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COMMONWEALTH OF PENNSYLVANIA
DEP;;RTMENT OF REVENUE
bUREAU OF INDIVIDUAL TAXES
DEPT 280601
HARRiSBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
UNCH TRACEY
2940 BEADEN DR
VIRGINIA BEACH, VA 23456
____u_ f.::-,Id
ESTATE INFORMATION: SSN: 200-32-2830
FILE NUMBER: 2106-0454
DECEDENT NAME: FRY HAZEL K
DA TE OF PAYMENT: 06/12/2006
POSTMARK DATE: 06/11/2006
COUNTY: CUMBERLAND
DA TE OF DEATH: 08/12/2005
NO. CD 006825
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
05149241 I $5.08
I
I
I
I
I
I
I
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TOTAL AMOUNT PAID:
$5.08
REMARKS: TRACEY lUNCH
CHECK# 6536
SEAL
INITIALS: CMM
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WilLS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
*'
INFORMATION NOTICE
',"'" ..AND,,_,..... ',__ "...
TAXPAYER ReSPONSE
FILE NO.
ACN
DATE
21 -l'h-- 4SCf
05149241
10-26-20-05
REV-1543 EX AFP (09-00)
TRACEY LUNCH
61Z W L6e:tJST *
CLEARFIELD ~A 16839
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REMIT PAYMENT AND
REGISTER OF WILLS
CUMBERLAND CO COURT
CARLISLE, PA 17013
TYPE OF ACCOUNT
o SAVINGS
o CHECKING
IXI TRUST
o CERTIF.
FORMS TO:
EST. OF HAZEL; ~::FRY
S.S. NO. 200-32-2830
DATE OF DEATH 08-12-2005
COUNTY CUMBERLAND
HOUSE
CLEARFIELD BANK & TRUST CO 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 fro. 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
cf Pen~.c::yl\la~!~.. Questicr-s !'fay be =n~"~o!""gcl '"'~ ~;!l! il1g (71.7) ?R.'?-8327 ~
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 12122602 Date 10-10-1997
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
4,892.63
33.333
1,630.86
.15
244.63
TAXPAYER RESPONSE
To insure proper credit to YOUr account, two
(Z) copies of this notice must acco.pany 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 infor.ation and tax due is correct.
1. You .ay 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.
~ above information is incorrect and/or debts and deductions were paid by you.
You .ust complete PART ~ and/or PART ~ below.
If you indicate a differen
relationship to decedent:
PART
~
DATE PAID
DEBTS AND DEDUCTIONS
</) ssf. :i;/3 ~ I; S/'I,eiJ
AMOUNT PAID
d-
PART
~
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
1
2
3
4
5
6
7
8
TAX ON JOINT/TR ST ACCOUNTS
IA~'~q~ 'l1'7
X 33'. ~3.~
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/~) S ( It . (0/) ~
__ 1 I/'), 'JSl
" 04S
S,~9
X
~under penalties of
lete to the best
0-
TAXPAYER SI
PAYEE
cJ.
DESCRIPTION
facts I
and
b-S.--o"
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 becomes delinquent nine months after the decedent's date Df death.
3. A jDint account 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 prior to
death are fully taxable as transfers.
5. AccDunts established jDintly between husband and wife more than one year prior to death are not taxable.
6. AccDunts held by a decedent "in trust for" another or others are taxable fully.
REPORTING INSTRUCTIONS - PART
1
- TAXPAYER RESPONSE
1. BLOCK A - If the infDrmatiDn and cDmputatiDn in the notice 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 your check for the amount of
tax tD the Register Df Wills Df the cDunty indicated. The PA Department of Revenue will issue an official assessment
(FDrm REV-1548 EX) upDn receipt of 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 infDrmation is incorrect and/Dr deductions are being claimed, check blDCk "C" and cDmplete Parts 2 and 3
according to the instructions below. Sign tWD copies and submit them with YDUr check fDr the amDunt Df tax payable tD the Register
of Wills of the county 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 account 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. However, there is an exclusiDn nDt tD exceed $3,000 per transferee regardless Df the value Df
the account or the number Df accDunts held.
If a dDuble asterisk (KK) appears befDre YDur first name in the address portiDn of this nDtice, the $3,000 exclusion
already has been deducted from the account balance as repDrted by the financial institution.
2. Enter the tDtal balance Df the account inclUding interest accrued tD the date Df death.
3. The percent Df the accDunt that is taxable for each survivor is determined as fDIIDws:
A. The percent taxable fDr jDint assets established mDre than Dne year priDr tD the decedent's death:
DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 PERCENT TAXABLE
JOINT 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
16.7X (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
OWNERS OR TRUST BENEFICIARIES
X 100
PERCENT TAXABLE
Example: Joint 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 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 deductiDns (line 5) frDm the amDunt subject tD tax (line 4).
7. Enter the apprDpriate tax rate (line 7) as determined belDw.
KThe tax rate ImpDsed Dn the net value Df transfers frDm a deceased chIld twentY-Dne years Df age Dr younger at
death tD Dr fDr the use Df a natural parent, an adDptive parent, Dr a stepparent Df the child is OX.
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 or not they have been adDpted by others, adDpted descendents and their descendants
and step-descendants. "Siblings" are defined as individuals whD have at least one parent in common with the decedent, whether by blDDd
Dr adoption. The "CDllateral" 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
AIIDwable debts and deductiDns are determined as follows:
A. YDU legally are responsible for payment, Dr the estate subject tD administratiDn by a persDnal representative is insufficient
to 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" x II". PrDof Df
payment may be requested by the PA Department Df Revenue.
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