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REV-483 (8-78)
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF FIE LD OPE RA nONS
INHERITANCE TAX SECTION
OFFICIAL NOTICE OF DETERMINATION
AND ASS~SSMENT OF PENNSYLVANIA
ESTATE TAX
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DATE:
EST ATE OF:
FILE NO:
COUNTY OF:
DATE OF DEATH:
TO:
A. DETERMINATION:
1. Taxable estate based upon:
~nited States Estate Tax Return (Form 106)
The communication from the Federal Govemment
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. Normal inheritance tax paid to other States or
Territories of the United States (excluding
any discount 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)
$ /.5Z;j/~t).t
$
2, /J-
$tOJ~77
$ ---. Cj - /( ~ /~ 7 7
$
$ - c:J -
NOTE: Complete line items 1 and 8 ONL 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 1) ~~
Dot."'."'o. p..po.... by, .-
Date: ",/' ~-- -~
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8.
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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
($ )
($ )
($ )
CREDIT
=
=
3. Balance of Pennsylvania estate tax due
=
$
Interest is due at the rate of six (6) percent per annum from
to the date of payment.
Assessment prepared by:
AGENT FOR THE COMMONWEAI.TH
Date:
SEE REVERSE SIDE FOR INSTRUCTIONS