian Homes Inc/Green Ridge/Swaim c/o Helen M Szollosy P 0 Box 416825 13 Hazel Circle Boston MA 02241-6825 Mechanicsburg PA 17050 Please detach and return this portion with your remittance to the address above. Comments PreBill 0-30 31 -60 61 -90 >90 BALANCE DUE!' $6.41 Date Description biyi i Ake '.–dharges i'1-0*y�,ne-W.sj—lia ance Units Balance Forward $669.19 11/21/14 11/21/14 Thank you for your payment ck 5620 $66919 11/05/14 11/05/14 Telephone 1 $6.41 $6.41 Total Balance Due $6.41 Lf /"fzv f d 6fve FACILITY NAME RESIDENT NAME ACCOUNT NUMBER IGREEN RIDGE VILLAGE Dolores King 167 � � N Q � � � � . � � � � � � -,. � o ' ttnn � � Q3 'j: �« � "'- ! "�, � � t. �! �' � i "�' cn `�" �� fi S`� V.r t �' � � � �`1 i� �� -� � � � � � �- � � � ��; \, � � f �r�, .f;J, #'1 t . +,f� r� � ;� � �. � z,• i�� ,� ��;' �� II . �� i .� �..-----