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Home My WebLink About01-28-15 BOR�� oF INDIVIDUAL TAXES Pennsylvania lnheritance Tax � pennS�/LVdl11d PO BOX 280601 HARRISBURG PA 17128-0601 IfIfOClllat1011 NOtICe DEPARTMENT OF REVENUE �� REV-1543B EX OocEXEG (OB-12) And Taxpayer Response FILE NO.2114-1048 ACN 14509144 DATE 12-29-2014 Type of Account Estate of CAROL A COOLEY Security X SEC Acct Date of Death 10-23-2014 Stock DAVID A COOLEY CountyCUMBERLAND Bonds 6003 SKYHAVEN LN SPRING TX 77379-2440 ��-.a C? � ;--.� !� c Q r.t.� � �.. � r <�-.> �,� e-� =.� _... � �> ;;,, :�r� '� =.�= � ."...• c-., �..,.. N � _ °�y i''`l .. '_.. � a 1 � ,..—� a..»� ..... ....��: . .., ',....,;� ':'...) � : :... "�� ..._�.� —...,..� � _,•l 1--� '-_• l 3 FIDELITY INVESTMENTS provided the department with the information below indicating.that af�le c�ea� of the above-named decedent you were a joint owner or beneficiary of the account irlentified. "� `" -t� Remit Payment and Forms to: Account No.216742647 Date Established REGISTER OF WILLS Account Balance $539,059.77 7 COURTHOUSE S�UARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $539,059.77 Tax Rate X 0.045 Potential Tax Due $24,257.69 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 Potential Tax Due. g �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% I am a lineal beneficiary (parent,child, grandchild, etc.)of the deceased. (Select correct tax rate at right, and complete Part � �2% 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. Complefe 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 fo 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), 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. 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. ��\\��' � ' ��, �� y �\\� � � �� . If indicating a different tax rate, please state �� \ �\�\ your relationship to the decedent: �A�� `�� `� \ � 1. Date Established 1 ��A � ��`��\�\��`��`� �� \\�� \ \ ��. \��,, \ 2. Account Balance 2 $ 53�, o Sy •`�,S- �� ` \�� y � �� . .� �� , � � 3. Percent Taxable 3 X Ivo �� 4. Amount Subject to Tax 4 $ 535 , e,�4-4Y ��\�� . � � �� ,�� y� � ,,,� � ��` \\\�\� �\�\\\\�\"\ ` `\ "�� " 5. Debts and Deductions 5 - v �� `� �� ` � " � \ \\� .� \\�._ ��, \�� \�� .�. �\.��\�\ 6. Amount Taxable 6 $ S3�i o 5`t•�S :� ��0 � �:��\� ��\��\�\��\ \\`�\ �� \V�a\� 7. T3X RBte 7 X r�. v'tS' � �h��y��o��' �� '�� \�� V�� s�' �� `�� A \\ � . 8. Tax Due 8 $ �.'i 2S"�,�i S � ��A\�� V�� \�� V\\�� \�� , � �� 9. With 5% Discount(Tax x .95) 9 X ;;`\��0��oo�\��a��a��G�\��,�� 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 Wilis,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 �l3 -�.4�- 7 632- l �?l►,s-r 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 BUREAU oF INDIVIDUAL TAXES Penns Ivania lnheritance Tax � � � ennS Lvania PO BOX 280601 Y P Y HARRISBURG PA 17128-0601 Information Notice ' DEPARTMENT OF REVENUE - � REV-15438 E%OocEXEC (OB-12) And Taxpayer Response FILE NO.2114-1048 ACN 14509145 DATE 12-29-2014 Type of Account Estate of CAROL A COOLEY Security X SEC Acct Date of Death 10-23-2014 Stock DAVID A COOLEY County CUMBERLAND Bonds 6003 SKYHAVEN LN SPRING TX 77379-2440 ;�,, c) .'��.. � � (: �+ - �. o ��"� � ,-,., ;.� � c-� � '"�l Z7 C'j ;�'—' C:�] ��J _ r__ �� :;r „ . 2 „�� . ": � , , , ,. ,,; � �.:� . < a , ., ., -n ,:i -,� ._.. _...._ . , ,�. - � ,i N_► _.:: K-7 ...; N P__ (71 � r.,_ CJl G"� C� .,. W `�'� FIDELITY INVESTMENTS 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.2 Remit Payment and Forms to: Date Established REGISTER OF WILLS Account Balance $62,271.34 7 COURTHOUSE S(IUARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $62,271.34 Tax Rate X 0.045 Potential Tax Due �2,gp2.21 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 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 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 � 12qo 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 mheritance 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), 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. 