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Home My WebLink About08-21-15 p°"�^° °` ,"°'°'°°"` '""� I Penns Ivania lnheritance Tax � �`� enns lvania 0 BO% 280601 Y J ,`' P Y HPRRiSBURG PA IIIIB-0601 IIIfOIIII$IIO�I NOIICB � � �EPARTMENT OF PFVENUE And Taxpayer Response Fi�E No.2iun�5 o�}A�� e Lz, ACN 15125128 DATE OS-OB-2015 ��. . _- � . , _ ' �;� " " — . ..�. . ... � TypeofAccoun� �a �;;� Estate of JOHN T WORK Savings ��I� '-u z� ��'� � Checking D E�of Death 04454015 Tmst KELSEA L EZBIANSKY �; CountyCUMBERLANO Certificate 103 FAIRWAY DR � ' - MECHqNICSBURG PA 17055-511D�FP��,',',r� � �U��3, ;., . MEMBERS isT ccu 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. Accoun�No. 156654 Remit Payment antl Forms�o: Date Established 0417-2001 REGIS7ER OF WILLS Account Balance $2,4g3.83 1 COURTHOUSE SOUARE Percent Taxable X 16.667 CARLISLE PA 17013 Amount Suhject to Tau $413.98 Tax Ra[e X 0.150 $62.10 NOTE': If tax a ments are made within ihree months of[he Potential Tax Due P Y decedenfs date of death, deduct a 5 percent discount on ihe tax With 5% Discount(Tax x 0.95) $(see NOTE') due. Any inheritance�ax due will bewme delinquent nine mon�hs afterthe date ofdeath. 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. Proceed fo Step 2 on reverse. Do not check any other bozes and disregaid the amount �;owr e�e.e an Potaniial Tax O✓e. g ❑The information is The above iniormation is correct, no deduc�ions are being taken,and payment will be sen� correct. wi�h my respanse. Proceed Po Step 2 on reverse. Do not check any other boxes. p �The tax ra�e is incorrect. � 4.5% I am a lineal beneficiary(parent,child, grandchild, etc.) of�he deceased. (Select correct ta�e rete a� righ�, and complete Part � 7 p� I am a sibling of Ihe deceasetl. 3 an reverse.) � 15% All other relationships (including none). p �Changes or deductions The iniorma�ion above is incorrec�and/or dehts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back ol this lorm. E ❑Asset will be reported on The above-identified asse�has been or will be repotled and tan paid with the PA Inheritance Tax inheritance tan Porm ReWm filed by the estate representative. FEV4 W 0. Pmceed ro Sfep 2 on reverse. Do not check any other 6oxes. t/ Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable deb[s and deductions musl meet 6oth of�he following criteria: A. The decedent was legally responsible for payment, and the estate is insufficient to pay the deductible items. B. You paid ihe debis aRer the death of the decedent and can furnish proof of payment it requested by the department. Qf additional space is required, you may attach 81/2"x 17"sheels of paper.) Da�e Paid Payee Description Amount Paid Tolal (En�er on Line 5 of Tax Calcula�ion) $ PART Tax Calculation 3 H you are making a correction to the esWblishment tlate(Line 1)account balance(Line 2),or percent tazable(Line 3), please obtain a written correction from ihe tinancial ins�itu�ion antl attach it to ihis tortn. t 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 ihe percentage of the account that is taxable to you. a. First,determine the percen�age owned by�he decedent. i. Accounts that are held"in�mst�or"anolher or others were 100%owned by lhe decedent. ii. Por joint accounts established more than one year prior to the date of death,the percentage taeable is 100%divided by lhe total number of owners induding the decedent. (For example:2 owners= 50%, 3 owners=33.33%,4 owners =25%,etc.) b. Nex�,divide�he decedenPs percenla9e owned by�he number of surviving owners or beneficiaries. 4. The amount subjed to tax is delermined by multiplying the account balance by lhe percent taaable. 5. Enter(he total of any deb�s and deduc�ions daimetl irom Part 2. 6. The amoun�taxa6le is determined by subtracting the debts and deductions from the amounl subject to tax. Z Enter the appmpria�e�ax rate tmm S�ep 1 based on your rela�ionship to the decedent. If indicating a diHerenl tax rate, please state Q(flCid) �S8�f11y[]qp� ,� your relationship to the deceden�: (1/\ dgPy,��pgp[Of FjQygpU@'� ' 1. Date Established 1 :�;�� "^^�� ;�� 2. Account ealance 2 $ PA�' ` x � s.,ra.,� � 3. PercentTaxable 3 .Z �� ry.�n : ' � 4. Amount Subject ro Tax 4 $ � . �,r , ,,, 5. Debis and Deductions 5 - 4 ,�„�; 6. AmountTauable 6 S $ - .- Tax Ra;e � "=-- S — e. T� Due 8 $ $ �4 �,*y":�:i ` '4��A3.,�. 