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HomeMy WebLinkAbout12-08-05 1500 EX 16-001 REV-1 500 *~m~ PENNSYLVANIA .. DEPARTMENT OF REVENUE INHERITANCE TAX RETURN FILE NUMBER DEPT. 280601 Ot L - .C2.. .5 Q.~9..~_ HARRISBURG. PA 1712lHl601 RESIDENT DECEDENT COUNTY CODE YEAR NUMBER DECEDENTS NAME (lAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER I- Breitbach. Frank W. 063-26-1938 Z W - 0 DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE W 03/18/05 02/15/34 REGISTER OF WILLS 0 W (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE IN mAl) SOCiAl SECURITY NUMBER 0 N/A w [i] 1. Original Retum o 2. Supplemental Retum o 3. Remainder Retum (daleofdealhpfiofto 12-13-82) SU) o 4. Limited Estate o 4a. Future Interest Compromise (dale 01 deaIh after 12-12-82) o 5. Federal Estate Tax Retum Required ll:~ a..u 00 o 6. Decedent Died Testate (AlIadl copy 01 WdO o 7. Decedent Maintained a Living Trust (AlIadl copy 01 Trust) 8. Total Number of Safe Deposit Boxes ll:..J a..fX1 - a.. D 9. Litigation Proceeds Received D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1+95) o 11. Eleclion to tax under Sec. 9113(A) (Attach Sch 0) < ... THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: z w NAME COMPLETE MAILING ADDRESS Q Linda S. Hansen z 1420 Silver Creek Drive 0 FIRM NAME (If Applicable) a.. Mechanicsburg, PA 17050 U) w ll: ll: TELEPHONE NUMBER 0 u (717) 737-5516 1. Real Estate (Schedule A) (1) 34,720.48 2. Stocks and Bonds (Schedule B) (2) 0.00 t.,,"...., c"---'- r-:-'} ( :: -~ _.....J 0.00 .:, t__.r, - , ill 3. Closely Held Corporation, PartnefShip or Sole-Proprietorship (3) 1 .----., . '.-) , ( ) 4. Mortgages & Notes Receivable (Schedule D) (4) 0.00 t... .; J I , f I 5. Cash. Bank Deposits & Miscellaneous Personal Property (5) 66,597.59 C:J \,~~) , Z (Schedule E) '"':':"... , ~f' 0 - . 6. Jointly Owned Property (Schedule F) (6) 0.00 -.,....... _'1:'-"; ~ -~"-'- D Separate Billing Requested - _.- .. -I ",-::,"l , ') ,-") (7) 0.00 . ,1 ::J 7. Inter-VIVos TransfefS & Miscellaneous Non-Probate Property ill !:: (Schedule G or L) Q. 101,318.07 <( 8. Total Gross Assets (total Lines 1-7) (8) 0 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 6,234.82 W 0:: (10) 1,175.00 10. Debts of Decedent. Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) (11) 7,409.82 12. Net Value of Estate (Line 8 minus tine 11) (12) 93,908.25 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to lax has not been (13) 0.00 made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 93,908.25 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPUCABLE RATES Z 15. Amount of Line 14 taxable at the spousal tax 0 0.00 ~ rate, or transfers under Sec. 9116 (a)(1.2) -~-,-- x.O_ (15) 93,~98.25 x.O ~5 _ 4,225.87 ~ 16. Amount of Line 14 taxable at Hneal rate (16) ::J a. 17. Amount of Line 14laxable at sibling rate _9J).l:l x .12 (17) :!E 0 18. Amount of Line 14 taxable at collateral rate 0.00 x .15 (18) 0 ._-~------'- X 19. Tax Due (19) 4.225.87 ~ 20.n CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT lecedent's Complete Address: iTREET ADDRESS 1420 Silver Creek Drive ~ITYM h . b ec ames urg I STATEpA I ZIP 17050 ax Payments and Credits: Tax Due (Page 1 Une 19) Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 4,225.87 0.00 0.00 0.00 Interest/Penalty if applicable D. Interest E. Penalty Total Credits ( A + B + C ) (2) 0.00 TotallnteresllPenalty ( D + E ) If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Une 20 to request a refund 0.00 0.00 If Une 1 + Une 3 is greater than Une 2, enter the difference. This is the TAX DUE. (3) (4) (5) (SA) (58) 0.00 A. Enter the interest on the tax due. 4,225.87 0.00 B. Enter the total of Line 5 + SA. This is the BALANCE DUE. 4,225.87 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;.......................................................................................... 0 ~ b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 ~ c. retain a reversionary interest; or.......................................................................................................................... 0 ~ d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 ~ 2. If death occurred after December 12. 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 [!] 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 ~ 4. Did decedent own an Individual Retirement Account. annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 ~ F THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ler penalties of per;..ry. I declan! 1I1all have ell8lTllned lhis relum, including accornpenying schedules and slalBmenls, and to hi best of my knowledge and belief. ~ is true. COIl'llCl and complete. :laration of preparer o1her lhBn 1he personal represenllltM! is based on all information of which Jll1lIlIII8f has any knowledge. 3NATURE OF PERSON RESPONSIBLE F,O~ FILING RETURN ---~~~~ DRESS -_ \'t2..0 -::,'L..\I~~K ~~. ME~A:Nlc..sBU.R.G- #- I7D50 3NATURE OF PREPARER OTHER THAN REPRESENTATIVE I DATE t2.- .5-05 DATE DRESS , dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on thf! net value of transfers to or for the use of the surviving spouse is 3% . P.S. 99116 (a) (1.1) (i)). ~ . dates of death on or after January 1,1995, the tax rate imposed OIl the net value of tran5fl UUe_ d toD 'OU is 0% [72 P.S. 99116 (a) (1.1) (ii)l. ~ statute does not exemot a transfer to a surviving spouse from tax, and the statutory require 0.-1 f') l 0 ax return are still applicable even if surviving spouse is the only beneficiary. ~-c \ d- (,) D . dates of death on or after July 1, 2000: f\. P D c:::.. (....... . o'i) ~ tax rate imposed on the net value of transfers from a deceased child twenty-one years of a 1\ <-/ U 1 natural parent, an adoptive parent, 3 stepparent of the child is 0% [72 P.S. 99116(a)(1.2)). ~ -C'~ ~ tax rate imposed on the net value of transfers to or for the use of the decedenfs lineal benefi( U lo 5 <g 116(1.2) [72 P.S. 99116(a)(1)]. REV-1503 EX+ (6-98. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF ~" \/'I. 6tl~ITN'c+4. J (2 All property joInIIy-owned with right of survivorship must be dIscIoIed on Schedule F. FILE NUMBER ITEM NUMBER 1. DESCRIPTION Dreyfus Premier State Municipal Bond Fund VAlUE AT DATE OF DEATH 2 General Motors Acceptance Corporation Notes 13,287.98 21,432.00 TOTAL (Also enter on line 2, Recapitulation) $ ; 34,719.98 REV-15G8 EX+ (6-98).. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Frank W. Breitbach, Jr. RLE NUMBER Include the proceeds of litigation and the date the proceeds were rec:eiYed by the estate. AU property joIndy-ownecl with right of survivorship must be dlsc:Iosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Members 1st Federal Credit Union Acct 237560-05 45,262.01 2 Member 1 st Federal Credit Union Acct 237560-41 10,194.79 3 Member 1 st Federal Credit Union Acct 237560-40 10,124.67 4 Member 1st Federal Credit Union Acct 237560-11 (2,032.25 x .5) 1,016.12 TOTAL (Also enter on line 5, Recapitulation) $ 66,597.59 REV-1511 EX+ (12-99* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H fUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Frank W. Breitbach, Jr. FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Malpezzi Funeral Home Flowers and Food 1,873.82 386.00 2 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City . State Zip Year(s) Commission Paid: 2. Attomey Fees 3. Family Exemption: (If decedent's address is not 1he same as daimant's, attach explanation) Claimant Linda S. Hansen Street Address 1420 Silver Creek Drive 3,500.00 City Mechanicsburg Relationship of Claimant to Decedent Daughter State PA .Zip 17050 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Executor Expenses - Frank W. Breitbach III 475.00 TOTAL (Also enter on line 9, Recapitulation) $ 6,234.82 REV-1512 EX+ (12-03) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE UABILmES, & LIENS ESTATE OF Frank W. Breitbach, Jr. Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, Including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH FiLE NUMBER 1. Bridges Nursing Home 180.00 2 Hospice - Messiah Village 699.00 3 Pennsylvania Income Tax 52.00 4 Cumberland County Registar of Wills 244.00 TOTAL (Also enter on line 10, Recapitulation) $ 1,175.00 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 '*' INFORMATION NOTICE AND TAXPAYER RESPONSE FILE ACN DATE NO. 21 05- 0398 05132482 07-13-2005 REV-1545 EX AFP 109-00l EST. OF FRANK W BREITBACH S.S. NO. 063-26-1938 DATE OF DEATH 03-18-2005 COUNTY CUMBERLAND TYPE OF ACCOUNT [XJ SAVINGS o CHECKING o TRUST o CERTIF. ** LINDA S HANSEN 1420 SILVER CREEK DR MECHANICSBURG PA 17050 REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 MEMBERS 1ST FCU 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 Pennsylvania. Questions may be answered by calling (717) 787-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 237560- 05 Date 07 -26-20 04 Established Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due x 45,262.01 100.00 45,262.01 .045 2,036.79 TAXPAYER RESPONSE To insure proper credit to your account, two (2) copies of this notice must accompany your payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". x NOTE: If tax payments are made within three (3) months of the decedent.s date of death, you may deduct a 5Z discount of the tax due. Any inheritance tax due will become delinquent nine (9) months after the date of death. Tax PART [!] A. [ CHECK ] ONE BLOCK B. ONLY c. [] 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 a discount or avoid interest, or you may check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. ~he 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. [] The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART ~ below. PART ~ DATE PAID DEBTS AND DEDUCTIONS CLAIMED PART ~ TAX RETURN - COMPUTATION If you indicate a different tax rate, please state your relationship to decedent: OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Established 1 2. Account Bal~ce 2 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 5. Debts and Deductions 5 6. Amount Taxable 6 7. Tax Rate 7 X 8. Tax Due 8 PAYEE DESCRIPTION AMOUNT PAID I TOTAL (Enter on Line 5 of Tax Computation) I $ Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. HOME ( WORK ( TElEPHONE ) ) NUMBER DATE TAXPAYER SIGNATURE GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted 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 more 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 "A" 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 Oepartment 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 Oepartment 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 and/or deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit 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 assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN PART 2 TAX COMPUTATION LINE 1. Enter NOTE: the date the account originally was established or titled in the manner existing at date of death. 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 name 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 OWNERS 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 X 100 l6.7X (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): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT OWNERS OR TRUST BENEFICIARIES X 100 PERCENT TAXABLE 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 50X (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 amount 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. 