HomeMy WebLinkAbout12-29-14 BUREAU oF INDIVIDUAL TAXES Pennsy�vania �nheritance Tax � Per11'1S�/LVa111a
PO BOX 280601 DEPARTMENT OFREVENUE
HARRISBURG PA 17128-0601 Information Notice
REV-1543B E%OocE%EC (OB-12)
R����D�� ����i�T�ayer Response FILE N0.2114-1048
�ry n �. „i�� ACN 14508568
���j����Y `�" ��"-�-5 DATE 12-09-2014
?�l� `}��' 2� �� 3 �a Type of Account
C L���'--`'� �'� Estate of CAROL A COOLEY Security
^�(�'''�Y X SEC Acct
�R P t�A p��� 'J''`'�t` �,,, Date of Death 10-23-2014 Stock
DAVID A COOLEY C�J�,�i��:�� f - � � � `` CountyCUMBERLAND Bonds
6003 SKYHAVEN LN
SPRIN6 TX 77379-2440
TWEEDY BROWNE FUND 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.
Rerr�t Payment and Forms to:
Account No.1019179278
Date Established REGISTER OF WILLS
Account Balance $62,037.47 1 COURTHOUSE S(�UARE
CARLISLE PA 17013
Percent Taxable X 100
Amount Subject to Tax $62,037.47
Tax Rate X 0.045
Potential Tax Due $2,791.69 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 ofher boxes and disregard the amount
shown above as Potentia/Tax Due.
g dThe 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 nof 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 nof check any other boxes.
�
Please sign and date the back of the form when finished.
,1
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),
- please obtain a written correction from the financial instituiio�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 ore 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.
,�y� ������� �a. , � � r. t��\ � ���
If indicating a different tax rate, please state � � � �,, � � � ��� \��
your relationship to the decedent: �� ���• '�- ` ` �� �� ���
1. Date Established 1 ���� � V �`
\���\�\\. \ ��\ \��� �
2. Account Balance 2 $ ��������� � � � � �
� � \ \\; ' \ �\
3. Percent Taxable 3 X �����\�� � �� � � ' � �
������� � '. � ������ ��, ��
4. Amount Sub'ect to Tax 4 $ "���`
\\\�\\���o�\ � �. � \�\� . .��\ �\\�
� ���;� � \V �\v � \ \
5. Debts and Deductions 5 - ������������ ��, ��������� � ��� � \���
���\��\� �.\ �����s., �� �� ��.���
� � \\\ \
6. Amount Taxable 6 $ ���� � � � � �y��������
7. Tax Rate 7 X -_.--------- `���\��y A��V\ ��\�A������\��A\�� \\�.A �A \\�\
__'__"_ ___ '.__'__._ �`�V A� �A��\�A A� ��m'^v� y .. �� �� - \.�`,�� ����V�:��<
8. T� Due 8 $ ���� �.: � �\
�A��`�A . � `� � ���
9. With 5°�a Discount (Tax x .95) 9 X ��\�\�\�������� ������`\\'\�� ����� \��O \\\� \\\\\.����\\
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 �113-'�46-763�. 1�1 �!� �
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
BOR�,� oF INDIVIDUAL TAXEs Pennsylvania lnheritance Tax � PennS�/LVd1118
PO BOX 280601 Information Notice DEPARTMENT OF REVENUE
HARRISBURG PA L71PB'OFOZ ' REVQ543B ex moexee <oe-in
And Taxpayer Response FILE NO.2114-1048
R�G���� ���}�� �'� ACN 14508569
� �,,.r� rJ,.- ��s.,����c� DATE 12-09-2014
��I� (���' 2g �f� 3 2y Type of Account
G� `P ._ `;- Estate of CAROL A COOLEY Security
,••.,.,-�-
SSN 186-34-2120 X SEC Acct
����j',§t , � J � ��, � County CUMBERLAND14 Bonds
6003DSKYHAVENYLN ����'��`� �;
SPRING TX 77379-2440
WELLS FARGO ADVANTAGE 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.3903093500
Date Established REGISTER OF WILLS
Account Balance $57,595.83 1 COURTHOUSE SGIUARE
CARLISLE PA 17013
Percent Taxable X 100
Amount Subject to Tax $57,595.83
Tax Rate X 0.045 NOTE': If tax payments are made within three months of the
Potential Tax Due $2,591.81 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 otd 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 �fhe 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% 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
2 Debts and Deductions
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),
please obtain a written correciion firom ihe fiinancial insiiiution and a�tach it to this fiorm.