9 W th 5% D t (Tax x 95) 9 X ' ,StQP 2: Sign and date below. ReNrn TYJO completed and signed copies ro ihe Register of Wills listed on the fron�of this form, along with a check for any payment you are making. Checks must be made payable to"Re9ister of Wills,Agent:' Do not send payment directly to the Department of Revenue. Under penalry of perjury, I declare that lhe tacts I have reported ahove are hue.. correcl and complete to[he best of my knowledge and beliei. Work '� �- ,�o,:� - Home �/7/ /a-- /S 03- �7 '„2D/.f Taxpayer Si � ure Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 777-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-4473020 euuewu oc �Hoxv�oue� 1nxEs penns Ivania lnheritance Ta�c � � � DennsV lvania PO BO% '1806Y�1 Y � • + NARRISBONG ll128-0601 InformationNotice �� OEVAPTMENTOFflEVENUE And Taxpayer Response Fi�E NO2i�iY4�IG '�•-," R� CC.i?;`": � � - - . . . . . _ "' ACN t5125129 � � �ATE OS-08-2015 �ois F,�� zl :�� s iy Type of Account � '- Esta�e of JOHN T WORK Savings 02r Checking � Date of Dea[h 04-15-2015 Tmst HONORA M EZB[ANSKY ��,U� ' CouniyCUMBERLAND CetlifiCate 103 FAIRWAV DR MEGHANICSBURG PA 17055-5710 MEMBERS isr 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 o�the account identified. Account No. 156654 Remit Payment and Forms to: Date Establishetl 04-17-2001 REGISTER OF WILLS Account Balance $2,qg3.83 1 COURTHOUSE SQUARE Percent Tauable X 16.667 CARLISLE PA 17013 Amount Subled la Tax $413.98 Tax Rate X 0.045 Po[ential Tax Due g�g_g3 NOTE': If�ax paymen[s are made within�hree mon�hs of the decedenPs date of death,deduct a 5 percent discount on the[ax With 5% Discoun�(Tan x 0.95) $(see NOTP) due. Any inheri�ance tax due will become delinquent nine momhs aker ihe tlate 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. Pmceed to Step 2 on reverse. Do not check any othei boxes and disregard Ihe amount shown above as Pe!ential Tax Due. g �The information is The above information is correct, no deductions are being taken, and paymen�will be sen� correct. with my response. Proceed ro Sfep 2 on reverse. Oo not check any other boxes. p ❑The tax rate is incorrect � a.5% I am a lineal beneFiciary (parent, child, grandchild, etc.)of[he deceased. (Seled correct tax ra�e at right, and complete Parl � �p� I am a sibling of the tleceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or detluctions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriafe on the back ol this lomn. E �Asset will 6e reported on The above-identi�ied asset has been or will be reported and tax paid with Ihe PA Inheritance Tax inheritance tax form Retum filed by Ihe estate representative. REV4 W 0. Proceed(o Sfep 2 on reverse. Do not check any othe�bozes. � ) Please sign and date the back of Ihe form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meel both of the following criteria: A. The decedent was legally responsible for paymen[,and ihe estate is insufficient to pay the tleductible items. B. You paid ihe debls after ihe death of the decedent and can fumish proof ot payment if requested by[he depatlment. (If additional space is required,you may atlach 8 1/2"x 11"sheets of paper.) Dale Paid Payee Description Amount Paid Total (Enler on Gne 5 of Tax Calculalion $ PART Tax Calculation 3 If you are making a corredion to ihe establishmen[tlale(Line 1)account balance(Line 2),or percent laxable(Line 3), please ob�aln a wri[ien correction from[he flnancial institution and attach it to this torm. L Enter the date the account was established or titled as it existed at the date of death. 2 Enterchetotal balance ofihe accountinduding anyinterestaccrued atthe date ofdeath. 3. Enter ihe percentage of the account that is taxable to you. a Firet,determine the percentage owned by the decedent. i. Accounts ihat are held"in tmst for"another or others were 100%owned by the decedent. ii. For joint accounts eslablished more lhan one year prior to the date of death,the percentage laxable is 100%divided by the total number o�owners includin9[he decedent (For example:2 owners= 50%,3 owners=33.33%,4 owners =25%,etc.) b. Next,drvide the decetlenYs percentage owned by the number of surviving owners or beneficiaries. 4. The amoun[subjec�to�ax is determined by mulliplying the accoun�balance by the percent�axable. 5. Enter the total of any deb�s and deductions daimed from Part 2. 6. The amount taxable is determined by subiracting the debts and deductions imm the amount subject to tax. Z Enter Ihe appmpriate lax ra�e irom Step 1 based on your relationship�o�he decetlent. I�indica�ing a different tax ra�e, please sta�e QF(G13��S8�il��+�AAF , yourrela�ionshiptothedecedent (�J;��yqmep[qf'..I�EV0t1t��, � 1. Date Established 1 �k PRb � 2. Accoun�Balance � $ ,� � 3. Percent Taxable 3 X .� 4: Amount Subjec[to Tau 4 S g _ 5. Debts and Deductions 5 - 4 - 6- AmountTaxa6le 6 $ 5 i Tax naie � ^ & e. Tax Due 8 $ g 9. With 5% Discount(Tax x .95) 9 X StQP 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on ihe front of this form, along with a check for any paymen[you are making. Checks must be made payable to"Register of Wills, A9ent" Do not send payment direcity to ihe Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are ime,correct and complete to ihe best of my knowledge and belief. Work 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