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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG~ PA 17128-0601
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
/ -,- 9/ - /2- /
NO. 21 -01.. '8'8'7
02138998
09-10-2002
REV-1545 EX lFP [D9-0Dl
EST. OF JESSIE S BLACK
5.5. NO. 159-24-9930
DATE OF DEATH 06-17-2002
COYNTY CUMBERLAND
TYPE OF ACCOUNT
D SAVINGS
IX] CHECKING
D TRUST
D CERTIF.
SAMUEL H BLACK
12 E PORTLAND ST
MECHANICSBURG PA 17055~3349
REHIT PAYHENT AND FORHS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
ALLFIRST FINANCIAL SERVICE has provided the Department with the inforllation listed below which has been used in
calculating the potential tax due. Their records indicate that at the death of the above deCBdBnt~ you were a joint owner/baneficiary of
this account. If you feel this information is incorrect, please obtain written correction from tha financial institution, attach a copy
to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth
of Pennsylvania. Questions may be answereti by calling {,l7) 757--8327.
Date
Established
REVERSE SIDE FOR
08-28-1964
FILING AND PAYMENT INSTRUCTIONS
COMPLETE PART 1 BELOW
Account No. 0015814165
.. .. .. SEE
Account Balance 1,810.27
Percent Taxable X 50 . 000
Allount Subject to Tax 905.14
Tax Rate X .15
Potential Tax Due 135.77
PART TAXPAYER RESPONSE
mliiiil!~~~~Mii!i~iii!~~'~.iiii!~~~!i!i!lg~~i!~~!!ii~!!ii.i~~~~~ii!ii~gii!ii~~U1~.!I'iiig~~i!!!~!!!!il!i~~i!i!il!~~~!f!iiiiil
To insure proper credit to your account~ two
(l) copies of this notice must accompany your
payment to the Register of Wills. Make check
payable to: "Register of Wil1s~ Agent".
NOTE: If tax payments are ~ade within three
(3) months of the decedent"s date of death~
you may deduct a 5% discount of the tax due.
Any inheritance tax due will become delinquent
nine (9) Months after the date of death.
[CHECK ]
ONE
BLOCK
ONLY
A. rQ The above inforllation and tax due is correct.
~l. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest. or YOU may check box ""A" and return this notice to the Register of
Wills and an official assess.ent will be issued by the PA Department of Revenue.
B. c=J The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
to be filed by the decedent's representative.
c. D The above infor.ation is incorrect and/or debts and deductions were paid by you.
You must complete PART 0 and/or PART 0 below.
PART
@]
TAX RETURN - COMPUTATION
LINE 1. Date Established
2. Account Balance
3. Percent Taxable
4. Amount Subject to Tax
5. Debts and Deductions
6. Allount Taxable
7. Tax Rate
8. Tax Due
TAX ON JOINT/TRUST ACCOUNTS
If you indicate a different tax rate, please state your
relationship to decedent:
OF
1
2
3
4
5
6
7
8
x
x
PART
@J
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUth PAID
I
TOTAL (Enter on Line 5 of Tax Computation)
I
$
penalties of
the best 0
declare that the facts I
belief.
have reported above are true~ correct and
HOME (7/1) /(,.6-79117
WORK ( )
TELEPHONE NUMBER DATE
GENERAL INFORMATION
1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information
sub.itted by the financial institution.
2. Inheritance tax bBCO~8S delinquent nine months after the decedent's date of death.
3. A joint account is taxable Bven though the decedent's na.8 was added as a matter of convenience.
4. Accounts (including those held between husband and wife) which the decedent put in joint names within one year prior to
death are fully taxable as transfers.
5. Accounts established jointly between husband and wife more than one year prior to death are not taxable.
6. Accounts held by a decedent "in trust for" another or othsrs are taxable fully.
REPORTING INSTRUCTIONS - PART
1
- TAXPAYER RESPONSE
1. BLOCK A - If the information and cOlllputation in the notice are correct and deductions are not being claillled~ place an "X"
in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and subgit them with your check far the allount of
tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment
(Forll REV-1548 EX) upon receipt of the return froll the Register of Wills.
Z. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance
Tax Return filed by the decedent"s representative~ place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one
copy and return to the PA Department of Revenue~ Bureau of Individual Taxes~ Dept Z80601~ Harrisburg~ PA 171Z8-0601 in the
envelope provided.
3. BLOCK C - If the notice inforllation is incorrect and/or deductions are being claillled~ check block "C" and complete Parts Z and 3
according to the instructions below. Sign two copies and subllit them with your check for the amount of tax payable to the Register
of Wills of the county indicated. The PA Department of Revenue will issue an official assessllent (Form REV-1548 EX) upon receipt
of the return froll the Register of wills.
TAX RETURN - PART
2
- TAX COMPUTATION
LINE
L Enter
NOTE:
the dete the account originally was established or titled in the lIanner existing at date of death.
For e decedent dying efter lZ/IZ/8Z: Accounts which the decedent put in joint names within one (1) year of death are
taxable fully as transfers. However~ there is an exclusion not to exceed $3~DOO per transferee regardless of the value of
the account or the nUlllber of accounts held.
If a double asterisk (M.) appears before your first nalle in the address portion of this notice~ the $3~DOO exclusion
already has been deducted frolll the account balance as reported by the financial institution.
