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Home My WebLink About07-06-06 (2) REV-l500 EX + (6-00) '* COMMONWEALTH OF PENNSYLVANIA , DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFRCIAL USE ONLY F~U~B~ 0 CS' tFt ~ 3 COuiirY~ -YEAR- - - NuMBER- - DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) I- Z W C W o w C MOSES TIMOTHY P. DATE OF DEATH (MM-DD-Year) DATE OF BIRTH (MM-DD-Year) SOCIAL SECURITY NUMBER 2 1 0-4 0-2 0 9 9 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER w .... :.: ~U) u D::.: wQ.u zoo U D:.... Q.ID Q. c( 10/15/2005 06/21/1950 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST, AND MIDDLE INITIAL) D 3. Remainder Return (dateoldealhprioflD12.1J.82) D 5. Federal Estate Tax Return Required _ 8. Total Number of Safe Deposit Boxes D 11. Election 10 tax under See. 9113(A) (AIlach SchO) MOSES JANET L. 00 1. Original Return D 4. Limited Estate D 6. Decedent Died Testate (Atta:hcopyolW.j D 9. Litigation Proceeds Received D 2. Supplemental Return D 4a. Future Interest Compromise (daleoldealh after 12-12-82) D 7. Decedent Maintained a Living Trust (Atta:h copy 01 Trust) D 10. Spousal Poverty Credit (dale oIdea1h beIween 12-31-91 and 1-1-95) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS WILLIAM A. DUNCAN 1 IRVINE ROW FIRM NAME (If Applicable) DUNCAN & HARTMAN P.C. TELEPHONE NUMBER 717-249-7780 CARLISLE PA 17013 .... z w c z o Q. U) W D: D: o U z o i= c( -oJ :J l- ii: c( o w It:: 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (Iotal Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (1) (2) (3) (4) (5) OFFICIAL USE ONLY 1'-." ) ~-'~-~ 65,436.34 (6) (7) -;-~'l 5,967.78 c.) --.J (8) 71,404.12 (9) 10. Debts of Decedent Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (Iota I Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Govemmental Bequests/See 9113 Trusts for which an election 10 tax has not been made (Schedule J) 4,191.44 14. Net Value Subject to Tax (Line 12 minus Line 13) SEe INSTRUCTIONS ON REVERSE SIDE FOR APPlICABLE RATES z o i= c( I- :J Q. :E o o )( c( I- 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under See. 9116 (a)(1.2) 67,212.68 3,136.71 X ~(15) X .045 (16) X .12 (17) X .15 (18) (19) (11) (12) (13) 4,191.44 67,212.68 0.00 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate (14) 67,212.68 18. Amount of Line 14 taxable at collateral rate 0.00 141.15 141.15 19. Tax Due 20. D CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < Decedent's Com lete Address: STREET ADDRESS 330 HOLLOWBROOK DRIVE CITY CARLISLE STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 141.15 3. Interest/Penalty if applicable D.lnterest E. Penalty Total Credits (A + B +C) (2) Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) 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 00 b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 00 c. retain a reversionary interest; or ...................................................................................................... 0 00 d. receive the promise for life of either payments, benefits or care? ............................................................. 0 00 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................. 0 00 3. Did decedent own an 'in trust for' or payable upon death bank account or security at his or her death? ................. 0 00 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....................................................................................................... 