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Home My WebLink About08-13-15 / BOREAO OF IHO[VIOIVL iA%ES Pennsylvania lnheritanceTax �j ��- PennS�/LVdllld xa0501 pEPNflTMENT OF flEVENUE IWPRIS90RG'V< 1)1>8-0601 Information Notice RECOfC_^ �?¢T@�Pg}'erResponse Fi�ENo.�i -�S�LS33 RESI:'-.�... _ '�.._i S ncN isiaaiss DATE 07-28-2015 _ .!_� 13 °"1 3 �1 C 7ype of Account Q��, , .. . Estate of FLORENCE V SPOTTS Savings Checking �UM� � ' � Dateo�DeathOS-25-2015 Tms� KAREN A NAUMAN � CounryCUMBERLAND �Certificate 14] SALEM CHURCH RO MECHANICSBOBG PA 1]O50 CITIZENS BANK OF reNNsv�vaNia provided the department with the information below indicating that at [he death of the above-named decedent you were a joint owner or beneficiary of the account identified. Account No.6208801074 Remit Payment antl Forms to: Date Establishetl 11-03-2004 REGISTER OF WILLS Account Balance $�,gpq,73 1 COUflTHOUSE S�UARE Percent Taxable x 50 CARLISLE PA 17013 Amount Subjecl to Tax $912.37 Tax Rate %0.045 NOTE': I�tax payments are made within�hree months of�he Potential Tax Due $41.06 decedenPs date of death, deduct a 5 percent discount on the tax Wi[h 5%Discount(Tax x 0.95) $(see NOTE') due. Any inheri�ance tax due will become delinquent nine mon[hs afterthe date ofdea�h. PART St2P 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or 1 am the parent of a decedent who was 21 years old or younger at date of death. Proceed ro Step 2 on reverse. Do not check any other boxes and disregartl the amount shown above as Pofential Tar DUe. g �The inbrmalion is The above information is wrrecl, no tleduc[ions are being[aken, and payment will 6e sent correc�. with my response. Pmceed to Step 2 on reverse. Do nof check any other boxes. � �The tax rate is incorrect � 4.5% I am a lineal beneficiary (parent, child, grandchild, e[c.) of ihe deceased. (Seled correc�tax rata a[ righ�,and comple�e Patl � �p� �am a sibling of the deceased. 3 on reverse.) � 15% All o�her rela[ionships (Including none)- p �'Changes or deductions The information above is incorrect andior dehts and deductions were paitl. . listed. Complete Part 2 and part 3 as appropriate on the back ol this lorm. E �Asset will be reported on The above-identified asset has been or will be reportetl and tax paid with ihe PA Inheri�ance Tax inheritance ta<�orm Retum filed by�he estate representative. REV-i W0. Proceed to Step 2 on reverse. Do nof check any ofher boxes. � Please sign and date the back of the form when finished � PART ` � Debts and Deductions Allowa6le debis and deductions must meet both of Ihe following criteria: A. The decedent was legally responsible for payment, and the estate is insuHicient to pay the tleductible items. B. Vou paid the debis atler the death of ihe decedent and can fumish pmof of payment if requested by the depahment. Qf additional space is required,you may attach 8 V7'x 11"sheets of paper.) Date Paitl Payee Description Amount Paid (,,-J6" / S �{� , /�,'- , <' !'.. " : %S�. O � " - � - i � �l i " ��rS - -' i; �_ _ �,� � _ ( / :,_ . si�., �. � � 'C� -i Ci To�al Enter on Line 5 of Tax Calculation $ -!J PART Tax Calculation 3 If ou are makin a correction to ihe establishment date Line 1 account balance Line 2 , or Y 9 ( ) ( ) percent taxable(Line 3), please obtain a written correctian from the tinancial InStitutian artd allach it to[his form. t Enter the da�e the account was established or�itled as it existetl at the date of death. 2. Enterthe btalbalance ofihe accountincluding anyinterest accrued atthe date ofdeath. 