Z. Enter the total balance of the account including interest accrued to the date of death.
3. The percent of the account that is taxable for each survivor is determined as follows:
A. The percent taxable for joint assets established more than one year prior to the decedent's death:
1 DIVIDED BY TOTAL NUMBER OF
JOINT OWNERS
EXBMple: A joint asset registered
DIVIDED BY TOTAL NUMBER OF X 100 PERCENT TAXABLE
SURVIVING JOINT OWNERS
in the nalle of the decedent and two other persons.
1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY Z (SURVIVORS) = .167 X 100
16.7% (TAXABLE FOR EACH SURVIVOR)
B. The percent taxable for assets created within one year of the decedent"s death or accounts owned by the decedent but held
in trust for another individual(s) (trust beneficiaries):
I DIVIDED BY TOTAL NUHBER OF SURVIVING JOINT
OWNERS OR TRUST BENEFICIARIES
X IDD
PERCENT TAXABLE
Exallple: Joint account registered
the decedent.
1 DIVIDED BY Z (SURVIVORS) = .50
in the nalle of the decedent and two other persons and established within one year of death by
X 100
5DZ (TAXABLE FOR EACH SURVIVOR)
4. The amount subject to tax (line 4) is determined by llIultiplying the account balance (line Z) by the percent taxable (line 3).
S. Enter the total of the debts and deductions listed in Part 3.
6. The alllount taxable (line 6) is determined by SUbtracting the debts and deductions (line 5) from the allount subject to tax (line 4).
7. Enter the appropriate tax rate (line 7) as deterllined below.
D.t. of Death Spouse lineal Sibling Collateral
07/01/94 to 12/31/94 3X &% 15X 15X
01/01/95 to 06/30/00 0% 6X 15X 15X
07/01/00 to present 0% 4.5%Mi 12X 15X
MThe tax rate ll1posed on t:ne not value of transfers froll a deceased chIld twenty-one years of age or yo
unger at
death to or for the use of a natural parent~ an adoptive parent~ or a stepparent of the child is oz.
The lineal class of heirs includes grandparents~ parents~ children, and lineal descendents. "Children" includes natural children
whether or not they have been adopted by others~ adopted children and step children. "Lineal descendentsft includes all children of the
natural parents and their descendents~ whether or not they have been adopted by others~ adopted descendents and their descendants
and step-descendants. ftsiblings" are defined as individuals who have at least one parent in COMmon with the decedent, whether by blood
or adoption. The "Collateral" class of heirs includes all other beneficiaries.
CLAIMED DEDUCTIONS - PART
3
DEBTS AND DEDUCTIONS CLAIMED
Allowable debts and deductions are deterlllined as follows:
A. You legally are responsible for pay.ent, or the estata subject to administration by a personal representative is insufficient
to pay the deductible items.
B. You actually paid the debts after death of the decedent and can furnish proof of payment.
C. Debts being claimed Illust be itemized fuUy in Part 3. If additional space is needed~ use plain paper 8 1/Z" x U". Proof of
payment gay be requested by the PA Department of Revenue.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT.2B0601
HARRISBURG, PA 17128-0601
REV-1162 EX{11-96}
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
BLACK SAMUEL H
12 E PORTLAND ST
MECHANICSBURG, PA 17055
n_nn_ fold
ESTATE INFORMATION: SSN: 159-24-9930
FILE NUMBER: 2102-0887
DECEDENT NAME: BLACK JESSIE S
DATE OF PAYMENT: 10/01/2002
POSTMARK DATE: 09/23/2002
COUNTY: CUMBERLAND
DATE OF DEATH: 06/17/2002
NO. CD 001673
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
02138998 I $135.77
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TOTAL AMOUNT PAID:
REMARKS: SAMUEL H BLACK
CHECK# 2386
SEAL
INITIALS: SK
RECEIVED BY:
REGISTER OF WILLS
$135.77
MARY C. LEWIS
REGISTER OF WILLS
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BUREAU OF INDIVIDUAL TAXES
INHE~ITANCE TAX DIVISION
DEPT. 280601
HARRISBURG~ PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
*
NOTICE OF INHERITANCE TAX
APPRAISEHENT. ALLOHANCE DR DISALLOHANCE
OF DEDUCTION~, AND ASSESSHENT OF TAX ON
JOINTLY HELD DR TRUST ASSETS
REV.1548 EX AFP [Ol-D2l
SAMUEL H BLACK
12 E PORTLAND ST
MECHANICSBURG PA 17055-3349
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
SSN/DC
ACN
11-25-2002
BLACK
06-17-2002
21 02-0887
CUMBERLAND
159-24-9930
02138998
JESSIE
S
Allount Rellitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
Rifv=is4-i-Eif-AFP--foi-=021------------------------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 11-25-2002
ESTATE OF BLACK
JESSIE
S DATE OF DEATH 06-17-2002
COUNTY
CUMBERLAND
FILE NO. 21 02-0887
TAX RETURN WAS:
S.S/D.C. NO. 159-24-9930
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
ACN
02138998
FINANCIAL INSTITUTION: ALLFIRST FINANCIAL SERVICE
ACCOUNT NO.
0015814165
TYPE OF ACCOUNT:
DATE ESTABLISHED
( ) SAVINGS (Xl CHECKING ( ) TRUST ( ) TIME CERTIFICATE
08-28-1964
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
x
1,810.27
0.500
905.14
.00
905.14
.15
135.77
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
x
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
09-23-2002 CDOO1673 .00 135.77
TOTAL TAX CREDIT 135.77
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
. IF PAID AFTER THIS DATE~ SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .
I IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" I CRI, YOU MAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. I