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NRRFISBORG PA VI]9-06Y1 Information Notice �EPAFTMENTOFqEVFNOE
� And Taxpayer Response Fi�E N0.2i i a-oass `�� ��
ACN 15138601
DATE 07-16-2015
Type of Accow[
Es�ate of SALVATORE J VALVO Savin9s
Checking
Date of Dea�h OB-30-2014 Tms�
RANDOLPH P VALV� CounryCUMBERLAND Certi�icate
212 ALLENOALE WAV
CAMP HILL PA ll011-8402
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SANTANOER BANK provided the department with the information below indicating thaj at�,tjecdeath of the
above-named decedent you were a joint owner or beneficiary of the account identi�d. "
Remit Payment and Forms to:
AccountNo.7677145817
Date Established OS-10-2073 REGISTER OF WILLS
Account Balance $571 AS 1 COURTHOUSE SOUARE
Percent Taxable X W
CARLISLE PA 17013
Amount Subject to Tax $285.73
Tax Rate X 0.150 NOTE': If tax payments are made within three months of the
Potential Tax Due $4286 tlecedenYs date of death,tletluct a 5 percent discount on the tax
With 5%Discoum (Tax x 0.95) $ (see NOTP) due. Any inheritance tax due will become tlelinquent nine months
after ihe date ot dea[h.
PART St@P 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.
Proceetl to Step 2 on reverse. Do not check any o(her boxes and disregard the amount
shown abcvc as Polential Tax Due.
g �The information is The above information is wrrect, no deductions are being[aken, and paymen[will be sent
correct. with my response.
Proceed to Step 2 on reverse. Do nof check any ofher boxes.
p �The tax ra�e is incorrect. � 4.5% I am a lineal beneficiary(parent,child,grendchild.etc.) o�the tleceased.
(Select correct tax rate a�
right.and complete Part � �p o I am a sibling of Ihe deceased.
3 on reverse.)
� 15% Allotherrelationships (Induding none).
p �Changes or tletluctions The information above is incorrect and/or debts and deductions were paid.
listed. Complefe Part 2 and part 3 as appmpriate on the back o/fhis lorm.
E �Asse�will be reported on The above-identified asset has been or will be reported and tax paid wi[h the PA Inheritance Tax
inheritance tax form Return filetl by the estate representative.
REV-1500. ProceedtoStep2onreverse. Donotcheckanyotherboxes.
� �Please sign and date the back of the form when finished. �
PART Debts and Deductions
2
Allowable deb�s and deduc�ions must mee�both o�the following criteria:
A. The decedent was legalty responsible for payment, and ihe estate is insu(ficient m pay ihe deductible i�ems.
B. You paid Ihe debis after Ihe dea�h of the decedent and can furnish proof of payment if requested by the department.
Qf additional space is required, you may a�tach 8 1/2"x 11"sheels of peper.)
Date Paid Payee Description Amount Paid
Total (En�er on Line 5 of Tax Calculation) $
PART Tax CalCulation
3 If you are making a correction to the establishment tlate(Line 1)account balance ILine 2),or percent tazablelLine 3),
please obtain a written correction irom ihe tinancial institution and attach it to this torm.
L ENer[he da�e the accoun[was established or�itled as i�exisled at�he date of dea�h.
2 Enterthe totalbalance ofthe accountincluding anyinterestaccrued atihe tlate oftleath.
3 En�er the percentage of the account that is taxable to you.
a. Firs�, determine the percentage ownetl by�he deceden�.
i. Accounts ihat are held "in tmst for"another or others were 100%owned by ihe deceden[.
ii. For joint accounis established more ihan one year prior to ihe date of death, the percen[age taxable is 100%divided
by the rotal number ot owners inclutling ihe decedent. (For example:2 owners= 50%, 3 owners=33.33%, 4 owners
=25%,atc)
b. Next,divide the decedenfs percentage owned by ihe number oi surviving owners or beneficiaries.
4. The amoun�subjec��o tax is determined by multiplying ihe account balance by Ihe percent�axable.
5. Enter lhe total a�any debts and deductions claimed irom Pan 2.
6. The amoun�taxable is de�ermined by subtracting the debts and deduc�ions from the amount subject to tax.
7. Enter the appropria�e tax rate irom Step 1 basetl on your relationship ro ihe decedent.
I�indicating a differem tax ra�e, please state OifiCi01 USC Only �qqF��
your relationship to ihe decedent pq DeP2fIm@nt Of flBVBnue � �
1. Date Established 1
2 Account Balance 2 $ PA� . . .....
3. Percen�Taxable 3 X � �
4. Amount Su6ject�o Tax 4 $ 2 .. .
3
5. Deb�s and Deductions 5 - q � ....
fi. AmountTaxable 6 $ 5
7. Tax aate 7 %� E
e. T� Due 8 S � �
8
9. With 5/Discount (7az x .95) 9 X
.SteP 2: Sign and date below. ReWm 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,A9enC' Do no�send
payment directty ro the Departmen�of Revenue.
Under penalry of perjury. I declare that the facts I have reported above are irue,correct and complete to the best of my knowledge and
belief.
/J/�/ Work
/� [ �//L Home ��L /j
Teupayer Signature Telephone Number Date
IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA DEPARTMENT OF REVENUE
DISTRICT OFFlCE, OR THE INHERITANCE TAX DNISION AT 717-787-8327. SERVICES FOR
TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-4473020