HomeMy WebLinkAbout05-11-15 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 020638
HARMON SANDRA K
1223 SCENERY DRIVE
MECHANICSBURG, PA 17050
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
-------- fold
__________ --------
15502379 $2,410.19
ESTATE INFORMATION: SSN: 15502380 $2,410.19
FILE NUMBER: 2115-0228 15502377 $2,892.88
DECEDENT NAME: HARMON STACEY L 15502378 $2,892.88
DATE OF PAYMENT: 05/11/2015
POSTMARK DATE: 05/11/2015
COUNTY: CUMBERLAND
DATE OF DEATH: 02/17/2015
TOTAL AMOUNT PAID: $10,606.14
REMARKS:
CHECK# 1003
INITIALS: DMB
SEAL RECEIVED BY: LISA M. GRAYSON, ESQ.
REGISTER OF WILLS
REGISTER OF WILLS
BUREAU OF INDIVIDUAL TAXESp`111ISytvania
Po BOX 280601 Pennsylvania Inheritance Tax
HARRISBURG PA 17128-0601 Information Notice ` DEPARTMENT OF REVENUE
""""'�"� REV-15438 EX DocEXEC (BB-12)
E C 0 R��d.Taxpayer f esponse
FILE NO.2115-0228
Ri> '�,'i (_S ACN 15502379
DATE 03-27-2015
?p1S Fiff 11 fiM 10 28
Type of Account
C L E F' 01: Estate of STACEY L HARMON Security
0 R P H h f i>` lye 0 ASSN X SEC Acct
s; Date of Death 02-17-2015 Stock
BARRY L HARMON M BR, J" County CUMBERLAND Bonds
1223 SCENERY DR
MECHANICSBURG PA 17050-1942
METLIFE 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.32044123171 Remit Payment and Forms to:
Date Established REGISTER OF WILLS
Account Balance $112,757.17 1 COURTHOUSE SQUARE
Percent Taxable X 50 CARLISLE PA 17013
Amount Subject to Tax $56,378.59
Tax Rate X 0.045
Potential Tax Due $ 0.045 04 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") R, V/0,/ 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.
BThe 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
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 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 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 \ \
i vvv.
v f#1o1 tly ❑AAE
your relationship to the decedent: ��� �� } j � eVenue
1. Date Established 1 \ p= app.
2. Account Balance 2 $ A .a
\\ : \
3. Percent Taxable 3 X
4. Amount Subject to Tax 4 $
01 A
2.
Z\
` \> \ o\ 4
5. Debts and Deductions 5 - 4 \\ \ \\ \
6. Amount Taxable 6 $ 5
\\\ .\
7. Tax Rate 7 x
\ b, \
8. Tax Due 8 $
\v � �`
9. With 5%Discount(Tax x .95) 9 X .--
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.
23 Work
Home / —
Taxpayer Agnature 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 Pennsylvania Inheritance Tax pennsylvania
PO BOX 280601 DEPARTMENT OF REVENUE
HARRISBURG PA 17128-0601 Information Notice
'—""— REV-1543B E%OocE%E[ (08-12)
�
RECORDE ,"p, ,T„�Fyer Response FILE NO.2115-0228
REGISTF ;y E V�IILt' S ACN 15502380
DATE 03-27-2015
?O15 fY 11 R9 10 29
Type of Account
C L E(' ` OF Estate of STACEY L HARMON Security
0 R P[i A ^'`''i SSN X SEC Acct
Date of Death 02-17-2015 Stock
SANDRA K HARMON C �, r h t"! County CUMBERLAND Bonds
1223 SCENERY DR
MECHANICSBURG PA 17050-1942
METLIFE 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.32044123171 Remit Payment and Forms to:
Date Established REGISTER OF WILLS
Account Balance $112,757.17 1 COURTHOUSE SQUARE
Percent Taxable X 50 CARLISLE PA 17013
Amount Subject to Tax $56,378.59
Tax Rate X 0.045
Potential Tax Due $ 0.045 04 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') /(J. % 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 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 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 state `�� � "��°°
your relationship to the decedent: & PA Dpartm+~nt of Revenue [
1. Date Established 1 i
\
\j \ ,_ a
\. ��•
2. Account Balance 2 $
3. Percent Taxable 3 x \
4. Amount Subject to Tax 4 $ 4t \ \\\ \ \\ \ \\
oI j
5. Debts and Deductions 5 - iR 060 X 2�0\ asy
