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COMMONWEALTH OF PENNSYLVANIA *'
DEPARTMENT OF REVENUE INFORMATION NOTICE FILE NO. 21 05 . 05loi
BUREAU OF INDIVIDUAL TAXES AND
DEPT. 280601 TAxPAyER RESPONSE ACN 05116599
HARRISBURG, PA 17128-0601
DATE 05-27-2005
REY-15~5 EX AFP (09-001
TYPE OF ACCOUNT
" ~... i' Est:. Idf EDITH M SMITH IXJ SAVINGS
S.S. NO. 193-16-4211 o CHECKING
DATE OF DEATH 11-19-2004 o TRUST
CQUNTY CUMBERLAND o CERTIF.
REMIT PAYMENT AND FORMS TO:
FLOYD SMITH REGISTER OF WILLS
9 E GREEN ST CUMBERLAND CO COURT HOUSE
SHIREMANSTOWN PA 17011 CARLISLE. PA 17013
PNC BANK has provided the Department with the information listed below which has been used in
calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of
this account. If you feel this information is incorrect, please obtain written correction from the 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 Pen"'!:~'lvan.ia. Questions may be answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AN" PAYMENT INSTRUCTIONS
Account No. 5130193691 Date 02-26-1990 To insure proper credit to your account, two
Established (2) copies of this notice must accompany your
Account Balance 5.205.02 payment to the Register of Wills. Make check
payable to: '"Register of Wills, Agent'".
Percent Taxable X 50.000
Amount Subject to Tax 2.602.51 NOTE: If tax payments are made within three
(3) months of the decedent.s date of death,
Tax Rate X .045 you may deduct a 57. discount of the tax due.
Potential Tax Due 117.11 Any inheritance tax due will become delinquent
nine (9) months after the date of death.
PART TAXPAYER RESPONSE
[!] ::m!FA!!tIijl1ii:::!!f.i!:!:il$~OMI!:!:i!tlijl:::::H~rrr:!::::!tN:!::AN:::::~!ljI:!ljAl!:!:!~AI!::::A$mSKlM!:!:_$I!Dm::OII:!::~H!t$:::::~!ljll::!::::
..................................................................................................................................................................................................................................................................................................................................................................................................................................
....................................-...........................................................................................................................-.............................................-.................................................................................................-...-.............................................................................................................
...........................-...........-.................-...............................-.......................................................................................................................-.....................................................................................-.................................................................-........................................................
. . . .... .. .. .... ..
A. The above information and tax due is correct.
1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain
CHECK a discount or avoid interest, or you may check box "'A'" and return this notice to the Register of
[ ONE ] Wills and an official assessment will be issued by the PA Department of Revenue.
BLOCK B. [] The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
ONLY to be filed by the decedent's representative.
C. [] The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
PART If you indicate a different tax rate. please state your
~ relationship to decedent:
TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS
LrNE 1. Date Established 1
2. Account Balance 2
3. Percent Taxable 3 X
4. Amount Subject to Tax 4
5. Debts and Deductions 5 - ~lImm~!iiilliw!~i~jID~miii1
6. Amount Taxable 6
7. Tax Rate 7 X
8. Tax Due 8 !!ll!lllll!lllll!llll!ll!l;l!l!;!l!;;;;;!I!i!!!!!!;!!!;l!!!!!l!;!;!;;;!;!;!;!l!!!!!!!!!!!!!!!!!!!!!!!;!!!!!\!l!m!i!i!i!i!i!;;:;;;;!!!\!;!!!!!:!i!:!i!!!i!i!J!i!!!!!
PART DEBTS AND DEDUCTIONS CLAIMED
~
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
I I I
TOTAL (Enter on Line 5 of Tax Computation) $
perjury. I declare that the facts I have reported above are true. correct and
my knowledge and belief. HOME (Iq ) &34- 53l.,O
WORK ( ) Sj.~J~
TELEPHONE NUMBER D TE .
GENERAL INFORMATION
1- FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSI1ENT with applicable interest based on inforllation
subllitted by the financial institution.
2. Inheritance tax becomes delinquent nine months after the decedent.s date of death.
3. A joint account is taxable even though the decedent's name 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 lIore than one year prior to death are not taxable.
6. Accounts held by a decedent "in trust for" another or others are taxable fully.
REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE
1. BLOCK A _ If the information and computation in the notice are correct and deductions are not being claimed, place an "X'"
in block nA" of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with your check for the amount of
tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment
(Form REV-1548 EX) upon receipt of the return from the Register of Wills.
2. 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 280601, Harrisburg, PA 17128-0601 in the
envelope provided.
3. BLOCK C _ If the notice information is incorrect andlor deductions are being claimed, check block "C'" and complete Parts 2 and 3
according to the instructions below. Sign two copies and submit the II 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 assessment (Form REV-1548 EX) upon receipt
of the return from the Register of Wills.
