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Home My WebLink About03-24-15 REV-1162 EX(11-96) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES . DEPT.280601 HARRISBURG,PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 020399 FULTON RAMAH L 2002 PRINCETON AVE CAMP HILL, PA 17011 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- fold ---------- -------- 15107337 � S 1 ,954.31 ESTATE INFORMATION: SSN: �s0-i6-o0�s 15107338 I $1 ,760.34 FILE NUMBER: 211 5-0308 15107340 � 52,025.60 �ECEpENT NAME: WAGNER RICHARD J 15107342 � S 1 ,147.20 DATE OF PAYMENT: 03/24/2015 15107344 � 51 ,282.10 POSTMARK DATE: 03/24/201 5 � CouNTY: CUMBERLAND I DATE OF DEATH: 01/23/201 5 � � TOTAL AMOUNT PAID: $8,169.55 REMARKS: CHECK# 1510 INITIALS: HMW SEAL RECEIVED BY: LISA M. GRAYSON, ESQ. REGISTER OF WILLS REGISTER OF WILLS BOR�,o oF INDIVIDUAL TAXES Pennsylvania lnheritance Tax � � pennsylvania PO BOX 280601 DEPARTMENT OFREVENUE HARRISBURG PA 17128-0601 Information Notice . .... ' REV-1543 EX 0 c (OB-12) <- And Taxpayer Response FILE NO.21 �� U�Od' ACN 15107337 DATE 02-10-2015 Type of Account Estate of RICHARD J WAGNER Savings SSN 160-16-0016 Checking Date of Death 01-23-2015 X Trust RAMAH L FULTON County CUMBERLAND Certificate 2002 PRINCETON AVE CAMP HILL PA 17011-5442 ,._-; ._..� .-�, ._.� ..._ , . ., c_ ,�. � c..�� c_�-, . ,.,.., --.� :.:, �—� � �+ _ _? i , ._�.. ��,�, ._.,J ��t .. .. , � � :.. �,�> . . __ .. , � . �.,_ �� y� FULTON BANK NA provided the department with the information below indicating that at the de�th of th� above-named decedent you were a joint owner or beneficiary of the account identified. �—+ ' _ ;., { .., Remit Payment and Forms to: - � , Account No.22 Date Established 01-09-2009 REGISTER OF WILLS Account Balance $43,429.07 1 COURTHOUSE SGIUARE CARLISLE PA 17013 Percent Taxable X 100 Amount Subject to Tax $43,429.07 Tax Rate X 0.045 Potential Tax Due $1,954.31 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 � 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 ou are makin a correction to the establishment date Line 1 account balance Line 2 or Y 9 ( ) ( ), percent taxable(Line 3), piease oi�tain a wrinen correction from the financiai institution and attach ig to this iorm. 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 ;��, �� \�� \� � � \� \\�� `�` your relationship to the decedent: � � �� , �� \�\� \\\`\��`` ��\ ��\��►��G� ��\� `�\\ � 1. Date Established 1 �� \�� \��`��o� � �� \ �� \�� ` ��\� �\\ ��\\��\�� \�� \\�. 2. Account Balance 2 $ �� \\� ��\ ;�\\ �\\�� \\�� \��\ ` �\� ��a\�� -��\\\``��\��\\\\\��y�� . 3. PerCent Taxable 3 X ; �� A� ��ti�\�� \��y��j��v��`�AV� oy�� A � . �o� � � � �`��\ ��VA�� "��A� �� \\\��` � A� �� A�� 4. Amount Subject to Tax 4 $ � ,,,�� , � �� „� �� A�� A\� �� 5. DebtS dnd DedUCtIOnS 5 �� '� �� °� �� "��0�� `�y� A�� AV �� A�� V�V� \��VAA�� AA � �� A�� A �A�� A��\ �� ti��O�\� 6. AmOUnt T3X3ble 6 � �a,`T `��v�. ��v �� ovA�yy�� v\\\�� v �v � �� v` �� °��\\��\\\��\�\��\\\� ��\��a� � � � � � �� .