0 00 0.00 141.15 141.15 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE F~ILlNG RETURN . DATE (levrLd:J L /J7~4./ 7-S-0h ADDRESS 33011oLLOWBROOK DRIVE R SL PA SIGNATURE OF P EPA R ADDRESS \ For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)). For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)). The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-<>ne 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% [72 P.S. ~9116(a)(1.2)). The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~9116(a)(1.3)). A sibling is defined, under Section 9102, as an inrlivirlll::ll whn h::ll: ::It IA::Il:t nnA n::lrAnt in r.nmmnn with thA rlP.r'.P.rlP.nt whAthAr hv hlnnrl nr ::Irinntinn REV-1508 EX + (6-98) . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MOSES TIMOTHY P. FILE NUMBER ITEM NUMBER 1. Indude the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. DESCRIPTION VALUE AT DATE OF DEATH 17,000.00 1967 MGB - See Attached Appraisal 2. 1963 Nove Super sport (SS) - See Attached Appraisal 18,000.00 3. 2000 Mercury - Book Value 5,425.00 4. Members First Federal Credit Union - Checking Account # 0000254164 9,181.83 5. Members First Federal Credit Union - Savings Account # 0000254164 1,209.17 6. Members First Federal Credit Union - Commercial Money Market _ Account # 0000254164 14,620.34 TOTAL (Also enter on line 5, Recapitulation) $ IIf more soace is needed. insert additional sheets of the same size) 65436.34 REV-1509 EX + (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF MOSES TIMOTHY P. FILE NUMBER If an asset was made joint within one year of the decedenfs date of death, It must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Andrew J. Moses 435 1 st Street Carlisle, PA 17013 Son B Leslie A. Frey 327 Franklin Street Carlisle, PA 17013 Daughter c Janet L. Moses 330 Hollowbrook Drive Carlisle, PA 17013 Wife JOINTL V-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER ATTACH DEED FOR JOINTL V-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 1996 Members First Credit Union Savings Account # 33037-05 6,792.54 16.667 1,132.11 See attached info notice 2. A. 1983 Members First Credit Union Savings Account # 33037-00 7,534.45 16.667 1,255.77 See attached info notice 3. A. 2000 Members First Credit Union Checkin Account # 33037-11 611.27 50. 305.64 See attached info notice 4. B. 1997 Members First Credit Union Savings Account # 55598-05 2,659.11 16.667 443.19 5. C. 1997 Members First Credit Union Savings Account # 55598-05 2,659.11 16.667 443.19 6. C. 1996 Members First Credit Union Savings Account # 33037-05 6,792.54 16.667 1,132.11 7. C. 1983 Members First Credit Union Savings Account # 33037-00 7,534.45 16.667 1,255.77 TOTAL (Also enter on line 6, Recapitulation) $ 5 967.78 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+(12-99) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MOSES TIMOTHY P SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Hollinger Funeral Home & Crematory, Inc. 2,494.30 2. First United Church of Christ 384.14 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. Attorney Fees Duncan & Hartman, P.C. 1,000.00 3. Family Exemption: (If decedents address is not the same as daimants, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees Register of Wills Cumberland County Filing Fees 213.00 5. Accountants Fees 6. Tax Return Preparer's Fees 7. In Reserve 100.00 TOTAL (Also enteron line 9, Recapitulation) $ 4191.44 (If more space is needed, insert additional sheets of the same size) ...."""". COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER . IIMufHY P RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Ust Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS pndude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. JANET L. MOSES WIFE 100% 330 HOLLOWBROOK DRIVE CARLISLE, PA 17013 2. ANDREW J. MOSES SON 00% 435 1 ST STREET (RENUNICA TION CARLISLE, PA 17013 ATTACHED) 3. LESLIE A. FREY DAUGHTER 00% 327 FRANKLIN STREET (RENUNCIATION CARLISLE, PA 17013 ATTACHED) ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. OPPENHEIMER & CO INC. CUSTODIAN FBO TIMOTHY P. MOSES IRA ACCOUNT A87-0907894 $276,934.87 See attachment B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAl OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0.00 (If more space is needed, insert additional sheets of the same size) 1967 MGB Vehicle: 1967 MGB VIN: GHN3L118509 The estimated value of vehicle listed above is based on the current condition as of 10-15- 05. The vehicle in its current condition is restored to exceed the original factory condition. The assessed value is $17,000.00. The vehicle was assessed by Brandon Otto on 10-31-05. Brandon Otto * _ -=r-./~-CI , L ;;25::> -r tt) 6..