TAX RETURN - PART 2 - TAX COMPUTATION
LINE
1. Enter the date the account originally was established or titled in the manner existing at date of death.
NOTE: For a decedent dying after 12/12/82: 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 $3,000 per transferee regardless of the value of
the account or the number of accounts held.
If a double asterisk (MM) appears before your first nalle in the address portion of this notice, the $3,000 exclusion
already has been deducted from the account balance as reported by the financial institution.
2. 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 DIVIDED BY TOTAL NUMBER OF X 100 = PERCENT TAXABLE
JOINT DWNERS SURVIVING JOINT OWNERS
Example: A joint asset registered in the name of the decedent and two other persons.
1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) = .167 )( 100 = l6.7Z (TAXABLE FOR ~ACH 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):
1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT X 100 = PERCENT TAXABLE
OWNERS OR TRUST BENEFICIARIES
Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by
the decedent.
1 DIVIDED BY 2 (SURVIVORS) = .50 X 100 = 50Z (TAXABLE FOR EACH SURVIVOR)
4. The amount subject to tax (line 4) is determined by multiplying the account balance (line 2) by the percent taxable (line 3).
5. Enter the total of the debts and deductions listed in Part 3.
6. The allount taxable (line 6) is determined by subtracting the debts and deductions (line 5) from the amount subject to tax (line 4).
7. Enter the appropriate tax rate (line 7) as determined below.
Date of Death Spouse Lineal Sibling Collateral
07/01/94 to 12/31/94 3% 6% 15% 15%
01/01/95 to 06/30/00 OY. 6Y. l5Y. l5Y.
07/01/00 to present OY. 4.5Y.. l2Y. 15Y.
MThe tax rate Imposed on the net value of transfers from a deceased ChIld twenty-one years of age or younger 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 descendents" 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. "Siblings" 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 determined as follows:
A. You legally are responsible for payment, or the estate 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 must be itemized fully in Part 3. If additional space is needed, use plain paper 8 1/2" x II". Proof of
payment lIay be requested by the PA Department of Revenue.
11.~rllll'"~11.'I'Jfill;llli
COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96)
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 005462
SMITH FLOYD
9 E GREEN ST
SHIREMANSTOWN, PA 1 7011
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
-------- fold ---------- --------
05116599 I $117.11
ESTATE INFORMATION: SSN: 193-16-4211 I
FILE NUMBER: 2105-0564 I
DECEDENT NAME: SMITH EDITH M I
DATE OF PAYMENT: 06/21/2005 I
POSTMARK DATE: 06/1 0/2005 I
COUNTY: CUMBERLAND I
DATE OF DEATH: 11/19/2004 I
I
TOT Al AMOUNT PAID: $117.11
REMARKS:
CHECK# 3999
INITIALS: JA
SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WillS
REGISTER OF WILLS
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COMMONWEALTH OF PENNSYLVANIA *'
DEPARTMENT OF REVENUE INFORMATION NOTICE FILE NO. 21 05- 5~ 4
BUREAU OF INDIVIDUAL TAXES AND
DEPT. 280601 TAXPAYER RESPONSE ACN 05116580
HARRISBURG, PA 17128-0601
DATE 05-27-2005
REY-15~5 EX AFP <D9-DO'
TYPE OF ACCOUNT
. i ~ EST. OF EDITH M SMITH D SAVINGS
~. IXJ CHECKING
S.S, NO. 193-16-4211
DATE OF DEATH 11-19-2004 D TRUST
COUNTY CUMBERLAND o CERTIF,
RE"IT PAY"ENT AND FOR"S TO:
FLOYD SMITH REGISTER OF WILLS
9 E GREEN ST CUMBERLAND CO COURT HOUSE
SHIREMANSTOWN PA 17011 CARLISLE, PA 17013
PNC BANK has provided the Department with the information listed below which has been used in
calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of
this account. If you feel this information is incorrect, please obtain written correction from the 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
..I!annsvlvania. Questions may be answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 5140059242 Date 08-01-1959 To insure proper credit to your account, two
Establishad (2) copies of this notice must accompany your
3,493.13 payment to the Register of Wills. Make check
Account Balance payable to: "Register of Wills, Agent...
Percent Taxable X 50.000
Anount Subject to Tax 1,746.57 NOTE: If tax payments are made within three
(3) months of the decedent's date of death,
Tax Rate X .045 you may deduct a 57. discount of the tax due.
Potential Tax Due 78.60 Any inheritance tax due will become delinquent
nine (9) months after the date of death.
