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BUREAU 28 INDIVIDUAL TAXES Inheritance Tax
PO BOX 280601 Pennsylvania,
HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE
---" REV-1543 E%DocEXEC (08-12)
RECORDED Q T F i Ancl�jT�xpayer Response FILE NO. 21 -
R E v l S T i_ : - V,`1 L.LS ACN 15128197
DATE 05-25-2015
MIS MY 29 F0 11 91.
Type of Account
C i_Ci t F Estate of KATHY A UHL Savings
Q R F I I A'?c . SSN X Checking
CUM L r:`_ _.: Date of Death 04-02-2015 Trust
MARION F WELLS County CUMBERLAND Certificate
500 LANCASTER AVE
ENOLA PA 17025-2636
METRO BANK 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.536946486 Remit Payment and Forms to:
Date Established 03-24-2005 REGISTER OF WILLS
Account Balance $536.22 1 COURTHOUSE SQUARE
Percent Taxable X 50
CARLISLE PA 17013
Amount Subject to Tax $268.11
Tax Rate X8:13@+
Potential Tax Due Q /-;z , 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*) l/ oto due. Any inheritance tax due will become delinquent nine months
after the date of death.
PART
1 Step 1 : Please check the appropriate boxes below.
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 U The inforrnation 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 1-1 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.