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Home My WebLink About03-19-15 B�R�,� �F INDIVIDUAL TAXES Pennsylvania lnheritance Tax � � pennS�/LVd111d PO BOX '�80601 DEPARTMENT OFREVENUE Y4ARRISBURG PA 17128-0601 Information Notice . . . � RE�-,543 Ex uo�exEc coa-i And Taxpayer Response FILE N+o.21- -��v��v ACN 14131562 DATE 06-06-2014 Type of Account Estate of PEARL L WARNER Savings X Checking Date of Death 05-10-2014 Trust CHERYL W L I NDSEY County CUMBERLAND Certificate 4447 DUNMORE DR HARRISBUR6 PA 17112-1559 r"> �� c— cry :.., �"i -"; r`�? ;--; _.. , ... -� t : '','' _,..�:J .�- . - .. _ .....y ::� . _ . , � , -. _-,_� ..� , ; .. . , ., ., .I �� METRO BANK provided the department with the information below indicating that at the death of t�ie above-named decedent you were a joint owner or beneficiary of the account identified. _t-, __� Remit Payment and Forms to: Account No.513167205 �4 = ' ; ,� Date Established 07-12-2000 REGISTER OF WILLS ,._, Account Balance $2,097.57 1 COURTHOUSE Sf�UARE �;n , Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $1,048.79 Tax Rate X 0.150 Potential Tax Due NOTE*: If tax payments are made within three months of the $157.32 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 uThe 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. 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 5-ao G�� o � � me►� r n r •� �a � 1 3S(. �' - — i Cevr� i 'r - , � D� 6 p Total (Enter on Line 5 of Tax Calculation) $ � S �. �' 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 writf�en caireafiar��ru�itic�'s��ar��'sa{Ii7Siiiuiit'iii a11G�attaCli C#4a t�76.y�ar�ve. 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 lea state ��\��\�� '� ` � � �`�`� ��`�`�� 9 , P �� ,�� \��\�\� your relationship to the decedent: u� �� "� `� "`��"`��` °`� �� `�`��`��`�� - 1 C�!`J ; �\\�\\:\�\\�� \�`\�\�� \\\\�\\"�\�\��\\�`\\ 1. Date Established 1 7 a- a G ��\\��\��\�\��`\`��\�\\\\\\\��„�\\. �� \\��\��\��\�\�� 2. Account Balance 2 $ � �� - �� \\\\�\��\\\�� \"\\�\��\\\� �� \\��`��\�\\\\��\� � ��\�\��\��\\��\\��\�\\��\�\\��\�\�� X ��\��\�\��\�� \� �\��\�\ \� �\\� o� 3. Percent Taxable 3 5� �\��\�\�\��\��\�\��`��\��°��o\\��\��\�� \ \ \\\\\ � \ \ \ ��` ��\ �\\ �� \��\�� 4. Amount Sub'ect to Tax 4 $ � �c�g• �� : � �� \�o�� \��\��\�ti\��.��\��\�\��\\`�`\\��\�\�\��\��\\� 5. Debts and Deductions 5 - ] s y � • �� "�� ' �� \ ��\��\��\�\�\�\��\.`\��\\\��\� ��\\��\ � �� \ � \�� \\� ��\ ��o�\� \o�� 6. Amount Taxable 6 $ � ��` ��" �� "� ` e �� `��\��\��\\��\\\\\��\\\�\��\`\\\\��\��\\\\ 7. Tax Rate 7 X �• � �O ��\\��\��\��..��\��\��\�\ ��`��\�\\��\��\\ �\\\�� \ @ /�� < � � �� Q � \�� v�� \\\�� 8. Tax Due 8 W lf` ��\� ��\�\�� \�\\ � \��\��\�� \�� \�\�� \�\��`�� R ��\��\\��\\\\��`��\�\��\�\��\\��\��\��\��\\��\�� 1 v yV��v A \v v ��A\ �v� � 9. With 5% Discount(Tax x .95) .7 ^ ��\��\��\\�\�\��\.�\�\��\�\�\\,��\\\��.��\�\oaao\��:\\��\.��\��.....a��o��v��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 � (_ `7 3 - /(�. -�.r"' ��- ��7 g� I 1 Taxpayer Sig ature 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 Pennsylvania lnheritance Tax � Per111S�/LVarlla PO BOX 280601 ` DEPARTMENT OFREVENUE �HARRISBURG PA 17128-0601 �nf�rl�at��n NOt�Ce ,,,,,, , ' And Tax a er Res onse REV-1543 EX E� <oa-�z�n p y p FILE NO.21 � ��'0,2'I � ACN 14131562 DATE 06-06-2014 Type of Account Estate of PEARL L WARNER Savings X Checking Date of Death 05-10-2014 Trust CHERYL W L I NDSEY County CUMBERLAND Certificate 4447 DUNMORE DR HARRISBURG PA 17112-1559 , -,, �-__� c� �-' c_ `�,.; '°' r,t � __--� ;; r•� '? �.�� _..:.. �.:7 , �� _.�`-i r:J . �..7 , . ,.;.... .. .� , F� C:'7 � �"Y1 METRO BANK provided the department with the information below indicating that at the death of#� above-named decedent you were a joint owner or beneficiary of the account identified. �.