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REV.4B3 (B"7BI
COIo'MONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIONS
INHERITANCE TAX SECTION
OFFICIAL NOTICE OF DETERMINATION
AND ASSESSMENT OF PENNSYLVANIA
ESTATE TAX
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DATE:
ESTATE OF:
FILE NO:
COUNTY OF:
DATE OF DEATH:
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t\, DETERMINATION:
1. Taxable estate bo sed upon:
~United States Estate Tax Return (Form 706)
The communication from the Federal Government
confirming the acceptance of or changes to the
Federal Estate Tax Return
2. Amount of credit for State death taxes (as verified)
3. Pennsylvania inheritance tax assessed
(excluding any discount and/or interest)
4. Hormal inheritance tax paid to other States or
Territories of the United Sto1tes (excluding
any di scount and/or interest)
5. Total inheritance tax credits (line item 3 plus line item 4)
6. Total liability for Pennsylvania estate tax (line item 2
minus line item 5)
$ J,9lo7; ,,3S""
$ :~5:J.'1, 7 (,
s/t/3<f.30
-0-
$
/~ /3 ~ ) (,
$
$
- 0--
NOTE: Complete line items 7 and 8 OHL Y when determination
is based on Federal Closing Letter
7.
Amount of Pennsylvania estate tax assessed on determination
dated
Addition (reduction) to Pennsylvania estate tax (line item 6
minus line item 7)
s
8.
Determination prepared b .
Date:
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B. ASSESSMENT:
1. Pennsylvania Estate Tax reflected on:
line item A (6)
line item A (8) $
2. Less credits:
DATE OF PAYMENT
AMOUNT PAID
INTEREST
(S I
(S )
($ )
CREDIT
=
=
=
3. Balance of Pennsylvania estate tax due
$
Interest is due at the rote of six (6) percent per annum from
to the date of payment.
Assessment prepared by:
AGENT FOR THE COMMONWEAL TH
Date:
SEE REVERSE SIDE FOR INSTRUCTIONS