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 OX. 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. 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 0% 6% 15% 15% 07101/00 to present 0% 4.5%. 12% 15% 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 cen 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 may be requested by the PA Department of Revenue. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 *' INFORMATION NOTICE AND TAXPAYER RESPONSE FILE NO. 21 05-0398 ACN 05132483 DATE 07-13-2005 REY-1543 EX RFP (09-00> EST. OF FRANK W BREITBACH S.S. NO. 063-26-1938 DATE OF DEATH 03-18-2005 COUNTY CUMBERLAND TYPE OF ACCOUNT D SAVINGS [X] CHECKING D TRUST D CERTIF. LINDA S HANSEN 1420 SILVER CREEK DR MECHANICSBURG PA 17050 REHIT PAYHENT AND FORHS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 HEHBERS 1ST FCU 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 PennsYlvania. Questions may be answered by calling (717) 787-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 237560-11 Date 11-10-2003 Established Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due x 2,032.25 50.000 1,016.13 .045 45.73 TAXPAYER RESPONSE To insure proper credit to your account, two (2) copies of this notice must accompany your payment to the Register of Wills. Make check payable to: ..Register of Wills, Agent". x NOTE: If tax payments are made within three (3) months of the decedent.s date of death, you may deduct a 57. discount of the tax due. Any inheritance tax due will become delinquent nine (9) months after the date of death. Tax PART [!] A. [ CHECK ] ONE BLOCK B. ONLY c. [] 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 a discount or avoid interest, or you may check box ..A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. [] 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. [] The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART ~ below. PART ~ DATE PAID DEBTS AND DEDUCTIONS CLAIMED If you indicate a different tax rate, please state your relationship to decedent: PART @J TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax S. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 4 5 6 7 8 x x PAYEE DESCRIPTION AMOUNT PAID I TOTAL CEnter on Line 5 of Tax Computation) I $ Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. HOME ( WORK ( TELEPHONE ) ) NUMBER DATE TAXPAYER SIGNATURE GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted 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 more 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 "A" 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 Oepartment 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 and/or deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit 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 assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN PART 2 - TAX COMPUTATION LINE 1. Enter NOTE: the date the account originallY was established or titled in the manner existing at date of death. 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 (HH) appears before your first name 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 DF X 100 PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons. 1 DIVIDEO BY 3 (JOINT OWNERS) OIVIDED BY 2 (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): 1 DIVIOEO BY TOTAL NUMBER OF SURVIVING JOINT OWNERS OR TRUST BENEFICIARIES X 100 PERCENT TAXABLE 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 OIVIDEO BY 2 (SURVIVORS) = .50 X 100 50% (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 amount 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. HThe 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 0%. 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. Date of Death Spouse Lineal Sibling Collateral 07101/94 to 12/31/94 3X 6X lSX lSX 01101195 to 06/30/00 OX 6X lSX lSX 07101/00 to present OX 4.SXlI l2X lSX 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. Oebts 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 may be requested by the PA Department of Revenue. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRIS8URG, PA 17128-0601 - INFORMATION NOTICE AND TAXPAYER RESPONSE FILE ACN DATE NO. 21 05-0398 05132481 07-13-2005 REV-1545 EX AFP 109-00l EST. OF FRANK W BREITBACH S.S. NO. 063-26-1938 DATE OF DEATH 03-18-2005 COUNTY CUMBERLAND TYPE OF ACCOUNT D SAVINGS D CHECKING D TRUST IX] CERTIF . LINDA S HANSEN 1420 SILVER CREEK DR MECHANICSBURG PA 17050 REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 MEMBERS 1ST FCU 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 PennsYlvania. Questions may be answered by calling (717) 787-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 237560-40 Date 07 -26-20 04 Established Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due x 10,124.67 100.00 10,124.67 ,045 455.61 TAXPAYER RESPONSE To insure proper credit to your account, two (2) copies of this notice must accompany your payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". x NOTE: If tax payments are made 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. Tax PART [!] A. [ CHECK ] ONE BLOCK B. ONLY c. [] The above information and tax due is correct. I. 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 assessment will be issued by the PA Department of Revenue. [] 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. [] The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART ~ below. If you indicate a different tax rate, please state your relationship to decedent: PART ~ DATE PAID DEBTS AND DEDUCTIONS CLAIMED PART @J TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3, Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7, Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 4 5 6 7 8 x x PAYEE DESCRIPTION AMOUNT PAID I TOTAL (Enter on Line 5 of Tax Computation) I $ Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. HOME ( WORK ( TELEPHONE ) ) NUMBER DATE TAXPAYER SIGNATURE GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSHENT with applicable interest based on information submitted by the financial institution. Z. 