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Home My WebLink About04-15-15 COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES . DEPT.280601 HARRISBURG,PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 020511 KLINE FAITH E 63 INNSBRUCK DR TOMS RIVER, NJ 08757 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- fold __________ -------- 15107336 $1 ,954.31 ESTATE INFORMATION: SSN: 15107339 $1 ,760.34 FILE NUMBER: 2115-0308 15107341 $2,025.60 DECEDENT NAME: WAGNER RICHARD J 15107343 $1 ,147.20 DATE OF PAYMENT: 04/15/2015 15107345 $1 ,282.10 POSTMARK DATE: 04/15/2015 COUNTY: CUMBERLAND DATE OF DEATH: 01/23/2015 TOTAL AMOUNT PAID: $8,169.55 REMARKS: CHECK# 2270 INITIALS: DMB SEAL RECEIVED BY: LISA M. GRAYSON, ESQ. REGISTER OF WILLS REGISTER OF WILLS BUREAU INDIVIDUAL TAXES Penns lvania Inheritance TaxW er11'1SVLvania 28 PO BOX 280601 Y HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE REV-1545 EX D..EXEC (88-12) And Taxpayer Response FILE NO.21 - 15- 50Y ACN 15107336 DATE 02-10-2015 Type of Account Estate of RICHARD J WAGNER Savings SSN Checking Date of Death 01-23-2015 X Trust FAITH E KLINE County CUMBERLAND Certificate 2002 PRINCETON AVE CAMP HILL PA 17011-5442 0 C) C-ri :�a rrtl 3` D o M n r r',r rT1 C> -n C7 FULTON BANK NA provided the department with the information below indicating that at the �death'atth rn above-named decedent you were a joint owner or beneficiary of the account identified..,,, C J, Account No.22 Remit Payment and Forms to: Date Established 01-09-2009 REGISTER OF WILLS Account Balance $43,429.07 1 COURTHOUSE SQUARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $43,429.07 Tax Rate X 0.045 Potential Tax Due $ 0.04531 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 F�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. B 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% 1 am a lineal beneficiary(parent,child,grandchild, etc.) of the deceased. (Select correct tax rate at right,and complete Part 12% 1 am a sibling of the deceased. 3 on reverse.) 15% All other relationships (including none). D F-]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 F-]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"intrust 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 statefGtB)�SenyP,F i four Date Established shed to the decedent: 1 \ \\\\ party ent cif Revenue\ ,f A �\ I 2. Account Balance 2 $ � �7WM > s411 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 $ w, 100021 5. Debts and Deductions 5 000 I 6. Amount Taxable 6 $ �� 7. Tax Rate 7 o� .c �� v j 8. Tax Due 8 $ 9. With 5%Discount(Tax x .95) 9 X _ :.�, I Imo.. 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 yxj�z�, /, , ,�,0. ) Home 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 Inheritance Tax pennsyLVania PO BOX 280601 Y HARRISBURG PA 17128-0601, Information Notice DEPARTMENT OF REVENUE 7, REV-1543 EX D..EXEL (08-12) And Taxpayer Response O. FILE N21 -- ACN 15107339 DATE 02-10-2015 Type of Account Estate of RICHARD J WAGNER Savings SSN Checking Date of Death 01-23-2015 X Trust FAITH E KLINE County CUMBERLAND Certificate 2002 PRINCETON AVE CAMP HILL PA 17011-5442 0 C7u �� rn Cn rTl Cl) r-a r- ►- r n rn ( _ m CJS C7 G� p C) J a �t. -TI T1 ►--A r- m 't 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. Account No.22 Remit Payment and Forms to: Date Established 02-12-2010 REGISTER OF WILLS Account Balance $39,118.64 1 COURTHOUSE SQUARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $39,118.64 Tax Rate X 0.045 Potential Tax Due $ 0.045 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 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 F-]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. B M 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 F�The tax rate is incorrect. 4.5% 1 am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased. (Select correct tax rate at right, and complete Part F-] 12% 1 am a sibling of the deceased. 3 pn reverse.) , 15% All other relationships(including none). D F—]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 F-]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. r Please sign and date the back of the form when finished. 1 � - PART 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 insufficient0opay the deductible items. B. You paid the debts after the death cdthe decedent and can furnish proof ofpaymmrtifrequestedbythedepartmnnt. (if additional space imrequired,you may attach 81/2^x11~sheets ofpaper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation) , $ PART -Fax Calculation �--�-� rfyou are making mcorrection tmthe establishment date account balance(Line 2),orpercent taxable(Line 3), . ' - please obtain aWritten correction from the financial institution and attach it tmthis form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance o(the account including any interest accrued at the date ofdeath. 