--/( C Appraisers license #: 235490 1963 Chevrolet Nova SS Vehicle: 1963 Nova Super Sport (SS) VIN:30437N250987 The estimated value of vehicle listed above is based on the current condition as of 10-15- 05. The vehicle in its current condition is factory original except for the drive train which is upgraded. The assessed value is $18,000.00. The vehicle was assessed by Brandon Otto on 10-31-05. Brandon Otto ~ /'d/ ;;2 5:r~" 6 ~ Appraisers license #: 235490 , , 6 --J OJ ~ W ~ CJ1 DI . r,j " ~" ;} .> "" " " k :~:e~ ,'"" ' ' .' ,'", (f rf ,<;, " I 7, ,,,';, /,< ';'";' 1;",'; , ;'~ ;: " ,,',,' , I '''1Ir,I/:1'III':.' ... I' ,11 II , , I VI"' TRANSPORTATION '., "CO E FOR A VEH~~L ~;: \j:':-; , .' "., , " ",', , ,", ;j, I ," ,,:< ,,' , I ; ; I ",/, IUE:'; ;,r I" , ' " :'i ;' / ,,' '" , ;, .'" '~ ',';: MJ' 'i, '. >/ ~;";/; '!: /, > ' , ,:i, 1,~~;'~~~i,~~~AG;~: ,', ,< :2 ~f:~~i~~ _:~:;, < 3 "" NOT THE ACTU LA iii 4= ;~~~~~I~~~~ I y:: J C H E ~A~E ~~::LE /, I I lJt/21/9bl DOOM, PROCD, DATE PRIOR TITLE STATE UNLADEN WEIGHT GVWR ~tJtR DISCLOSURE/EXEMPT BY FEDERAL . . o OWNER(S) THY P MOSES I nlol BROOK DR rSlE PA 17013 1, . . " " rnF' II . I . . RELEASED DATE BY MAILING ADDRESS \ AU:',~P~-\;;g~,~r'~~f~~.~~~~I~i:,,~;~:t;,-,;,i' 1;~; . . 029513 TIMOTHY P MOSES 330 HOLLOW BROOK DR CARLISLE PA 17013 . SECOND LIEN FAVOR OF' TITLE BRA A "" ANTIQUE VEHICLE C .. CLASSIC VEHICLE F .. OUT OF COUNTRV) G"" ORIGINALLY MFGD. FO DISTRIBUTION H... AGRICULTURAl YEHle L "" lOGGING VEHICLE P =' FORMERLY A POLICE A "" RECONSTRU S"" STR!::ET ROD 1 ~: ~~~~~R~gN w ~FLOOD VEHle .'. x '" FORMERLY A "Jj , , / '~~)'? \ It a second lienholder IS Irsted, upon satisfaction of the fu'St hen" ~th~e ~ lIenholder must forward thIs Title to the Bureau of Motor Vehicles ~ appropriate form and fee ---,~~:':':=:. ~, DV ,'''', 1'0" ~ ':.' , .' .', . .....;<;::<:;., V. '. " ',",' ';,<:, '" " ," ,/ :, , '. , "", ';. ,;". '.:..... .; ";,' 'J;' , ' ',," ~ ;, . ',' ...;... ..~,:~ ;:.:;"'/<';;, , ';d '. " . ". n,.../:". -.. ntS~ '~'";; '{.,: ...... .j\i , \ ~~~:'4at~':~fi~$Y~}}~' iift~lftt~?t~/51"6t;1h~'. P8fin$ylvan.j~ D~pa~trnent " 'f~ffee;tJh~~~P:E?t~9J!~l:P~Jim~Ui~:fi?f:T:led-,h~rejn.jS _Ui~.I_~wful owl1er "-h<;:.~%';t;fg(::Z~!{;{~i~1iA~ilf:'r~}f}>/:-o'" :;'-:::: '- I . . . . . . . . . ,,; "" <'" J~~~. '; : --;--:- " ' \ ':..; .: /~ ""F' ;: . ;.: ',' " , '", ; ': ",," ',/, ,) ;J>.... ..' ;" ;, ';' 'j" '. .1:,>, .' . . if; ,..' ,,'~T; ;, , ",,:" , , /:, ,', ,; .. I . . = . , , . . . . When':,applyirlg for title with a t~-'q; - , ' f' :% ,/ thes€:.:;t>!ocks. If no block is checkeq; , ~t~;#/ A p', t~i;~eT:~~v~~~n;j~~~~r~.t of'sy ',;'_";, _'/<:/":___/; :_,":: ~,':;,_ :-';"_"":':;"',',': :, :".:_ ,~;o~~~:::. .~;?Jl:;' B-- 0 Tenants In Common (on d.eattl:qf-"on~:9W-n~rJnt~~eS:t:'o(i.feceas~d:ow:h~r'<-:-::L/ goes to his or her heIrs or est~ta). ' ~: .)-,:, /~" '<:--'.;;:,, :'" _: :_.' ,', .;' :; ,':,~:,;, " :-;.; :;{/(:>~;; .IF-NdtiE'N.-,:' -"': ,-: r7f),,/ ,;,i'C.,' " 9HECKEjOX, ' Wi,,' ,', ,;,' . > ... ., ,;,' /':-', >? /%~, YEAR: LIEN DATE: FIRST LIENHOLDER: NAME /. "''-; STREET' ~ <~ ;-:, , , ~;'" ;' :'" '.' , c, , 1 to the v~hicle described " , r " ': e, ,"t~, ,-;" i " :; "<Tun~mn SIGNER ~ /.. " '/:: n. SIGNER ::,.. .'. < .... CITY STATE LIEN DfTE SECOND LIENHOLDER NAME . ZIP , / , " IF NO LIEN Ct:iS~.'K sox [J,,,,, >,::-:,<" > STRE ET /~; ~ CITY STATE ZIP , , ..'