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.
��� � �� �., F ,� � �,,. ,. � �
m icating a different tax rate, please state ������ ��������� '�� � �
your relationship to the decedent: ���\� �` � ��� ��o, � � � � V�
��������� � � A �����a ��
1. Date Established 1 \�� ��V� � � `�' � � ��
� �\� � � A �� ����
, ._.� .� ,, , � ����
2. ACCOUtIt B8I311C@ 2 $ ��` ��� � �� �� .� � ��
3. Percent Taxable 3 X ��\��\\ � , : � �
��\������ �\\`���\ �� �� �\\\ �\ �� ���`�
4. Amount Subject to Tax 4 $ �\��\�� �� �\�\��\�\� \�� ����, � �� � � � \
��������� � �\\�� ��\\�\\�\\�� �\� \�� �
5. Debts and Deductions 5 - ` �
����\�������. . �,. � .\`\\ \��� �� �. �`\\��
6. Ar710Unt T3X3b18 6 � �����\V � � S \\�� ` V�V�'�\\� \�� �\�\AV �"
������\��� ���\ \\� �\\������ �������
7. Tax Rate 7 X ����������o� � y � ���s������� � �
��� ��`��x\��\�V`�� ����VAr`� " �VO V�.�� � �
8. Tax Due $ $--�----------�-�---___ ___--- ������ ������ �., �� �
�������`,\� �` \\ ` \� � `\`�
���\\�. �� ��� \ \\ `�� `� �a`��
9. With 5% Discount(Tax x .95) 9 X \��\\�\� ��\�� ���'�:����� ���������\�a�\��� \��,�����\o��;�va��
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 i3 ��l`t6��63Z, Iez..li /
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 SPECtAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020
B�R�,� oF INDIVIDUAL TAXES Pennsy�vania �nheritance Tax � PennSY�Va111a
Po BOX 280601 Information Notice DEPARTMENT OF REVENUE
HARRISBURG PA 17125'OGOL ' REV4543B ex na�exec eoe-iz�
And Taxpayer Response FILE NO.2114-1048
� R E G 4 ���� !�a i��� �F ACN 14508570
R��t .�_., ,,� , ,, DATE 12-09-2014
Z��y ��L 2s �f� 3 2y Type of Account
Estate of CAROL A COOLEY Security
�'-�-' �` "' SSN 186-34-2120 X SEC Acct
�R F N�;; ' �';�'','i� Date 2014 Stock
DAVID A COOLEY R,�ounty CUMBERLAND Bonds
6003 SKYHAVEN LN ����`"�i}+ ` ^
SPRING TX 77379-2440
ROYCE FUNDS 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.880027796
Date Established REGISTER OF WILLS
Account Balance $38,848.53 1 COURTHOUSE S�UARE
CARLISLE PA 17013
Percent Taxable X 100
Amount Subject to Tax $38,848.53
Tax Rate X 0.045 NOTE*: If tax payments are made within three months of the
Potential Tax Due $1,748.18 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 a6ove as Potentia/Tax Due.
g dThe 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% 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 dAsset 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.
,l
f
Please sign and date the back of the form when finished. �~ `�
�
�/
PART
2 Debts and Deductions
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(�ine 3),
please obtain a written correction from the financial instiiution and aiiach it to this#orm.