�� '. Tax �at8 7 X � �� 8. TaX �U8 8 �j �� A�VA�� A��: ��A �AVA ��\��V�A� �� Aq�� A�A �� A\�� A\\� ��\� �� ° ��:` �� \��AoA��V��V �V��VA�� a X �� ``\V� �� A\ � ��VV � ��\� � A��.�� A ��.A�A\�� A 9. With 5/o Discount(Tax x .95) 9 � �� .:��\\��\....:o� ..\...\v\��o�� ....,o..: ,.„��\��\.��\\aa\��;\��\�....a....o��\\�.\\\\�z;.�...\op�� 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 ��+ � e,� �� _� a�...�a9 ,�. .�.,.�.� Home°-r i� -t�i ��a 7 Taxpayer Signature Telephone Number Date 3 �1- 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 Pennsylvania lnheritance Tax �� pennS�/LVat11d PO BOX 280601 ; DEPARTMENT OFREVENUE HARRISBURG PA 17128-0601 Information Notice '�� REV-1543 EX DocEXEC (08-12) And Taxpayer Response FILE NO.21— /,�'O,�a�- ACN 15107338 DATE 02-10-2015 Type of Account Estate of RICHARD J WAGNER Savings SSN 160-16-0016 Checking Date of Death 01-23-2015 X Trust RAMAH L FULTON County CUMBERLAND Certificate 2002 PRINCETON AVE CAMP HILL PA 17011-5442 ,, �� , . ;_- . _.. ,..... ,1-; ---� ...� : c-� ,r t .::,,. . .� �� , ...,7 . .. ...:�..i ' �:-�., '-. ; _. ."',7 .. �..,� -_ I ,.. . , _... :_:J � . . ., : . ' �....... ...� '' ;. ' f11 _,[� i FULTON BANK NA provided the department with the information below indicating that at the de��h of the above-named decedent you were a joint owner or beneficiary of the account identified. ==3 Remit Payment and Forms to: '��` � < a Account No.22 _,._ _, , Date Established 02-12-2010 REGISTER OF WILLS �.� '"�I Account Balance $39,118.64 1 COURTHOUSE SC�UARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $39,118.64 Tax Rate X 0.045 Potential Tax Due $ 1,760.34 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 z 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 � 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/efe 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. h ck of the form when finished. � Please sign and date t e ba � 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 piease ot�iain a written correction from the financial inst tution and attach it to this form.)� �rcent taxable(Line 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%,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 � �� : �� your relationship to the decedent: ��`�� '�� ` \ \� �\ �� \�`\��\��\ �� \ �� \ �� \��`. 1. Date Established 1 ;�� ;��`��°�� .�a � �� `o�� \\\\\\ \`��. ��\��\�� ° ��C��\\ �\ �� 2 � �� \\��\\\�\�\�\��\��\�\\\\�`\�\\�\\�\�\��\\�p\\�\\�\\ \��\\�� \\ 2. Account Balance � \ O�\� �� \�\�\ � \��\�\�� \� �\� �� \�\O\�\\�\��\\��\��\\\\��\�\�\C\\\\��\`��\��\\�\�\ \\� \ \\ \ �5�.