~ .'" "" '.'3 f' .. ~ . ~ .:. . . . . f ,,\ tA (f) tit' i\:) . '. Df) n \JtXY\' '-- lJ--0~ ~.'-'----- ~ c;t/\, .Z)) l \ C\ \.{~ ,/1/'-' LCQ .k.(] ...'" (', . C.\ .~-l j .' / ;\" ,.' ' .... \ i "./ ' /' '\' .! \ \ ...\ / ,,' \ ,C., 2/ \; \/\d~~/^ CL/~J\l___;",L, . j '(,j \f \.. ,1-'" ., ,~~~.. / ".... .... (, '(' .... / ", c.., _.) ../" \.._",/ IN RE: TIMOTHY P. MOSES DECEASED, LATE OF MIDDLESEX TOWNSHIP, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, : PENNSYLVANIA : ORPHANS' COURT DIVISION : NO. 21-05-0953 CUMBERLAND COUNTY, PA DISCLAIMER AND RENUNCIATION I, ANDREW J. W. MOSES, hereby exercise the rights granted to me in Chapter 62 of the Probate, Estates and Fiduciaries Code (the "PEF Code"), and I hereby disclaim and renounce any interest to which I may be entitled as an Intestate Heir of TIMOTHY P. MOSES. IN WITNESS WHEREOF, intending to be legally bound hereby and intending that this Disclaimer and Renunciation shall be filed of record in the Office of the Register of Wills of Cumberland County, Pennsylvania, and a copy thereof delivered to Commonwealth of Pennsylvania, Department of Revenue, Inheritance Tax Division, Harrisburg, Pennsylvania, and Janet L. Moses, Administratrix, as provided in Section 6204 of the PEF Code, I hereunto set my hand and seal this C 'f'" day of 0,<,(12/':\ v-1V , 2005. /1. I) ./' , .' l ~1/r16h_t.LJ V LU ./1 le<~_Q.~> Andrew J. W!Moses COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND ''';-... On this, the ....i) day of L\:>c Gvn \) e\ , 2005, before me, a notary public, personally appeared Andrew J. W. Moses, known to me to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purpose therein contained. ; .,.el" ,,<- ;/)/1, I ,....'.'.',.1:.,( . ] U"--\i\/V '\.. I II ; L\/V Hii ,'lV/I.. ; ...... \.. .. Notary Pl'lblic - ",-..j (~---------_..,--- 1 WJTi\R~AL SEAL I L. f~jummert, Notary Public /'})OrOUGh of Carlisle, Cumberland Co., PA ."____~;omnl!~skm Expires t\U~1.11, 2007 -.--- IN RE: TIMOTHY P. MOSES DECEASED, LATE OF MIDDLESEX TOWNSHIP, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, : PENNSYL VANIA : ORPHANS' COURT DIVISION : NO. 21-05-0953 CUMBERLAND COUNTY, P A DISCLAIMER AND RENUNCIA nON I, LESLIE ANNE FREY, hereby exercise the rights granted to me in Chapter 62 of the Probate, Estates and Fiduciaries Code (the "PEF Code"), and I hereby disclaim and renounce any interest to which I may be entitled as an Intestate Heir of TIMOTHY P. MOSES. IN WIlNESS WHEREOF, intending to be legally bound hereby and intending that this Disclaimer and Renunciation shall be filed of record in the Office of the Register of Wills of Cumberland County, Pennsylvania, and a copy thereof delivered to Commonwealth of Pennsylvania, Department of Revenue, Inheritance Tax Division, Harrisburg, Pennsylvania, and Janet L. Moses, Administratrix, as provided in Section 6204 of the PEF Code, I hereunto set my hand and seal this 49' day of tlttrJ1br',I" , 2005. /J / <.> ./?' ._7) ;;. .. I ,/, v>Vr?f'2'L~ . reslie Anne Frey ~c. COMMONWEALTH OF PENNSYL VANIA COUNTY OF CUMBERLAND SS. On this, the -.aL day of lJecem \00\ ,2005, before me, a notary public, personally appeared Leslie Anne Frey, known to me to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purpose therein contained. I C~bl~ rYjlUVl1~ --- N{Tr,~HIAL SEAL f<alhy L Mummert, Notary Public E1DW,10h of Carlisle, Cumberland Co., PA rjly Gomrni~;3ion EJlpirp.s Aug. 11,2007 -~---- IN RE: TIMOTHY P. MOSES DECEASED, LATE OF MIDDLESEX TOWNSHIP, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, : PENNSYLVANIA : ORPHANS' COURT DIVISION : NO. 21-05-0953 CUMBERLAND COUNTY, P A DISCLAIMER AND RENUNCIATION I, JEANNE 1. WAGNER, hereby exercise the rights granted to me in Chapter 62 of the Probate, Estates and Fiduciaries Code (the "PEF Code"), and