3. Enter[he percenta9e ofihe accoun�thatis taxable to you. a. First,determine the percentage owned by ihe decedent. i. Accounts that are held "in ims�for"ano�her or others were 100%owned by the deceden[. ii. For joint accounts established more than one year prior to the date of tleath, the percentage tavable is 100%divided 6y ihe total number of owners inGuding the decedent (Por example:2 owners= 50%, 3 owners=33.33%,4 owners =25/.etc.) b. Next,divide the decedenPs percentage owned by ihe number of surviving owners or beneficiaries. 4. The amount subject to t� is tletermined by multiplying Ihe account balance by the perceM taxable. 5. En�er the total of any debts and deduc�ions claimed from Pah 2. 6. The amount taxable is determined by subtracting�he de6ts antl tletluctions fmm the amount subled�o tax. 7. En�er�he appmpria�e tax rate irom Step 1 based on your relalionship to�he decedent. it indicating a different tax rate, ple state pjf�y��y��y.0� yourrelationshiptothe decetlen�:�r��. � � 1. Da�e Established i PA Depanment of Revenue : 2. Account Balance 2 $ % Y i`/ ) �� PA� 3. Percent Taxable 3 X , 5-lJ �� 2 4. Amount Sublect[o Tax 4 S ��/.,2 � .-'L7 3.:.. . . . 5. Debts and Deduc�ions 5 - `/S G , 7 3 Q . s. nmo�oc ra=abie s $ �! G i. L� �/ 5 �. 7. TaxRate 7 X 6^9 , jit�5 6 7 8. Tax Due e $ ?G- � 7 $ 9. With 5% Discount(Tax x .95) 9 % � � ' .. SteF1 2: Sign and date below. ReWrn 7W0 comple�ed and signed copies to the Regis[er of Wills lis�ed on�he iron�of this form. along with a check for any payment you are making. Checks mus[be made payahle to"Register of Wills, Agen�" Do no[send payment directly to ihe Department of Revenue. Under penalty of perjury, I tleclare ihat the facts I have reportetl above are ime,correct and complete ta the best of my knowledge and belie�. WOrk 7/ J �LS- . `/�/.��7� �C��w.._ �'� � i�/ Cc�u-w..r�.,_ Home 7/ 7, �r/G �1"� ) g � 1 ' �S� 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 a�w�� f ��A� Ta=Es Pennsylvania lnheritance Tax ��`� ��^ PennS�/LV8�11B PO Bu% 200601 �'• � DEPARTMENTOFREVFNIIF HARRiSBORG PR ll128-06Y1 Information Notice p And T�payer Response Fi�E No.21��' ��y �3� RECO.,��^ .� ..,. rICE 0� ncN isiao�oo REGif'�--;-.. : �....:'i!.'_S oaTeoa2s-zois ?nls F�� 13 °f1 3 �1 Type of Account �' ' Esta�e of RORENCE V SPOTTS Savings �RP�i;,��.. . .. Checking Date of Death OS-25�2015 Tmst KAREN A NAUMAN ��!R��.� -.... � � '. CountyCUMBERLAND Certi�ica�e 147 SALEM CHURCH RD � MECHANICSBIIRG PA 17050 CITIZENS BANK OF PENNSVLVRNIA 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. Remit Paymen�antl Forms to: AccouniNo.6245599275 Date Established 11-03-2004 fiEGISTER OF WILLS Account Balance $3,973.91 � COURTHOUSE SOl1ARE CARLISLE PA 17013 PercentTaxable X 50 Amount Subjed ro Tv� $ 1,986.96 Tax Rate X 0.045 Potential Tae Due g gg,q� NOTE': I�lac payments are made within three mon[hs of the decedenfs date of dea�h,deduct a 5 percen[discouM on the tax Wi�h 5%Discount(Tax x 0.95) $(see NOTE') due. Any inheritance�ax due will become delinquen�nine months after the date ot 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 Potential7ax Due. g �The informa�ion is The above information is correct, no deductions are being taken,and payment will be sent correc�. with my response. Pmceed fo Step 2 on reverse. Do not check any ofher boxes. � ❑The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child,grandchild, etc.) of the deceased. (Select correc�tax ra�e at right,and wmplete Pah � �p o I am a sihling ot�he deceased. 