� \�,A�\ \ � �A y�Ao�� 3. Percent Taxable 3 X � �� \\�\�\��\�� \\�� \ \�� \\� \\� \\� �\ � \� ��A AV �� A 4. Amount SUb�ect to TaX 4 $ � � �� A �y� �� \\��\�� \\ �\\ �\\ `�p\� �� . \ �� 5. Debts and Deductions 5 - � � : �� V�� A�� , � �� 6. Amount Taxable g $ �,�� A� �� VA� �� V� � � �� A\ � A \� � � �V�� V �� \� �� A VA � �.A ��V `� ��A '�� \ �OA�y � �A � 7. Tc1X Rc.'1tG-' 7 '� \\� �� \\\�\�\�\�� \\\\\\�� „\\ ,�� \� �� Y �\\ . �\ �� \ �\\ �\�� \ �\� � � \ \Op \\\ 8. Tax Due 8 W ��\�\�\\ �� \�� \\\\\��\ � \� ��\ \ �\ � �a�� \ � ��\\ \\� ��\ �\\ �� D X ��\\�� \\\\\� ��\��\��\��\��\\� �� 9. With 5% iscount(Tax x .95) 9 �� ` � ��` �` � � � �� :� � �� A ..\��ov\��\��\�\�\\ \��\\,\\\\\��a\\��,:��...p�.�\:� � ...�aa�� l� .. .... 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 �2 P��. .�..�r� Home ^�i 7 '�!�i 3 � � Taxpayer Signature Telephone Number Date 3/a �+��5 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 � �L PennS�/�Vclllla Po BOX 2so6o1 DEPARTMENT OFREVENUE HARRISBURG PA 17128-0601 Information Notice . . . RE�-,54,Ex nooezEc coe-iz� And Taxpayer Response FILE NO.21 �� 5'(� �D�l ' ACN 15107340 DATE 02-10-2015 Type of Account �,y Estate of RICHARD J WAGNER Saui�gs SSN 160-16-0016 `� �`� C�l�king Date of Death 01-23-2015 r X T t F ",� RAMAH L FULTON County CUMBERLAND � - �ificat4 ar 2002 PRINCETON AVE ' ' �' • -' . c. CAMP HILL PA 17011-5442 !�� ' _ I. ,��7 ;;.� �-�, i; 4� �. FULTON BANK NA 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.402 Date Established 12-21-2004 REGISTER OF WILLS Account Balance $45,013.31 1 COURTHOUSE S(�UARE CARLISLE PA 17013 Percent Taxable X 100 Amount Subject to Tax $45,013.31 Tax Rate X 0.045 Potential Tax Due $2,025.60 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 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 � �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. 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 represer�tative. 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. � ; � s 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 ou are makin a correction to the establishment date Line 1 account balance Line 2 or _ y g � ) ( ), 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 \�� \\ your relationship to the decedent: �y��; `�� , ��,� �a,�,\�� \�\ �� \�\\�\��\\�` 1. Date Established 1 \��,��`��. �� \ ��\�� \� �\\\\�:`�� .�� \\��`O�\�\\�\\�\ \��`\"\�� =:�\�� \��\\�\\��\��\�\�\ \\\��\\ �`�� \�� O \�\�\\��\\\��\�\\�\\�\��\ 2. Account Balance 2 $ �� ; �� `��\��\\��\\�\\�\��\�\��\��\��\�`\\��\ 3. Percent Taxable 3 X � �\ � � �� \ �� \ �\�� \ �� o� ��o��\\\�o��\\��\�\��\��\��\�\�\�\��\\� 4. /�f1l0Ullt SUbJ2Ct t0 T8X 4 � � �� : �� \�A�� ' �A � ��\VA��\\�AV��\\��`��V��`�� 5. Debts and Deductions 5 - ` @ '�e`�� ` ��o\� � �D��\�� \\\\�� \��\\�� \\�\��o\� ��\��O \�� 6. Amount Taxable ��` � � �o��\��\��` �� 6 W �V�� A�0�� \� �� V��A�VA�A��AVAV�A��A�A�� ,�' �� VA � �A��V�\\\��V��A`��\\A��A��VV��\��. 7. Tax Rate 7 X �A �\ �V�� A .. �� _��A��o�� .��A��o��V`�� 8. Tc1X �U@ ��v� �\�A�� m ��V��AA��y��v��\vy��y\\V��y��y�� $ � \�\\� �A��` ��V�V �V`\\�� V�`��\�`�� y��\vy� ��\��\v� �\\�\\v\\��\ �� \\\�A�\��o`��, ��`��0�� 9. With 5% Discount(Tax x .95) 9 X � \��.