I hereby disclaim and renounce any interest to which I may be entitled as an Intestate Heir of TIMOTHY P. MOSES. IN WIlNESS WHEREOF, intending to be legally bound hereby and intending that this Disclaimer and Renunciation shall be filed of record in the Office of the Register of Wills of Cumberland County, Pennsylvania, and a copy thereof delivered to Commonwealth of Pennsylvania, Department of Revenue, Inheritance Tax Division, Harrisburg, Pennsylvania, and Janet 1. Moses, Administ~~rix, as provided in Section 6204 of the PEF Code, I hereunto set my hand and seal this J') day of "Deternh e-v- ,2005. .1kflHvN 'I.. J~lL~ J eann<J:- Wagner COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND On this, the ;~q day of ~.:>(e m 1Dt>.A , 2005, before me, a notary public, personally appeared Jeanne 1. Wagner, known to me to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purpose therein contained. 4rlA.1~ r1 O'fIlJ\11JYl'\.a..:A ot~~ublic ____ r NO"c,(\i,;llAL SEAL K,lthy L MUij:!i'i1(,lrt, NotOlr1! Public 1"""""-'l"~'l ,,,,~~..,,., C' h 'I"'d ,. '}' l-"~oh tJ.l:;jr .j~ \".f:{~ ~fsle, lU!h...(H t;;h'i" ~JO.,~" i\ I Conm'b' AUqj. -1'1,2007 L.._______.__... ',_,,_ __.._._.'-__.____ 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 05-0953 06104328 02-07-2006 REV-15~3 EX AFP (09-00) EST. OF TIMOTHY P MOSES S.S. NO. 210-40-2099 DATE OF DEATH 10-15-2005 COUNTY CUMBERLAND TYPE OF ACCOUNT IX] SAVINGS o CHECKING o TRUST o CERTIF. ANDREW J MOSES 435 1ST ST CARLISLE PA 17013 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 callin9 (717) 787-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 33037-05 Date 05-04-1996 Established Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due x 6,792.54 16.667 1,132.11 .045 50.94 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 ill 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 PART @] TAX RETURN - COMPUTATION If you indicate a different tax rate, please state your relationship to decedent: 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 X 4 5 6 7 X 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 COMMONWEALTH OF PENNSVlVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 INFORMATION NOTICE AND TAXPAYER RESPONSE FILE ACN DATE NO. 21 05-0953 06104330 02-07-2006 REV-15~3 EX AfP 109-001 EST. OF TIMOTHY P MOSES S.S. NO. 210-40-2099 DATE OF DEATH 10-15-2005 COUNTY CUMBERLAND TYPE OF ACCOUNT [i] SAVINGS o CHECKING o TRUST o CERTIF. ANDREW J MOSES 435 1ST ST CARLISLE PA 17013 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. 33037-00 Date 04-01-1983 Established Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due x 7,534.45 16.667 1,255.77 .045 56.51 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. r=J The above information and tax due is correct. 1. Vou 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. r=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. r=J The above information is incorrect and/or debts and deductions were paid by you. Vou must complete PART ~ and/or PART ~ below. If you indicate a different tax rate, please state your relationship to decedent: PART ~ TAX RETURN - COMPUTATION OF LINE 1. uate Established 1 2. Account Balance 2 3. Percent Taxable 3 4. Amount Subject to Tax 4 5. Debts and Deductions 5 6. Amount Taxable 6 7. Tax Rate 7 8. Tax Due 8 PART ~ DATE PAID DEBTS AND DEDUCTIONS CLAIMED TAX ON JOINT/TRUST ACCOUNTS 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 COMMONWEALTH OF PENNSVLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1712B-0601 INFORMATION NOTICE AND TAXPAYER RESPONSE FILE ACN DATE NO. 21 05- 0953 06104331 02-07-2006 REV-1543 EX AFP (09-00) EST. OF TIMOTHY P MOSES S.S. NO. 210-40-2099 DATE OF DEATH 10-15-2005 COUNTY CUMBERLAND TYPE OF ACCOUNT o SAVINGS !XJ CHECKING o TRUST o CERTIF. ANDREW J MOSES 435 1ST ST CARLISLE PA 17013 