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BUREAU OF INDIVIDUAL TAXES Pennsylvania Inheritance Taxpennsytvania
PO BOX 280601 � Information Notice DEPARTMENT OF REVENUE
17128-0601
HARRISBURG PA And Taxpayer Response QV REV-1543 EX DocEXEC(08-12)
FILE NO.21 - k5-'659
RE'3ORDLED OFFICE OF ACN 15138607
RqGISTER OF WILLS I DATE 07-16-2015
2015 AUG 7 M 9 58 Type of Account
C L E i'%'K 0 F Estate of JOHN E NOLAN Savings
ORPHANS �IN Chec' CC�jb6te of Death 07-04-2015 Trustking
CHRISTOPH J NOLAN CUMBERLAND C-9.90bnty CUMBERLAND X Certificate
8 MARY DR
DILLSBURG PA 17019-9483
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.17825 Remit Payment and Forms to:
Date Established 06-20-2014 REGISTER OF WILLS
Account Balance $10,114.83 1 COURTHOUSE SQUARE
Percent Taxable X 50 CARLISLE PA 17013
Amount Subject to Tax $5,057.42
Tax Rate X 0.045 NOTE*: If tax payments are made within three months of the
Potential Tax Due $227.58 decedent's date of death, deduct a 5 percent discount on the tax
With 5%Discount(Tax x 0.95) A(see NOTE*) due. Any inheritance tax due will become delinquent nine months
after the date of death.
PARTI Step 1 : Please check the appropriate boxes below.
A F-1 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 F—]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 12% 1 am a sibling of the deceased.
3 on reverse.)
15% All other relationships(including none).
DF]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 �4sset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax
heritance 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 Official Use Only ❑AAF
your relationship to the decedent: PA Department of Revenue
1. Date Established 1
2. Account Balance 2 $ PAD
3. Percent Taxable 3 X 1
4. Amount Subject to Tax 4 $
5. Debts and Deductions 5 - 4
6. Amount Taxable 6 $ 5
7. Tax Rate 7 X 5
8. Tax Due 8 $ 7
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
Home 70 -580- 7843 l 2r'd/S
Taxpayer SignatuA Telephone Number Date
IF YOU NEED FURT R 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