��\��: ..��.��.::� ��..�...��:��.��..:��.�,�� .�.� St@p 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 -r ,� 7i t 3 4� '7 Taxpayer Signature Telephone Number Date � �� ,S � 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 � {�ennS�/LVat11a Po BOX 2s06o1 DEPARTMENT OF REVENUE HARRISBURG PA 17128-0601 Information Notice . ... � RE�-,54,Ex uooexEc cae-iz� And Taxpayer Response FILE Nto.21 -- � 5� �� D� ACN 15107342 DATE 02-10-2015 Type of Account Estate of RICHARD J WAGNER Savings SSN 160-16-0016 Checking Date of Death 01-23-2015 X Trust RAMAH L FULTON County CUMBERLAND Certificate 2002 PRINCETON AVE CAMP HILL PA 17011-5442 _,> ,.� <.::.,� ... t_..._A �� - . ;} . " (.f��l .;...� f .-� ' ' �°.�) «_ . i �...., . . _.,., _ ,. . �,J __� .,. .... , �� ._ . .. .. - '-�'�-�i .., .�r FULTON BANK NA provided the department with the information below indicating that a�th�;deatti ofathe above-named decedent you were a joint owner or beneficiary of the account identified. ,r: Remit Payment and Forms to: . l -' - � _.:�, AccouM No.402 , Date Established 01-10-2007 REGISTER OF WILLS '�� . ��, Account Balance $25,493.34 1 COURTHOUSE S(�UARE ,� � � CARLISLE PA 17013 �-=3 �'% Percent Taxable X 100 Amount Subject to Tax $25,493.34 Tax Rate X 0.045 NOTE': If tax payments are made within three months of the Potential Tax Due $1,147.20 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 � 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. V 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 3 Tax Calculation If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable{Line 3), �iease 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 �� ,�� , �y your relationship to the decedent: �°"��"�;�� ` `, ` `\;\,�� ` � � ��\�\\\�� \��0��\` \ \ \\\ � ��\\3k�� p\\��\\�\��\��\ � 1. Date Established <�� ,��°,,�� \° �`\��` 1 �°'��,\,��\��\�`\��``�:`��;��a�`�\��\�`�\��` ��\\��`��. 2. Account Balance ��\��\�\\�\\\�� \��\ ��\��o��\\��`��` �\��. 2 $ \\��\ �\��\�� °\�\`o�\� O� \ � � � � �� 3. Percent Taxable 3 X ��\\�\�o��\��\��°��`��`��\`��\�``�� _ ��A �o � A�A \�V ��q� �� A � �o� � �� y� �� v� �� 4. Af110Uf11.SUbf@CttO TdX 4 $ �� \ V��\V\�\�� VA �� V� A� �� \��AA�AA ��A�� V �D VAA ��\�AA�� A�� \A �� QA" ,� � .�� , p�� \��A0�� \\��A�� \�A�A�O\ �� V ��o� J�. �@btS 3f1(� �BCjUCtIOf1S J� - � �\�� \ �\ ��A � �� `V�\��`��` ��"C�\� . � � �� \�� _. � A � V�A � ��AA� �� . 6. ARIOUfIt Tc1Xabl@ � � �� AA �� V� �A�� A�V �� .��\�� \\ �� \ `� \ �\\��\ \ 7 T3Y, R��,.te � V �\��\\�\\�� \\ \� \\ �� \�\\�� \�� \\\� ��\�� \��\\\\��\� • � � . \ � �\ �"�� \��\\�\\\��\��\��\��\��\o��\�� \ \ �� 8. Tax Due $ � �\\�\\�\�\\\\��\��\�\\��\��\�\\\\\\ O\��\\ \\��D��\\��\�\�� . � � �� \\\��\��\� ��\�\��\� �� 9. Wlth 5% DISCOUnt(T8X X .95 9 X ��`�� `V��A��\��o �V\��\�� oA��\�� \�� \��\��\�\\ \\��\��\��\��\��\��\\��\�\� :\��, �o,.:��\o\..�.a� \\�\�:�� ....�.: �\� �� \...a. \\��v\\��a� q\`..