3 on reverse.) � 15% All other rela[ionships (including none). p �Chanqes or deductions The information above is incorrect and/or debts and deduc[ions were paid. listed. Complefe Part 2 and part 3 as appropriafe on the back ol Ihis lorm. 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 ReNm filed by(he estate representa�ive. REV-1500. Proceed to Step 2 on reverse. Do not check any ofher 6oxes. � Please sign and date the back of the form when finished. �( 0 PART Debts and Deductions 2 Allowable debts and deduc�ions must mee�both of Ihe following cri�eria: A. The deceden�was legally responsible for payment,and the es�a�e is insuNicien��o pay Ihe dedudible items. B. Vou paid�he deb�s afler the death of�he tlecetlen�and can furnish proof of payment i�reques�ed by�he depanment. Qf additional space is required, you may attach 8 1/2"x 11"shee�s of paper.) Oate Paid Payee Descrip�ion Amount Paid � i� . �� o s , c.,�r � - � > � �� s�i , Tohal Enter on Llne 5 of Tax Calwlation) $ �C % PART Tax Calculation 3 If ou are makin a correction to Ihe establishment tlate Line 1 accoun[balance Line 2 , or Y g ( ) ( ) percenttaxable(Line 3), please obtain a written torret:ion from ihe financial institution and attach it to[his form. t Enter the date ihe account was es�ablished or titletl as it existed at the date of death. 2 Enter the�otal balance of[he account including any interest accrued at�he date of dea�h. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts tha�are heltl"in[ms�for"another or others were 100%owned by the deceden�. ii. For joint accounts established more Ihan one year prior�o the date of dea�h,Ihe percentage�a.able 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, tlivide the decedenCs percentage owned by ihe number of surviving owners or beneficiaries. 4. The amoun�subjec��o tax is de�ermined by mWtiplying the accoun�balance by the percent t�able. 5. Enter�he lolal of any deb�s and deductions claimed from Part 2. 6. The amount taxable is tletermined by sub�rac[ing ihe tlebis and deductions irom ihe amount sublect to tax. Z Enter the appropriate tax rate fmm Step 1 hased on your relationship to the tlecetlent. If indicaling a diHeren�tax rate,plea state � QffiC12I VS¢On�y;�AAF your relationship�o�he decedenC '�u� � . P/��ap(mept Of flQY8fiU6 � 1. Date Established 1 . . - . 2. Account Balance 2 S '� `� 7 3, j�� PAd�� 3. PercentTaxable 3 X � ��L� 2 4_ Amoun�Subjec�to Tax 4 $J 9 Sf �i , j/c 3 5. Debts and Deductions 5 - ' `� 3 �J / q 6. Amaun�Taxable 6 $ -l�— 5�.��. 7. Tax Ra�e 7 X s 8. Tae Due 8 $ -�?'— 7 8 9. WithS%Discount(Taxx .95) 9 X . .StOP 2: Sign and date below. Return TVJO completed and signed copies to the Register of Wills listed on the hont of this form, along with a check br any payment you are making. Checks must be made payable to"Register of Wills,AgenL" Do not send payment directly to the Department of Revenue. Under penalty oi perjury, I declare ihat the facts I have reported above are tme, correct and complete to ihe best ot my knowledge and belief. Work )� 7 �.Ji: ,�J�/.,7 2 n �'� c'��.P.,., Ci, � � V u-<-�-�� Home �i� �4/ -/��'i f s �� % � / 5 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: 1-800-4473020 WORKINGER SF�VIMEL b49 EAST MARKEf STREEf,YORK,PA U403•717-854-2315 FUNERAL HOMES �OHNT.SEMMEL, SUPV. °1��"11°M1O1��'r LARRY E.KAUFFMAN,FD STATEMENT OF FUNERAL GOODS pND SERVICES SELEC7ED C�ar9as are orNY brUbse itens ihet you sclectetl a tlw are repued, H we are mpure0 by lew w by a a �M' a^Y�ems. �wi etmlain Ihe reasors n wnOng belo.v. H fou selecletl a hncvJ tlat may requre e^�9.sich az a M1neral wAh Nexi^9.YW�Y haes �a��a�� gr�Y �e^��^9 YW 6tl rrol ePP«il you selecle0 amdngnrienl5 sr�h a5 a Eirea aana0ai w �9.