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. � "�� .. V' \��,. , . ., � .; o�� If indicating a different tax rate, lease state \� ;�' S your relationship to the decedent: �A ��, �� 1. Date Established 1 ` �� 2. Account Balance 2 � ��-� � � �� \ � �. �� V � � �, A �.,,�� 3. Percent Taxable 3 X lov �� . 36 �� .� � . �� 4. Amount Subject to Tax 4 � 6 z �� 's �, � � � \\ \\� .. �� ,�� 5. Debts and Deductions 5 ' v �� ' ��V ` �;�� \�`�� ` 6. Amount Taxable g $ ��— ��7! .36 �� ` ��b � �\�O \ �� 7. Tax Rate 7 X a• a'-!.� �� ` \��,��,��\�\�� o�o�.., �.� �. .��\\� 8. Tax Due 8 $ 2.g��- �-! ��, � \V� �� :. � , � � \ \��s �� '�� \� �� .� \� �� 9. With 5%Discount(Tax x .95) 9 X \��\\\��\��e��:� \��uoo��\��\�� oc �� 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 Wilis, 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�`�46-- ��3�. �/i7/►5� � 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 BUREAU OF INDIVIDUAL TAXES Penns Ivania lnheritance Tax • pennsylvania PO BOX 280601 y HARRISBURG PA 17128-0601 IllfOrf7latIOC1 NOtICe ' DEPARTMENT OF REVENUE - � REV-1543B E%DocEXEC (08-12) And Taxpayer Response FILE NO.2114-1048 � n�^-- --�,�_ r ��v ,�::;. - < �vL �i' ACN 14509146 n�,��r-�-.-: - +_;s� t DATE 12-29-2014 r��5 ur�� C� �{� 1� 5� Type of Account Estate of CAROL A COOLEY Security �i-- -f � X SEC Acct ��;.f,� Date of Death 10-23-2014 Stock DAVID A COOLEY County CUMBERLAND Bonds 6003 SKYHAVEN LN C�1�',�"�� . . ' SPRING TX 77379-2440 DODGE & cox 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. Account No.300119363 Remit Payment and Forms to: Date Established REGISTER OF WILLS Account Balance $24,45521 1 COURTHOUSE S�UARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $24,455.21 Tax Rate X 0.045 Potential Tax Due $ 1,100.48 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 other boxes and disregard the amounf shown above as Potentia/Tax Due. g �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% I am a lineal beneficiary(parent,child, grandchild, etc.)of the deceased. (Select correct tax rate at right, and complete Part � �2qo 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), 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. 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. ��.. � .. � � � ��.�e� �� \��, If indicating a different tax rate,please state �' � � ��. a` � \ your relationship to the decedent: � �� ' �� 1. Date Established 1 \� � \ �\ � ��\ �\ �\ 2. Account Balance 2 $ `�� `� ` \� � \ �\ � \�� 3. Percent Taxable 3 X �� \� � � � �� , ��\� � .� . � �� 4. Amount Subject to Tax 4 $ ;��' ' ��\�\��\�� \�� 5. Debts and Deductions 5 - �� \�\ ��\ .�� ,��.�� \ �� . � � 6. Amount Taxable 6 $ �� ` �\�� A �� `�� 5�� 7. T�C RatO ,�ti �� o� �� Q�� s��.�� X ��:� � �.�� \��\��\; � � �. ..�. � .._��....�� ..� :. 8. T� Due 8 $ � � �s �� oQ �� \ �. � ��\\� \�\�� \��\� 9. With 5% Discou nt (Tax x .95) 9 X �`�\�� ::��o��e��a�o��;�\��\� 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 713-'��-713Z �/I��LS� 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 B�R�� oF INDIVIDUAL TAXES Pennsy�vania �nheritance Tax � Per11'1S�/LVd111a Po BOX 280601 DEPARTMENT OFREVENUE HARRISBURG PA 17128-0601 Information Notice -�-� REV-1543B EX DocEXE[ (OB-12) And Taxpayer Response � ,, .