�aa,.,:,�aao�� 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 �2T._... �,� � � rn-,�� Home �t i 1 � r i 7 Taxpayer Signature � Telephone Number Date ��d.�-� ,s 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 Pennsylvania lnheritance Tax � � �� pennS�/LVal11a Po BOX 260601 DEPARTMENT OFREVENUE HARRISBURG PA 17128-0601 �nf�rmat�On N�t�C'e �-- �� eEv-isaa Ex uo�ExEc coe-iz> C And Taxpayer Response FILE NO.21 — � �J "D 30 J� ACN 15107344 DATE 02-10-2015 Type of Account Estate of RICHARD J WAGNER Savings SSN 160-16-0016 Checking Date of Death 01-23-2015 X Trust RAMAH L FULTON County CUMBERLAND Certificate 2002 PRINCETON AVE CAMP HILL PA 17011-5442 , ,-� ;.'_-> F:;� ; ,. ,._;.., � �.� . .. ��_.a �..� c-> � �� ,..., J , ��a �l FULTON BANK NA 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.402 --{- ' Date Established 02-15-2008 REGISTER OF WILLS '� ,�� Account Balance $28,491.07 1 COURTHOUSE S(�UARE CARLISLE PA 17013 Percent Taxable X 100 Amount Subject to Tax $28,491.07 Tax Rate X 0.045 NOTE': If tax payments are made within three months of the Potential Tax Due $1,282.10 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 detinquent 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 � 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. .� V Please sign and date the back of the form when finished. \� V� 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 8 112"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), pfease obYain a writien correction from the fiinancial institution and attach 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 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 �� y� � � �� ,�� "`� `\\�� S�� ' � ��' �`��`�� your relationship to the decedent: : �� "��„�� ,��,�� \�� \�� ;�o��\�� "� �� '� �� 1. Date Established 1 \� \\�� \��c�� `��\��`� � . ��\\�� \� ��\��\OO�\�\\\��\�� \� \\\�� 0�\O��o�\\��\\�\��\��\��\�\��\�\��\\ 2. ACCO U flt B3I3f1 C@ 2 $ � �'�"�� O�` �� A�V��V V�� `�� A��VA ��V��\\� ��A\�A� \ . :'�\��\��\��\�\��\\ ��\\\ ��\ ��\�\ � \�� \ 3. Percent Taxable 3 X �` ` `"``��` ` `°`�"`" "` � � `�` � � .. ��A�� A�� V��\� �V�� A\�A� ��V� � � 4. AIT10Uflt SUbfP.Ct t0 T3X � 4 $ �� v� �� v A�� ` � ��.� ��O� �y�� V ��\�A� ��\� � \� �� V� ��A �� A_ A�A�� 5. Debts and Deductions - � � �� 5 �y� ��y�� v� ��y� v��yyy � �� v� �y� �� 6. Amount Taxable 6 $ �� \VA �� V ��V�� VAVA ��A� �A A VA� �A i i ai< �BtE ] )( . ,�`��\\�\� \ �\\��\\\��\ �� `\\��\�\�\ �\� �....�,\\�� A �� \\��\ � � �� T �� . �\�� \��A �� V\C VA� 8. I[ZX ��.I e '�� y v��y��vv��y�v��v� �� vv�� vvp��v yvv �� $ � \�\� \ \\� \\\\��\\�\\��\�\��\\\\\�\��\\ ��\\� \��\�� 9. With 5% Discount(Tax x .95) 9 X � ��\�� A �;`� �� \�� \� `�,�� .. .___�\o� ,.�.�� .....:_. �Aa��v.�:�� ..��\VA ��A�..ti \ ..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 ��-_u_P� � a�-.,,� Home � � � �fi L I ti 3 �� i� �l ,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