�vAll m�lai�wty Gelvn. Fd}he Service W � -- ... _ — om m o�m Vurcheaer. —'.-- N� p�°68 Ciry Stete A GHA(iGE FOR SEqVICES SELECTED: ��9_ 1. PROFESSIONALSERVICES -- Besic Services d Fimeral Direclor. ---'--S— S�aHenGOve�heatl..__......._.._..._....... $ _ -- E— Embalrrcn $ — Crema6on um._._..._._....__.............._... S g................_......_......._.......... (Descn " .._ O�her MePe2tlon d botly --- P�) ..— —_ — Olher_ . � __$_"_ ..........._._....._........_................. ... _.. S _ $-- TOLLL MEfICHqNDISE SELECTED........._.. $—_ SUB-TOTAI OP PqOFES510NAL$EfMCES..___.A1 E__._ . ......_....8 5__ 2 FACIIITIES ANp EQUIPMENi Q SPECIAL CHApGES: Use o(faciliUes aq ytaR/p nexing Fwvrardlg of rerriai�s to arrother M�¢ral Iqrre ry��ran«vwa�)..__...____........_...... a — -- - $— Use o�facilities arq staR br fur�eral (F�rrery Home) ceremony......_._._.__.........._......_... $ Raceivingoiremainshomarrotherlurieralhome Use d facilNes an0 sfafl br _ $ mamonal servke..........._.................._. $ ___ (Funeral Home) Um d eWprt�en�aM siaif br gravestle Irtxnedute Banal._......_._..._..........__..... 5 ._ urvke........_.._.....__.._.............._......._ $ __.— Direcl Cremation....._.._...._._........_....._ S _..— —_ $ _ . SU6TOTAL OF SPECIA�CHAFGES..._._.._.__......_.0 y_,_ _—— ..._......__....................._........_....__.._.. S _— D. CASH AUVANCE REMS 5118-TOTAL OF FACILITIES�EpU1PMENT.....__.....A2 S___ We charge you Ipr q,r xrvices in ob(yining dems marketl: 3. AUTOMOiNE EOUIPMENT �7aMrg Grave....__............._........_..... $ _ Transkr remans to Funeral Home Ceme�e7 Equipmani..._...._.._........_... $ __ Local._......_._.....__....._........__............ 5 — NtaritlDeetl...__....__..__......._.......... 5 Hearse �'spaPer NoGces-Local.._......._...... $ _ ' Local......_.....__.............._.__..._........... $ __ NawsPeGerNotices-Ou�of-Town._..... $ —_ Teleol�meBTelefax__..___.._. ... . .. S J ��r� f i ci l E' �'�P�lSe S�C1' / � ��` � ��1 fG+� i�'{�e�lc . l�c%�� c�i� he i c�,o� ��S Y�, ov ,��-�//� U/!SP � f�fc� Limousirie ' __ Local_........_... Airtare.._....._._......_.......................__... § _ . .._._.................._....._.... E —_ Ge M1ass OHerin Flowerprorfloraldis�rositim �9Y 9..._.............._....._ S _ CerUfietl wpies of tlie Dea�h Local._..._........._.......__............___...... $ _ CeNficate....._.....__..........__............. $ Leatl car/dergy car _ Local.._..._..._.... r�b�e�e�..............._...._...._._..._.._. a —.:. artormw� .............._....- � Fwwars._.._.._..........._ s ._..... ...... — ._...._.._........._. Uansportaeon_.........__...... S __ VauttServiceQurge_...._......_..._....... S _._ — S -�— Organist...__....................._...._......._.... S SUB40TAL OFAUTOMpTIVE EOUIVNENT.._....A3§_ a___ — _— _s_ : TOTAL OF PqOFESSIONAL SERVICES, _ �_ y_ FACILITES AND AUTOMOTIVE _ �_$__ ' EQUI7MENT._........._........_._.............._................A1 5_._ SU6TOTAL OF CASH ADVANCE ITEMS..... ._..D$_ B. CHARGEFOPNEHGMpNDiSESELECTED: TOTALCOSTOFMqqNGEMENTS.� CaskeL_._......_..._.........._........_....._... 5 __ PAIDATTIMEOFOFlPNIONTb (DescriPtion) _. ARRANGENEHIS_.__........_....__... § Otl— --� $ -- BALANCE DUE._...___................._..._ E . . ier..................................................... y — (�O°��O"�—' - _ pEASON FOR EMBALN�NG --__ Olherbunalconlainer..............__..._._. S _ Itvry�ggy.cemetery.