�"�,n�. � FILE NO.2114-1048 �� - �;� ��t'�� c�y ACN 14509147 t��-f ' �•,` ,., 1 � DATE 12-29-2014 �� $ �� -2 �� Type of Account , - Estate of CAROL A COOLEY Security �'"_ ` ' X SEC Acct Q s��,;. � �; � Date of Death 10-23-2014 Stock DAVID A COOLEY �Wi�;�r:� - �Gounty CUMBERLAND Bonds 6003 SKYHAVEN LN `-' � SPRIN6 TX 77379-2440 HENNESSY 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.521274 Date Established REGISTER OF WILLS Account Balance $21,655.77 1 COURTHOUSE SGIUARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $21,655.77 Tax Rate X 0.045 Potential Tax Due $974.51 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 Potential Tax Due. g 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% 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. list d. 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), 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. 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 � � �,� � �' � �� ;�� V �V �� your relationship to the decedent: � ; �\ 1. Date Established 1 � \�� A � \\ � 2. Account Balance 2 $ -�� "� �"� � � \� 3. Percent Taxable 3 X � \ � � � ,�,� 4. AmountSubjecttoTax 4 $ �� , . 5. Debts and Deductions 5 - �� '�V'� , , � 6. Amount Taxable 6 $ .�� \ ��\� � � �' �� V ��\ � � ��.A 7. T3XR3t6 7 � � a��a� � y��o��. ��,y ._ �� ;�� \\�� \�\ �� \ ��..��\\ � � �� 8. Tax Due 8 $ ` �� .� �`�� ,�, ��\ \� 9. With 5%Discount(Tax x .95) 9 X ��\��\��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-��r�;_ � I��lt.� 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 B�R�o oF INDIVIDUAL TAXES Penns Ivania lnheritance Tax � er1r1S Lvania PO BOX 260601 Y P Y HARRISBURG PA 17128-0601 IllfOrf7latIOC1 NOtICe DEPARTMENT OF REVENUE - � REV-1543B E%OocE%EC (OB-12) And Taxpayer Response �L� ��W ;� r: i':�� FILE NO.2114-1048 ACN 14509148 ��,'d, "....`.� DATE 12-29-2014 ?�� `.�r�l�i 28 �� 2 �� Type of Account �� , ,, Estate of CAROL A COOLEY Security _:._ X SEC Acct �� rt � - Date of Death 10-23-2014 Stock DAVID A COOLEY �}��r��±` �� County CUMBERLAND Bonds 6003 SKYHAVEN LN " SPRING TX 77379-2440 HENNESSY 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. Account No.521273 Remit Payment and Forms to: Date Established REGISTER OF WILLS Account Balance $53,204.76 1 COURTHOUSE S�UARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $53,204.76 Tax Rate X 0.045 Potential Tax Due NOTE*: If tax payments are made within three months of the $2,394.21 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 other boxes and disregard the amount shown above as Potential Tax Due. g �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% I am a lineal beneficiary(parent,child, grandchild, etc.) of the deceased. (Select correct tax rate at right, and complete Part � 12qo 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 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 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. �\�\ �� ,. � \ ..� o \ If indicating a different tax rate,please state ��\� � �� your relationship to the decedent: �� 1. Date Established 1 \\, � �� 2. Account Balance 2 $ ��- � � 3. Percent Taxable 3 X �`�V��` '� �`� ` � �-�� , , �� „ 4. Amount Subject to Tax 4 � ��\ , `�� \ . � .�� ,� �. 5. Debts and Deductions 5 - �;` �� ` �� V� ` � �� :. �� 6. Amount Taxable 6 � �� ` � � �� X ��\\� �� ,�� Q�� `\� � � 7. Tax Rate 7 \\��.�� \� \ �� \��, � �� ' � � � ' \�� 8. Tax Due 8 $ �� \ . �� \�� o �\ �� 9. With 5% Discount(Tax x .95) 9 X \��\\��o��o��;�� a��0�� .....:��o�o��e��a'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 � -��-�13Z, � �t71 lS� 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. 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