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Home My WebLink About05-29-15 (2) 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 020741 BOWERS HELEN E 10204 TYBURN TERRACE BETHESDA, MD 20814 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- fold 15124987 $285.00 ESTATE INFORMATION: SSN: FILE NUMBER: 2115-0435 DECEDENT NAME: ROURKE VERA DATE OF PAYMENT: 05/29/2015 POSTMARK DATE: 05/26/2015 COUNTY: CUMBERLAND DATE OF DEATH: 03/28/2015 TOTAL AMOUNT PAID: $285.00 REMARKS: CHECK# 2986 INITIALS: CJ SEAL RECEIVED BY: LISA M. GRAYSON, ESQ. REGISTER OF WILLS REGISTER OF WILLS BUREAU OF INDIVIDUAL TAXESPenns Ivania Inheritance Tax pennsylvania PO BOX 280601 y HARRISBURG PA 17128-0601 Information NoticeDEPARTMENT OF REVENUE -'"-'"- REV-1543 EX UocE%EC (08-12) And Taxpayer Response ��Out ( �� OF FILE NO.2115-0435 ACN 15124987 R E u I C I '' CF WILLS DATE 05-07-2015 FIRY 29 9M 10 57 Type of Account CLEF"", C I" Estate of VERA ROU RKE Savings t� C ,..._ SSN Checking ORPi.AI Date of Death 03-28-2015 Trust HELEN M BOWERS ;C n County CUMBERLAND Certificate 10204 TYBURN TER CU `' ''''' BETHESDA MD 20814-2268 MEMBERS 1ST 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.2494 Remit Payment and Forms to: Date Established 07-07-1953 REGISTER OF WILLS Account Balance $4,000.30 1 COURTHOUSE SQUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $2,000.15 Tax Rate X 0.150 Potential Tax Due $ 0.1 02 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 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 El 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 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 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 o � �6 , our relationship to the decedent: Nr e t e. C3ffieta1se Cn�yAt= sm Y p \ F' bepartt ten ft ege6tue 11 1. Date Established 1 O?—0 7 (�1 3 �� _ : ��`y� ��mv I k'46 2. Account Balance 2 $ 3Q °� ��.� O A b 3. Percent Taxable 3 X bM �� MMM � ��`. �"� �� ` . maw 4. Amount Subject to Tax 4 $ o-2, 15 \6,` �;�� c . \ O' 5. Debts and Deductions 5 ��AME i \ \�\� � 6. Amount Taxable 6 $ 9--?7Z �1411, oF 1a 7. Tax Rate 7 X 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. Worker ql`�Z /745' 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 1 REC"r,.:l { �vti o 29 qM 10 57 � �ops `�'f `• "' 0RFH r,' 41 4 J y ;rj r 11,1 vl` 4 Y f� W 3