HomeMy WebLinkAbout04-24-15 (4) RECORD`-D OFFICE OF
REGISTER � 1, , T- 1
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BUREAU DF INDIVIDUAL TAXES Pennsylvania IQrl an a TaxPD BOX 280601HARRISBURG PA 17128-0601 u�J j)(b oati CDEPARTMENT OF REVENUE
u JAJrid enc ay TPpXi.e REV-1543 EX DocEXEL(0Bi12)
FILE N0.21 -- �.
CLERK O,,_ ACN 15120132
n DATE 04-14-2015
}_ten ;
j Type of Account
Estate of MILDRED A JEZ Savings
Checking
Date of Death 03-22-2015 Trust
LINDA A SMELTZ County CUMBERLAND X Certificate
4 WHEATLAND DR
MECHANICSBURG PA 17050-1600
MEMBERS IST FCU 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.12629 Remit Payment and Forms to:
Date Established 10-12-2013 REGISTER OF WILLS
Account Balance $ 112,639.55 1 COURTHOUSE SQUARE
Percent Taxable X 50
CARLISLE PA 17013
Amount Subject to Tax $56,319.78
Tax Rate X 0.045
Potential Tax Due $ 0.04539 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
AF-]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 ElThe 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 El The tax rate is incorrect. F-] 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 set 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.
' .
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PART Debts and Deductions
Allowable debts and deductions must meet both ofthe following criteria:
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(if additional space isrequired,you may attach 81/2"x11^sheets nfpaporl
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Date
Paid Payee Description Amount Paid
Total.(Enter on Line 5 of Tax Calculation) $
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TaxCalculation
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[--�--] # nmakingmcwrmestablishment date(Line 1)account balance(Line 2),orpercent taxable(Line 3).
please' obtain a written correction from the financial institution and attach it to this form.
1Enter the date the account was established or titled as it existed at the date of death.
2. Enter the total balance ofthe account including any interest accrued at the date ofdeath.
3. Enter the percentage ofthe account that iotaxable 1oyou.
a. First,determine the percentage owned bythedecedent.
i Accounts that are held"intrust for"another or others were 100%owned by the.decedent.
ii For established more than one year prior 0othe date ofdeath,the percentagetaxable ie1U0%divided
bvthe total number ofowners including the decedent. (For example:Downers=50%.3owners=33.33%.4owners
~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 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 tax rate from Step 1 based on your relationship to the decedent.
If indicating a different tax rate,please state Official Use Only 0 AAF
your relationship to the decedent: PA Department of Revenue
2. Account Balance 2 $ PAD
4. Amount Subject to Tax 4 $ 3
5. Debts and Deductions 5 - 4
Step 2: Sign and date below. Return TWO completed signed copies Vothe Register ofWills listed onthe front nfthis form,
along with ocheck for any payment yuuammaking. Checks must bemade payable to"Register ofWills,Agent.^ Oonot send
payment directly tuthe Department odRevenue.
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.
VVUM«
dL Home
Taxpayer Signature Telephone Number Date
IF YOU NEED FURTHER ASSISTANCE, CONTACT PENN I SYLVANIA 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
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