«crema — (DescnPtion) . a _ Wrtliase oi arry oi�he items Ys�etl abae,we 'xaA«SplanNtha Ihe AckriowletlgemeMcards.............._....... $ �Quiremenibebw. Re9isterbook�s)_................_._............ S -- ' ._ Memwybltlers............_.._......_......_... $ - __—_ PraYercaNs..........._............_._....._.__ $ TemPora7 92ve msrker.__...._......_._. E _.._ eurlel tlomifg.___........._...._...._.__..... S I herebY agme tlat I taee axamveJ IM abrne sla[atl ilems ar�tl buntl ihem ro be mnecl antl aarortling ro Ne anargerrienls reqies�eU antl I hereGl��t at a capy W tliis memordrrYun entl a9reen�,rit I hareby r¢Preser��tlW I ha�re sulfitlent are6legelty aralade Wr �aymem o�tt�e rash reor agree ena caenant idritlr and sevarwy m malce pay„�em o�S_. 4 le[e charge of 1-12% per monN arnounArg b 18%P�Y�is aPP�ietl lo Ne unP� bala�ce begimmg ihirtYma tlays from ihe tlate oi�his 3greemem. My aOtliGonal senices«merc�arMise wderetl a requesfetl aRer tle da�M tl�is agreernen�witl be consftlered part d tlis agreemenf 3ntl Me cost piereot vnn be reflecteG on Ihe fual sia��rp (4YE),THE BUYER�S), HEflEBY AGREE TNAT IN CONSIDEHATION OF THE GOOD$ pXpypp $�qyICES TO BE OELIVERED,THAT 3UVEfl�3) INqVIWpLLY AND JOINTLY IS (APE) HEREBY OBLIGATED TO Ppy q�L AMOUNTS OWNINC AND SHOULD BUYEH(5) )EFAULT IN THE I1GpEEMEM WRII SELLEq, IN pCCpRDANCE WRH THE TEpM$ OF THE CANTpqCT BETWEEN gUYER(S)AND {ELLER,BUYER(S)XEHEBY I1GpEE(S)TO PAY ALL COLLECTION COSiS,qEASONABLE ATTORNEY FEES ANU COUAT CO5T5 UPON :OMMENCEMENr OR INRIATION Of ANV GOLLECTION EFFOqTS OH LEGAL PfiOCEEDINGS. ieel)_, .. (Purchaser) — — teal)_' . (Date) (aurchaser) (Licensed Funeral Director) e�una.rn r.�rrine s t'.rnn •.• .�. zars r�.,�r••�•w��u�„a IorL R\ IO�Oi .�n�p.1515 I ♦q w.eiu ��• � d�'er. .� A� � . _��i �'T _ — _ _� � V�iremia li»r fi.ld � ._ ' . . �/- �� .. � 0/J �// Invoice �� ` ,,,,,,,,,,,,,,, ,,,,,,,,,,, �,,,. ,,, ,,,,: I��: �yy� IW Iv d Nyo116n Mau++� Nnuuu Yavu aN 11LN. I.V•J' L�o Imviny4aJAelonlai a 4 In. M�vvlWa IW4i �uf41a1 N�•�) knlM'. �L��w Ine �� n • 1.� �.11 ly PaW 141yy� � mtll iw..�..w.�r.neu�..n..• ��.nv:swa.+..ya..�.� www�..n,�...;..�a�wrrys.....r wrw r a,b Y�........ lu�+l..m.Arr..9 u,,...�.. . sbw. W�wrBva/��FMf�w py� �u»os.as.�.�o.,�.m - �o�nm�sn�r�nm�a„ e......,,,�.�...,. / U/� C'/Cl � /�{� C��)�lO�.� �J—� r �D/c'!�L-� , [ �� _ a � � l . % �2 Irl7JJ`P/S� ��/ � G G � HOLY SPIRIT EMS - BLS � � � 205 GRANDVIEW AVE SUITE 27'I CAMP HILL, PA 1 7011-1 7 0 8 ONREVERSESIDE 0., , _ Phone#: (800) 367-0512 Federel Tax ID: 23-2463002 A fFI51.VGFR 1�lILIATF PAnENT nuee FLORENCE SPOTTS iHSunnnCE NOVITAS SOLUTIONS, INC. WCS BANKERSLIFE-CARMEL NONE cauNUMeen: 25337933W DATEOFGAIl �252015 FROM: HOLV SPIRIT HOSPITAL Tp; ACUTE REHAB HOSPITAL ACCOUNTSUMMARY FLORENCESPOTTS 147 SALEM CHURCH RD TOVLL CHARGES: 755.04 MECHANICSBURG, PA 77050 PAVMENTS/ADJUSiMvfiS: 25.67 PLEnSE PnY ni�s nmOUNT: 129.37 _ DElACHALON6 PERFOFATI0NAN0 REIUpN S7UH WfiH PAYMEM OESCRIPTONOFCHRHGE OUANRTY �-UNRPNICE AMOUN! Stre[cherOneWayTransMember T2005 i.0 128.33 128.33 Sfretcher Van Mileage T2049 5.6 4.77 26.71 �� q � l \ � � TOGI Charges 155.04 DESGIIIPTION OF PAYMENT pECE1PT PAVMENf DAiE AMOUNT SUBSCRIBERWRITEAFFADJ 05/04/2015 25.fi7 Tobl Cretlifs . 25.67 � c; r, .... . .. •:,:^:VMT- INVOICE ��"._ .. '.?^,•J RECEIPT �-.-. 5�29.37 REiI r�.tL . � . _. �. PA7IENTNAME SPOTTS,FLORENCEV CALLNIIMBEH: ZS337933W �,o�„��,o: l ,� — 3 _ OS/052015 / �r�,�-pC "��.r r,�r^ � -. :._. This service is not covered by y ur insurance. Please remit payment to our office.` ,�_ `%.,.P�,J ��,�� Ql2i �'Z�ar� ti ' �� 3� HOLY SPIRIT EMS- BLS 205 GR4NDVIEW AVE SUITE 211 CAMP HILL, PA 17011-1 70 8