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°/a, 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 �� ������������ "�� ��;, � � ��� ���� ������,���
our relationshi to the decedent: ������� �"�\� �,, ��s' � � �V�
Y P
\�\���\ � � � � �.. \\\\
1. Date Established 1 �� ���\��\ �\ �\ � ����
� � \
2. Account Balance 2 $ : � ` ` ` ,' '��. <���� � �� ��
. �
3. Percent Taxable 3 X �\`�� , "
����\� \� � �� �\ `, �� \, � ��
4. Amount Subject to Tax 4 $ ��, , � � � '
` �\ �� � �. �� �' \��� \�A ���� ,
�����\�\\�. e \���� � � ���\� ��\\
����� � �. �� � o �\���\�
5. Debts and Deductions 5 - � ��� �� �� � ��� ����� ��
: \\���� \\ � �� �\ �����`\��\\.\
6. Amount Taxable 6 $ \,
� �� � � \ `V�\V��� A \
7. T3x R3t@ 7 X ��� �� ����������A\�o������ � �V ���
���\�\\\�\V�°`\ \� \\�O \\V ��O �\ � � � ��`0�
�, � � �\ ��\\
$ � ���� � a� .. ��Ao�.:�A� `�� ���� ����AO� :�� � V\o �p0������
8. Tax Due � �� � � �
X ����\�� ��� ��\ \� �\ � \ �
9. With 5% Discount(Tax x .95) 9 ��\������\����,:��o� ���� \ ��� ����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 "1�3 -� 6 - �3� ��C l�/ r'1
Taxpayer Sign ture 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 Penns �vania �nheritance Tax � Per11'1S�/LVat11a
PO BOX 280601 �
HARRISBURG PA 17128-0601 IIIfOCI71atI011 NOtICe DEPARTMENT OF REVENUE
REV-1543B EX DocEXEC (OB-12)
And Taxpayer Response FILE NO.2114-1048
ACN 14508571
DATE 12-09-2014
RECORCE�J CiFFiCE �f TypeofAccount
����`�v'Y� �" �����}�-�state of CAROL A COOLEY Security
X SEC Acct
DAVID A COOLEY 7��� `�`-U �J �� � �oUntyCUMBERLAND14 Bonds
6003 SKYHAVEN LN
SPRING TX 77379-2440 �`Lr��;,; ;?��
'1^T
ORF�':�.;�ti�` C �i ;
����n r,l. '. � +,
VANGUARD 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.9896745017
Date Established REGISTER OF WILLS
Account Balance $41,697.83 1 COURTHOUSE SQUARE
Percent Taxable X 100
CARLISLE PA 17013
Amount Subject to Tax $41,697.83
Tax Rate X 0.045 NOTE": If tax payments are made within three months of the
Potential Tax Due $ 1,876.40 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 Potentia/Tax Due.
g �The information is The above information is correct, no deductions are being taken, and payrnent wii! 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% 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 �sset 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 ofher 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 tinancial institution and anach 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 tax rate,please state ��������`�\�"`�\ �� �`; ��� ���'�\ � ����
���\�o��\� � ��,�� o��� �� ����\\ \ ������
your relationship to the decedent: � A� �� , � ,_ � ���;�
�� \
����
1. Date Established 1 \�\�`,, ���\ ' �\�\\` \�� \ �\��
.� �� ,���:�� ��`\
2. Account Balance 2 $ ����`` ` `' ` .� ` �\�
��� �., � . ' ' �. ,
3. Percent Taxable 3 X �\������ � � �A ` ��` s� � �� � ` `����
4. Amount Sub'ect to Tax 4 $ �\� `� � ��
1 \\�� � ��\
�� � �� �A\ ��
5. Debts and Deductions 5 - ` �� ` ��� ��A �' �`��
��� � ,� o. .� ��� � �� �. � \ �A�
6. Amount Taxable 6 $ ` ` � ` �` ` �`"
`� \� �� �\ a��� �\ ���\
�. T1X R 2t8 7 X ` �`���V�V �VAA�V� ���\�� \A `�\\ VA� �\�V��\�_ AA`�A\���A�
� S�C O��� ��������� \\��\\������'�\\� ��\����\�� �.::����`s`� \��\���
8. Tax Due 8 $ � �, ������� �� � ���� � :� s �.
��� � ���� �� �� �� ���� ��.� � ����\"���
X ��� � � ���\��� �\�\ �\u\�\\\ \c��Y�\�\\��\�o��
9. With 5% Discount(Tax x .95) 9 ���������oo� ��. ���
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.
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Home `1�3.- -�63 «-1
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
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