PART TAXPAYER RESPONSE
[!]li!i!i!l~i~~~lli!i!I'!i!i.lII!i!i~i~~~ji!i!.Br:n1!ijij~li!i!.!i!ilTI~i~I~.!i!iil.!i!i!~I!.I.~r:n1!j!ill.lji!j!liii!~I~I!i!j.i~~~!i!i!i!1
A. ~he above information and tax due is correct.
1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain
CHECK a discount or avoid interest, or you may check box "A" and return this notice to the Register of
[ ONE ] Wills and an official assessment will be issued by the PA Department of Revenue.
BLOCK B. [] The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
ONLY to be filed by the decedent.s representative.
C. [] The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
PART If you indicate a different tax rate, please state your 111111!11111111!1!I"'I':!llllilll!!llliillll~llllllli11(1111111
~ relationship to decedent:
TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS iliillliiiiiiiii!!!i!J!l!!!l!i!!!i!i!!!i!!!i!i!!!i!i!!!;!!!i!!!!!i!i!i!i!i!i!i!i!l!i;;!!!!!i!i!i!i!i!i!i!!!i!i!i!l!i!i!i!i!!!i!!!i!!!!!!!i!!!!!i!l!i!I!;!!!!!
LINE 1. Date Established 1 ililii,:"liiiiiiiili!iijl!!:!:!'I:I:i'!I!I!I!I!I!I!!!!!!!!!!!!!!!!!!!!i:!:j:!IIIII!i!:!ll"i!i!,!!I!!!!!!!!!!!!!I:I;li!ii~i!illl!l!!!!!!!!!!!!!i!!!!j\ji!\;\;l~l\;
2. Account Balance 2
3. Percent Taxable 3 X !I!!!":':'!'::,!!!;!!!!i!!!!ii!!!!!!!!1!I,!,!:::!i!:l:llllillliiiI!I"!!!!!!!!!!!!I!!:!:I:I:lilllillillli!!!i!!!!!'!!!i!1!!!!!!!!:::!:I:lllllillll1IIIIil;i!i!!!!!i!
4. Anount Subject to Tax 4
5. Debts and Deductions 5 - ~~llillmml~!!!!~lli'~lii!illlllliilr:
6. Amount Taxable 6
7. Tax Rate 7 X
8. Tax Due 8 !llli/lll/lllli!!III!!!!!!!!!!!!!!!!!!!i!!!i!:!!!!!!!!!!!!!!!!!!!!!!!l!!!i!i!!!!!i!:!i!i!i!i!i!!!i!i!i!i!;!!!;;;!i!i!!!!!i!i!i!i!i!i!i!i!i!!!i!i!i!!!!!i!i!i!i!i!i!i!
PART DEBTS AND DEDUCTIONS CLAIMED
~
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
I I I
TOTAL (Enter on Line 5 of Tax Conputation) $
perjury, I declare that the facts I have reported above are tr~ correct and
ny knowledge and belief. HOME (1r7) B-S4- .::::>3~
WORK ( S/?"o)Ob"
TElEPHONE NUMB R DATE
GENERAL INFORMATION
1- FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based Dn infDrmatiDn
submitted by the financial institutiDn.
2. Inheritance tax becDmes delinquent nine mDnths after the decedent.s date Df death.
3. A jDint accDunt is taxable even thDugh the decedent's name was added as a matter Df cDnvenience.
4. AccDunts (including thDse held between husband and wife) which the decedent put in jDint names within Dne year priDr tD
death are fully taxable as transfers.
5. AccDunts established jDintlY between husband and wife mDre than Dne year priDr tD death are nDt taxable.
6. AccDunts held by a decedent "in trust fDr" anDther Dr Dthers are taxable fully.
REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE
1. BLOCK A _ If the infDrmatiDn and cDmputatiDn in the nDtice are cDrrect and deductiDns are nDt being claimed, place an "X"'
in blDCk "'A" Df Part 1 Df the "Taxpayer RespDnse"' sectiDn. Sign tWD cDpies and submit them with YDur check fDr the amDunt Df
tax tD the Register Df Wills Df the cDunty indicated. The PA Department Df Revenue will issue an Dfficial assessment
(FDrm REV-1548 EX) upDn receipt Df the return frDm the Register Df Wills.
2. BLOCK B _ If the asset specified Dn this nDtice has been Dr will be repDrted and tax paid with the Pennsylvania Inheritance
Tax Return filed by the decedent.s representative, place an "'X"' in blDCk "B"' Df Part 1 Df the "'Taxpayer RespDnse"' sectiDn. Sign Dne
CDPy and return tD the PA Department Df Revenue, Bureau Df Individual Taxes, Dept 280601, Harrisburg, PA 17128-0601 in the
envelDpe prDvided.