I MOW MONO Um 4100100-0,4:1
6. Amount Taxable 6 $ o
7. Tax Rate 7
8. Tax Due 8 $ U11 \ ' 'a
9. With 5%Discount(Tax x .95) 9 x
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= 7&6'
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 Pennsylvania Inheritance Tax pennsyLvanla
PO BOX 280601 Y
HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE
� REV-1543B EX D-EXEC (08-12)
And Taxpayer Response FILE No.2115-0228
RECO ROD r D CFF CE 0 F ACN 15502377
B E G E T "7 CF 1,'I j_I-S DATE 03-27-2015
?015 MY 11 H-9, IO 29 Type of Account
CLEF.", OF Estate of STACEY L HARMON Security
} ( T SSN X SEC Acct
Date of Death 02-17-2015 Stock
BARRY L HARMON ' F ">, a County CUMBERLAND Bonds
1223 SCENERY DR
MECHANICSBURG PA 17050-1942
AMERIPRISE 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.93007777567 Remit Payment and Forms to:
Date Established REGISTER OF WILLS
Account Balance $135,339.64 1 COURTHOUSE SQUARE
Percent Taxable X 50 CARLISLE PA 17013
Amount Subject to Tax $67,669.82
Tax Rate X 0.045
Potential Tax Due NOTE*: If tax payments are made within three months of the
$3,045.14 decedent's date of death, deduct a 5 percent discount on the tax
With 5%Discount(Tax x 0.95) $(see NOTE*)� Aja,g� 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 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 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—I 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 state ����� ff la USO Onl AAF� `
71,
your relationship to the decedent: �rtr0 41 Ue�en�ie\ "I'll \
\\ \ \ `
1. Date Established 1 �� ����\ `�������� �` 12
2. Account Balance 2 $ O`
1 �\. \\ #
3. Percent Taxable 3 X
E
4. Amount Sub'ect to Tax 4 $ v a
5. Debts and Deductions 5 - "IP vs
\\ \\ \
6. Amount Taxable 6 $ \
7. Tax Rate 7 X y `" `macis.
\ p \
8. Tax Due 8 $ ����`
\?
9. With 5% Discount(Tax x .95) 9 X _
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
46 Home —
Taxpayer ignature 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 Pennsylvania Inheritance Tax pennsyLvania
PO BOX 280601 Y
HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE
Taxpayer Response BEV-1543X EX DocEXEC (08-12)
And
RE%0 `�` Cit ;CL OF FILE NO.2115-0228
ACN 15502378
F{'j ±, r WILLS- DATE 03-27-2015
?01S O<RY 11 fin 10 20
Type of Account
G L E i" t�F Estate of STACEY L HARMON Security
F I4 J, ,�, f SSN X SEC Acct
Date of Death 02-17-2015 Stock
SANDRA K HARMONCUFj4 ;'.,County CUMBERLAND Bonds
1223 SCENERY DR
MECHANICSBURG PA 17050-1942
AMERIPRISE 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.93007777567 Remit Payment and Forms to:
Date Established REGISTER OF WILLS
Account Balance $135,339.64 1 COURTHOUSE SQUARE
Percent Taxable X 50
CARLISLE PA 17013
Amount Subject to Tax $67,669.82
Tax Rate X 0.045
Potential Tax Due $ 0 045.14 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`) �89a 8 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 Potential Tax Due.
B CgThe 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-I 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 ❑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 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 b
our relationship to the decedent: IClil
1. Date Established 1
2. Account Balance 2 $ NNIJFVIIIF
\`\
3. Percent Taxable 3 ���� I `ky {
4. Amount Subject to Tax 4 $ \ \\\
\T� � � �
5. Debts and Deductions 5
6. Amount Taxable 6 $ 9 AM � 16 Ma,
All
t\ y y
7. Tax Rate 7 X ��f
_ ? �.
461
8. Tax Due 8 $ 1 I
9. With 5% Discount(Tax x .95) 9_ X ���.22, 1 a�o�0
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 /V/�
- � Home 7/7—706
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