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Home My WebLink About03-31-15 (2) REV-1162 EX�11-96) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF FiEVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 020433 BERNER LOUISE A 4593 SPANISH OAKS DR SAN LUIS OBISPO, CA 93401 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- f01d ---------- -------- 15109601 � 529.29 ESTATE INFORMATION: sstv: � � FILE NUMBER: 2115-0347 � �ECE�ENT rvannE: BERNER CLARENCE T I DATE OF PAYMENT: 03/31/201 5 � POSTMARK DATE: 03/25/201 5 � courvTY: CUMBERLAND I DATE OF DEATH: 01 /27/201 5 I � TOTAL AMOUNT PAID: $29•29 REMARKS: CHECK# 2910 INITIALS: HMW SEAL RECEIVED BY: LISA M. GRAYSON, ESQ. REGISTER OF WILLS REGISTER OF WILLS BUREAU oF INDIVIDUAL TAXES Pennsylvania lnheritance Tax � � PennSY�Vanla PO BOX 280601 Information Notice DEPARTMENT OF REVENUE HARRISBURG PA 17128-0601 ��- -�� aev-�saa EX DocEXEC <oa-in And Taxpayer Response FILE NO.21 — f�j�p 3�� ACN 15109601 DATE 02-24-2015 Type of Account Estate of CLARENCE T BERNER Savings SSN 2015 Trust LOUISE A BERNER County CUMBERLAND Certificate � o 4593 SPANISH OAKS DR � Q � � � SAN LUIS OBISPO CA 93401-7846 �� m h -..,. C� r� Z c� � � - ,� .-.. cn � ",, .,:� t� C.� � c� c;,� �r� C� ''� ►� ,- , -� C� ' �y7 `� C3 �.`� �=' � r r� �$� ,� .. � ,�,t • '";J � �F �"i � � � � _ _ � Cn p '�7 PNc 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.5140004209 Date Established 07-11-2012 REGISTER OF WILLS Account Balance $1,370.42 1 COURTHOUSE S(�UARE CARLISLE PA 17013 Percent Taxable X 50 Amount Subject to Tax $685.21 Tax Rate X 0.045 NOTE': If tax payments are made within three months of the Potential Tax Due $30.83 decedent's date of death, deduct a 5 percent discount on the tax With 5%Discount(Tax x 0.95) $(see NOTE`) o , o� 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�Ti�e in��rma;i;,r is ' 7h2 abave infarmation is corre�t, no deuuctions ar2 being take�,and payment wiii 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 inf�o��jete Part 2 and part 3 as�approprate o athe back of th s por�m. listed. P 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�oceed to Steta2 onpeverse.tl Do not check any other boxes. REV-1500. p 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(Lme 1)account balance Line 2 or , please obtain a written correction from the financial institution 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, lease state � �� \ � �� P �� \��\��.; � � � � � your relationship to the decedent: ��\�� , ��, � � ��\��\\\��`��\� \\\ � �� \�\\\\\\� 1. Date Established ��`�\��\��`\\ � ` � �� o�� .��\. �� \�\��\��\�� :;��\��\��\\\"�c\��\`\��\\\��\�\\��\��\�\ 2. Account Balance �r� \\`��\\��\�`�\��\��\��\�� 2 $ � � \ �\ \, ��,�� . \\\�� \�� \\�\ ��:�� \��„�� o� �� \��\��`��\\��\\�\�\��\\��\ 3. Percent Taxable X :��\�\��` "` �� \\�� \\\�\\�� 3 �� \�\\��\ ��\�y��O��\\�\\� �\\��\\��\��\\��\��\ 4. Amount Subject to Tax 4 $ �� "��` ��\ �� `��\��\��\��\\��\ ` `�� `��\�� o��\ ��`�� \ 5 - '��\� ��`�� \\��`\�\�`��`��\\�\\\��`��\�\��\��y��\\` 5. Debts and Deductions �� ,�� , � ��\�\\�\�\\\�\\\��\\\��\\\�\\��\\�\��\��\��\�\�\ ��\�� 6. Amount Taxable � �� \�� 6 $ �� \ \��\\\�� '��\�.�\�\��\\��\\��\�\��\��\��\�� \\\ 7. Tax Rate 7 X .,\�\ \ \ ��\��\�\\��\��\�\\\�� \��\\\\\\��\\\�\\�\\��\�\��\\�\,\� � �\\ ` � �\\ \��\�� `�� \��\\\�� 8. Tax Due g � � ��\��o�� \\��\��\ \ ��\\�\\��\�\��\ � �� \ �\\��\��\\�\\�\�\\��\��\��\��\\�\��\\.,� �\� \ �� \� \ �� 9. With 5% DisCount(T8x x .95) 9 X ��\��\\�a��o��\\\��\��\\\\,\\��\��\\\�\��`;��`\� \ ,•� 5��\o�\\\\O\�\\\\5��\�\�o��o\\�o\�\o��\.\��\�:a\\\�\.\\�\\�\��\\\\\\��CG��\\\�\\�\\\�\�\\\\� 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 ?cy�f� ._ ;��;� _ �_�,�� — ��_.f�-L�.�_�y.�_ ��.�`-r�-� Home � ��'_ ,5Y 3 - �?b`E� �" �� z_s j� 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 * N� r � � �,W� ��,� t °a � } ! 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