3. BLOCK C _ If the nDtice infDrmatiDn is incDrrect and/Dr deductiDns are being claimed, check blDCk "'C"' and cDmplete Parts 2 and 3
accDrding tD the instructiDns belDw. Sign tWD cDpies and submit them with YDur check fDr the amDunt Df tax payable tD the Register
Df Wills Df the cDunty indicated. The PA Department Df Revenue will issue an Dfficial assessment (FDrm REV-1548 EX) upDn receipt
Df the return frDm the Register Df Wills.
TAX RETURN PART 2 TAX COMPUTATION - -
- -
LINE
1. Enter the date the accDunt DriginallY was established Dr titled in the manner existing at date Df death.
NOTE: FDr a decedent dying after 12/12/82: AccDunts which the decedent put in jDint names within Dne (1) year Df death are
taxable fully as transfers. HDwever, there is an exclusiDn nDt tD exceed $3,000 per transferee regardless Df the value Df
the accDunt Dr the number Df accDunts held.
If a dDuble asterisk (MM) appears befDre YDur first name in the address pDrtiDn Df this nDtice, the $3,000 exclusiDn
already has been deducted frDm the accDunt balance as repDrted by the financial institutiDn.
2. Enter the tDtal balance Df the accDunt including interest accrued tD the date Df death.
3. The percent Df the accDunt that is taxable fDr each survivDr is determined as fDllDws:
A. The percent taxable fDr jDint assets established mDre than Dne year priDr tD the decedent's death:
1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 = PERCENT TAXABLE
JDINT OWNERS SURVIVING JOINT OWNERS
Example: A jDint asset registered in the name Df the decedent and tWD Dther persDns.
1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) = .167 X 100 = 16.77. (TAXABLE FOR EACH SURVIVOR)
B. The percent taxable fDr assets created within Dne year Df the decedent's death Dr accDunts Dwned by the decedent but held
in trust fDr anDther individual(s) (trust beneficiaries):
1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT X 100 = PERCENT TAXABLE
DWNERS OR TRUST BENEFICIARIES
Example: JDint accDunt registered in the name Df the decedent and tWD Dther persDns and established within Dne year Df death by
the decedent.
1 DIVIDED BY 2 (SURVIVORS) = .50 X 100 = 507. (TAXABLE FOR EACH SURVIVOR)
4. The amDunt subject tD tax (line 4) is determined by multiplying the accDunt balance (line 2) by the percent taxable (line 3).
5. Enter the tDtal Df the debts and deductiDns listed in Part 3.
6. The amDunt taxable (line 6) is determined by subtracting the debts and deductiDns (line 5) frDm the amDunt subject tD tax (line 4).
7. Enter the apprDpriate tax rate (line 7) as determined belDw.
Date of Death Spouse Lineal Sibling Collateral
07/01/94 to 12/31/94 3Y. 6Y. 15Y. 15Y.
01/01/9S to 06/30/00 OY. 6Y. ISY. ISY.
07/01/00 to present OY. 4.SY.. 12Y. ISY.
MThe tax rate lmpDsed Dn the net value Df transfers frDm a deceased chlld twentY-Dne years Df age Dr YDunger at
death tD Dr fDr the use Df a natural parent, an adDptive parent, Dr a stepparent Df the child is 07..
The lineal class Df heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children
whether Dr nDt they have been adDpted by Dthers, adDpted children and step children. "Lineal descendents" includes all children Df the
natural parents and their descendents, whether Dr nDt they have been adDpted by Dthers, adDpted descendents and their descendants
and step-descendants. "Siblings" are defined as individuals whD have at least Dne parent in CDmmDn with the decedent, whether by blDDd
Dr adDptiDn. The "'CDllateral" class Df heirs includes all Dther beneficiaries.
CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED
AllDwable debts and deductiDns are determined as fDllDws:
A. YDU legally are respDnsible fDr payment, Dr the estate subject tD administratiDn by a persDnal representative is insufficient
tD pay the deductible items.
B. YDU actually paid the debts after death Df the decedent and can furnish prDDf Df payment.
C. Debts being claimed must be itemized fully in Part 3. If additiDnal space is needed, use plain paper 8 1/2" xU"'. PrDDf Df
payment may be requested by the PA Department Df Revenue.
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COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96)
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT, 2B060 1
HARRISBURG, PA 17128-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 005463
SMITH FLOYD
9 E GREEN ST
SHIREMANSTOWN, PA 17011
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
n_n_n fold ---------- --------
05116580 I $78.60
ESTATE INFORMATION: SSN: 193-16-4211 I
FILE NUMBER: 2105-0564 I
DECEDENT NAME: SMITH EDITH M I
DATE OF PAYMENT: 06/21/2005 I
POSTMARK DATE: 06/10/2005 I
COUNTY: CUMBERLAND I
DATE OF DEATH: 11/19/2004 I
I
TOTAL AMOUNT PAID: $78.60
REMARKS:
CHECK# 3998
INITIALS: JA
SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WillS
REGISTER OF WILLS