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 more 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 "A" 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. 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 information is incorrect and/or deductions are being claimed, check block "C" and complete Parts Z and 3 according to the instructions below. Sign two copies and submit 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 assessment [Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN PART 2 TAX COMPUTATION LINE 1. Enter NOTE: the date the account originally was established or titled in the manner existing at date of death. For a decedent dying after lZ/lZ/8Z: Accounts which the decedent put in joint names within one [I) 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 name 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. 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 DIVIDED BY TOTAL NUMBER OF X 100 PERCENT TAXABLE JOINT OWNERS 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 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): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT OWNERS OR TRUST BENEFICIARIES X 100 PERCENT TAXABLE 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 Z [SURVIVORS) = .50 X 100 50~ [TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax [line 4) is determined by multiplying the account balance [line Z) by the percent taxable [line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount 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. 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 O~. 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. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3X 6X 15X 15X 01/01/95 to 06/30/00 OX 6X 15X 15X 07/01/00 to present OX 4,5Xll 12X 15X 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 lIZ" x 11". Proof of payment may be requested by the PA Department of Revenue. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 *' INFORMATION NOTICE AND TAXPAYER RESPONSE FILE NO. 21 05-0398 ACN 05132480 DATE 07-13-2005 REV-15~5 EX AFP 109-00l EST. OF FRANK W BREITBACH S.S. NO. 063-26-1938 DATE OF DEATH 03-18-2005 COUNTY CUMBERLAND TYPE OF ACCOUNT o SAVINGS D CHECKING o TRUST IX] CERTIF. LINDA S HANSEN 1420 SILVER CREEK DR MECHANICSBURG PA 17050 REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 MEMBERS 1ST FCU 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 Pennsylvania. Questions may be ans..en.Li b" "..11i"" (717) 787-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 237560-41 Date 07-26-2004 Established Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due x 10,194.79 100.00 10,194.79 .045 458.77 TAXPAYER RESPONSE To insure proper credit to your account, two (2) copies of this notice must accompany your payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". x NOTE: If tax payments are made 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. Tax PART [!] A. [ CHECK ] ONE BLOCK B. ONLY c. [] 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 a discount or avoid interest, or you may check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. [] 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. [] The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART [!] balow. PART [!] DATE PAID DEBTS AND DEDUCTIONS CLAIMED If you indicate a different tax rate, please state your relationship to decedent: PART @J TAX RETURN - COMPUTATION lINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax S. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 4 S 6 7 8 x x PAYEE DESCRIPTION AMOUNT PAID TOTAL (Enter on Line S of Tax Computation) I $ Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. HOME ( WORK ( TELEPHONE ) ) NUMBER DATE TAXPAYER SIGNATURE GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted 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 deeth 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 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 "A" 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 and/or deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit 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 assessment (Form REV-1548 EX) upon receipt of the return froM the Register of Wills. TAX RETURN PART 2 - TAX COMPUTATION LINE 1. Enter NDTE: the date the account originallY was established or titled in the manner existing at date of death. 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 name 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 TDTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 PERCENT TAXABLE JOINT OWNERS 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 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): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT OWNERS OR TRUST BENEFICIARIES X 100 PERCENT TAXABLE 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 50% (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 amount 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. 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 0%. 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. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3X 6X l.5X l.5X 01/01/9.5 to 06/30/00 0% 6% l.5X l.5X 07/01/00 to present OX 4..5XII 12X 1.5% 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 11". Proof of payment may be requested by the PA Department of Revenue.