� - Remit Payment and Forms to: `—" � ' ' Account No.513167205 �� ' Date Established 07-12-2000 REGISTER OF WILLS Account Balance $2,097.57 1 COURTHOUSE S(IUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $1,048.79 Tax Rate X 0.150 Potential Tax Due $157.32 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 Sfep 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 fo Step 2 on reverse. Do not check any other boxes. C The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent,c�h_il�d, 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 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 -S'oZ�� I +r 0 �oc�- � Ylursi � � ��/.. �- G C r c O Total (Enter on Line 5 of Tax Calculation) $ 5 (. 7' PART T$X CaICUIat1011 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2), or percent taxable(Line 3), pl�ase�bta�n a writter�or.2ctEar#rom.h�'Er.a^aEw! B^st's#u;Ea��nd at�acl: Et tc#hi�#or::3. 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 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, pleas state `� �� `�`�� `� `�� `� �� \\\� ��' o ` �\��\��\� �� your relationship to the decedent:� �� ` ��`�� \��\�� ` �� \\�\�� : . �� \\\\\\\\\��\� �� \� �\�� .. ��\� �� 1. DateEstablished 1 �- /a- aE'�'U ;�\\\��\��\�\�\\��\\�\��\�\\�\\�\��\��\�\�\`��\�\\\`\ �7 ��\��\��\��\�\�� \\��\��\\��\`�\\�� 2. Account Balance 2 � �.a� !- S� �� \��\�\��\��\�� \��\\��\��\��\\ ��\��\\��\�\\\�\��\o��\��0��0\�� \\\\��\ 3. Percent Taxable 3 X 5b o�� `��,��0��`�\� �� `�� \ �\�� \\ � ��°��\�\� � ��. �� 4. Amount Sub'ect to Tax 4 $ �, � �(•�. � � � \\�\\�\\\ � \ \\�\\\\\ \ \\ \�\\�\\° � �\\��\� �\\\\��\��` ��` � � �� .y:- ��\\`�\\\��\i��\��\��q��\\\\\��\�\�\�\��`�� ' 'rJ. �@btS 1f1C� �@CjUCtI0f1$ r'J - 1 _ �� • � � �khv� �� o��V Av o�Av� ��y�� , �� V�� A��A�\��A\��A��V��\��\\� 6. Amount Taxable 6 $ C� � �� >�<.��`�\��A��A�\\\V�\��A�� \\��A�A`�A��p� �`�� \\��\��\��\��\�� \��\\��\� 7. T� Rate 7 X y• � p � �� \��\\\V��VA��\�\��VV�V��` \�\�\��\\�� \�"��A�� y .� ti�� c � � � �A�` "�"1 V�� A�� @ �� 8. T3X ��.le $ W � ��VA��V�AA��A��V��\�� \ � A��V��\�� Y� � ��\� .��A��V��.��h� ��A�� V\ �A� A� ` 9. With 5% Discount(Tax x .95) 9 X ��\.�\\\��\.��o�\�\Y\\\\�0��\��a��\��v�.\�\\��\\\\\\�oo\��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 �l� �,(�. �� C�i`-�-'� Hom _ 3. e 7 I 1- (��1 �G�� I(�- 1 S 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 . DATE DESCRIPTION Un ti s� CHARGES CREDITS BALANCE Balance Forward 1,057.90 D4/22/2014 Payment on account 1,057.90 0.00 Deduction from Patient Liability -Insurance Premium Medicare Insurance Premium 04lO1-04/30 04/30/2014: $104.90 Deducrion from Patient Liability-Insurance Premium Monthly Health Insurance Premiums 04/01-04/30 04/30/2014: $205.62 04/17/2014 Shampoo & set 1 13.30 13.30 SET 04/23/2014 Shampoo & set 1 13.30 26.60 SET 05/O1/2014 Medical Assistance Patient Pa,y 05/O1-OS/31: OS/O1/2014 1 1,355.12 1,381.72 C.�'� �-� ) s � C3g�. � a s'- �.o - � H Please call the billing of�ce at 717-866-3256 with any statement questions. All checks should be made payable to Church of God Home. Please use the exclosed envelope to mail your payment. RESIDENT# CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 300 1,381.72 0.00 0.00 0.00 0.00 $1,381.72 Form PB-Ot �ESIDENT NAME Pearl L.Warner r Gingrich Memorials 568 N. Union Street Middletown, PA 17057 (717) 944-3441 Cheryl Lindsey 1/�VO/Ce 8/1/2014 4447 Dunmore Dr. Harrisburg, PA 17112 _` . . : . . - : r_ 11-12553 7/15/2014 Pearl Warner Andrew Gingrich 1 1 Cemetery Inscription Order Total: $160.00 2�ankyou, your memorial or cemetery payments: �o.00 inscription is finished. Balance Due: $160.00 a � i � � � �� - _ � . � � A finance charge of 1'/z%per month (18%annual[y)will be added after 30 days ------ - ------- -------- -- -- ---- -- ----- ---- (; _ - _ ,.� x � n _ _ _ ��r ; v � �, �• � .. . . .!� � dr ' ''7 f�� 1� ;=�; ? 1 a � � � 8 � d v � r � Q�n. ;;� . � ` C"�,°– {.,. �" �v -.a � s:�! -, �� ,..� ._.., ;;,} O i�t V, � �. �� r� rp �`' -� �t� .. T' �t� c� � � �7 � � � � � �� _ � `� _ � � � �; � � ---� ;� � - � '— � '� �� - � � :� �� _ :� �� v� w — ;� �: � a� � � � �