3. Enter the percentage cfthe account that iataxable toyou. a. First,determine the percentage owned bythe decedent. i Accounts that are held"intrust for"another or others were 100%owned by the decedent. ii For established more than one year prior to the date of death,the percentage taxable is 100Y&divided bythe total number ofowners including the decedent. (For example:2owners=5U%.3owners=33-33%.4owners =25%.et«.) 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 ofany debts and deductions claimed from Part 2. G. The amount taxable isdetermined bysubtracting the debts and deductions from the amount subject 8otax. 7. Enter the appropriate tax rate from Step 1 based onyour relationship 10the decedent. If indicating a different tax rate,please state your relationship to the decedent: VMS 1. Date Established X Uf F11 AN 04, 3. Percent Taxable 3 X 16 Ir 4. Amount Subject to Tax 4 $ 2114 5. Debts and Deductions 5 6. Amount Taxable 2 kM 7. Tax Rate 7 X Ilk Step 2: Sign and date below. Return TWO completed andsigned copies to the Register ofWills listed onthe front of this form, along with acheck for any payment you are making, Checks must bemade payable to"Register ofWills,Agent.^ Donot send payment directly 0uthe Department ofRevenue. Under penalty of perjury, I declare that the facts I have reported above are true,correctand complete tnthe best ofmyknowledge and belief. BUREAU OF INDIVIDUAL TAXES Pennsylvania Inheritance Tax pennsytvania PO BOX 280601 Y HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE --J REV-1543 EX D-EXEC (88-12) And Taxpayer Response FILE NO.21 - 5C� ACN 15107341 DATE 02-10-2015 Type of Account Estate of RICHARD J WAGNER Savings SSN Checking Date of Death 01-23-2015 X Trust FAITH E KLINE County CUMBERLAND Certificate 2002 PRINCETON AVE CAMP HILL PA 17011-5442 r �V n c C11-1 M cry �1 c� o x n �cl to zr. - t C] •. Z3 ,l FULTON BANK NA provided the department with the information below indicating 1-hat-At the death f tc" above-named decedent you were a joint owner or beneficiary of the account identified. c,) Cn o Account No.402 Remit Payment and Forms to: Date Established 12-21-2004 REGISTER OF WILLS Account Balance $45,013.31 1 COURTHOUSE SQUARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $45,013.31 Tax Rate X 0.045 Potential Tax Due $ 0 025.60 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 taxis 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. _ B 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. r"'711 4.5% 1 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). D n Changes or dQductions 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. i 1 PART Debts and Deductions Allowable debts and deductions must meet both ofthe 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\orequired,you may attach 81/2^x11^sheets ofpaperj Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation) , $ PA 7-ax Calculation L--��--J |fyou mm*making a correction to the establishmentdate(Line 1)account balance(Line 2),or percent taxable(Line 3), please obtain mm/rittmncorrection from the financial institution and attach it1mthis form. 1. Enter the date the account was established ortitled amitexisted a1the date ofdeath. 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 iutaxable Voyou. a. First,determine the percentage owned bythe decedent. ` i. Accounts that are held"intrust for"another or others were 100%owned by the decedent. ii. For established more than one year prior tothe date ofdeath,the percentage taxable io1OU%divided bythe total number ofowners including the decedent. (For example:2owners=5O%. 3owners~33.33%'4owners =2G%.etc.) b. Next,divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject totax iodetermined bymultiplying the account balance bythe percent taxable. 5. Enter the total nfany debts and deductions claimed from Part 2. 8. 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 1based nnyour relationship 0othe decedent. If indicating a different tax rate,please state your relationship to the decedent: NON, 1�1 o 1011 1. Date Established 1 4, ANIAN 41, 21 311, 4. Amount Subject to Tax 4 $ 5. Debts and Deductions 5 i��i V 108 1\ ' ' Tax Rate ' '` ME Step 2: Sign and date below. Return TWO completed mndokJnedoo i tothe Register ofWills listed onthe front cdthis form, along with ocheck for any payment yovammaNng. Checks must bemade payable tn"Register ofWills,Agont^ Dnnot send payment directly 0uthe Department ofRevenue. Under penalty ofperjury, }dao|one that the tooto | have reported above are true,correct and complete to the best of my knowledge and belief. BUREAU OF INDIVIDUAL TAXESPenns Ivania Inheritance Tax pennsyLvania PO BOX 280601 y HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE Iff REV-1543 EX D-EXEC (08-121 ( And Taxpayer Response FILE NO.21 - 1 '6 ---130U ACN 15107343 DATE 02-10-2015 Type of Account Estate of RICHARD J WAGNER Savings SSN Checking Date of Death 01-23-2015 X Trust FAITH E KLINE County CUMBERLAND Certificate 2002 PRINCETON AVE CAMP HILL PA 17011-5442 v C_ Ort1 M M C a co ;�o FULTON BANK NA provided the department with the information below indicating,that at the deal etthe above-named decedent you were a joint owner or beneficiary of the account identi��ed. r 1 w Account No.402 Remit Payment and Forms to:' rn Date Established 01-10-2007 REGISTER OF WILLS Account Balance $25,493.34 1 COURTHOUSE SQUARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $25,493.34 Tax Rate X 0.045 Potential Tax Due $1,145 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 I : Please check the appropriate boxes below. 1 A F-]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. B ®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. IX 4.5% 1 am a lineal beneficiary(parent, child,grandchild, etc.) of the deceased. (Select correct tax rate at right, and complete Part F_� 12% 1 am a sibling of the deceased. 3 on reverse.) 15% All other relationships (including'none). D F-1 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 F-]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 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 iarequired, you may attach 81/2^x11^sheets ofpaper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation) $ PART Tax Ca|Cu|at'C>[l If balance 2),or percent taxable(Line 3), � please obtain mwritten correction from the financial institution and attach itUmthis form. 1. Enter the date the account was established ortitled aodexisted atthe date cfdeath. 2. Enter the total balance of the account including any interest accrued at the date of death, 3. Enter the percentage ofthe account that iotaxable 0oyou. o. First,determine the percentage owned bythe decedent. i. Accounts that are held"intrust for"another or others were 100%owned by the decedent. ii For established more than one year prior tothe date ofdeath,the percentagetaxable iu100%divided bythe total number ofowners including the decedent. (For example:2owners~5O%' 3owners~3333%. 4owners =25%.a\c.) 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 ofany debts and deductions claimed from Part 2. G. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate taxrate from Step 1based onyour,relationship 10the decedent. If indicating a different tax rate,please state F' your relationship to the decedent: 61 1. Date Established 1 3 IS ON AJ o re.cn.0 .a^w=n o '` ONNt 4. Amount Subject to Tax 4 $ ISO IN 5. Debts and Deductions 5 affi, NAW 01 6. Amount Taxable 6 $ pp 0411 Step 2: Sign and date below. Return TWO completed signed copies to the Register o|Wills listed onthe front of this form, along with ucheck for any payment you are making. Checks must bemade payable to"Register ofWills,AgenL^ Donot send payment directly 0nthe Department ofRevenue. 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 BUREAU OF INDIVIDUAL TAXES Pennsylvania Inheritance Tax pennsytvanla PO BOX 280601 Y HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE '-- REV-1543 EX D..EXEC (08-12 And Taxpayer Response FILE N0.21 _ 1 � ACN 15107345 DATE 02-10-2015 Type of Account Estate of RICHARD J WAGNER Savings SSN c7 Checking Date of Death 01-23-2015 q Trust FAITH E KLINE County CUMBERLAND co -0 CAWii4e 2002 PRINCETON AVE n7 CAMP HILL PA 1701.1-5442 =5 rJ era co CJ-1 r77b 1.7) cj.c7 (.7 q ,..,, C:� �►T r1 a3 .y r- r7 O 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. Account No.402 Remit Payment and Forms to: Date Established 02-15-2008 REGISTER OF WILLS Account Balance $28,491.07 1 COURTHOUSE SQUARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $28,491.07 Tax Rate X 0.045 Potential Tax Due $ 0.04510 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 F-]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. B F'�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% 1 am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased. (Select correct tax rate at right,and complete Part F-] 12% 1 am a sibling of the deceased. 3 on reverse.) 15% All other relationships (including none). D [-]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 F-]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"intrust 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 Official Use Only ❑AAF your relationship to the decedent: PA Department of Revenue 1. Date Established 1 2. Account Balance 2 $ PAD 3. Percent Taxable 3 X 1 4. Amount Subject to Tax 4 $ 3 5. Debts and Deductions 5 - 4 6. Amount Taxable 6 $ 5 7. Tax Rate 7 X 6 8. Tax Due 8 $ 7 9. With 5% Discount(Tax x .95) 9 X $ i 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 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