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 c~ Pennsyl~a~is. QUDsti~ns m~~ b~ ans~cred by calling (717) 787-8327e COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 33037-11 Date 02-14-2000 Established Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due x 611 .27 50.000 305.64 .045 13.75 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 SZ 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. If you indicate a different tax rate, please state your relationship to decedent: 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 PART ~ DATE PAID DEBTS AND DEDUCTIONS CLAIMED 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 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 05-0953 06104326 02-07-2006 REV-154! EX AFP (D9-DDI EST. OF TIMOTHY P MOSES 5.5. NO. 210-40-2099 DATE OF DEATH 10-15-2005 COUNTY CUMBERLAND TYPE OF ACCOUNT iii SAVINGS o CHECKING o TRUST o CERTIF. lESLIE A FREY 327 FRANKLIN ST CARLISLE PA 17013 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 ~nswered by celline [7171 787-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 55598-05 Date 01-25-1997 Established Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due x 2,659.11 16.667 443.19 .045 19.94 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"'. Tax x NOTE: If tax payments are made within three (3) months of the decedent.s date of death, you may deduct a 5X discount of the tax due. Any inheritance tax due will become delinquent nine (9) months after the date of death. PART ill A. [ CHECK ] ONE BLOCK B. ONLY c. c:J 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. [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. [J 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 ~ 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 PART [!J DATE PAID DEBTS AND DEDUCTIONS CLAIMED 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 TAXPAYER SIGNATURE 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- 0953 06104325 02-07-2006 REV-15~5 EX AFP <09-00) EST. OF TIMOTHY P MOSES S.S. NO. 210-40-2099 DATE OF DEATH 10-15-2005 COUNTY CUMBERLAND TYPE OF ACCOUNT IXl SAVINGS o CHECKING o TRUST o CERTIF. JANET L MOSES 330 HOLLOW BROOK DR CARLISLE PA 17013 REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 MEMBERS 1ST FCU has prDvided the Department with the infDrmatiDn listed belDw which has been used in calculating the pDtential tax due. Their recDrds indicate that at the death Df the abDve decedent, YDU were a jDint Dwner/beneficiary of this aCCDunt. If YDU feel this infDrmatiDn is incDrrect, please Dbtain written cDrrectiDn frDm the financial institutiDn, attach a CDpy tD this fDrm and return it tD the abDve address. This aCCDunt is taxable in accDrdance with the Inheritance Tax laws Df the CDmmDnwealth cf Pennsylvania. Questions may b~ answered by callin~ (717) 787-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 55598-05 Date 01-25-1997 Established Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due x 2,659. 11 16.667 443.19 .00 .00 TAXPAYER RESPONSE TD insure prDper credit tD YDur accDunt, tWD (2) cDpies Df this nDtice must accDmpany YDUr payment tD the Register Df Wills. Make check payable tD: "Register Df Wills, Agent". x NOTE: If tax payments are made within three (3) mDnths Df the decedent's date Df death, YDU may deduct a 5% discDunt Df the tax due. Any inheritance tax due will becDme delinquent nine (9) months after the date Df death. Tax PART ill A. [ CHECK ] ONE BLOCK B. ONLY c. [] The abDve infDrmatiDn and tax due is CDrrect. 1. YDU may chDDse tD remit payment tD the Register Df Wills with tWD cDpies Df this nDtice tD Dbtain a discDunt Dr aVDid interest, Dr YDU may check bDX "A" and return this nDtice tD the Register Df Wills and an Dfficial assessment will be issued by the PA Department Df Revenue. [] The abDve asset has been Dr will be repDrted and tax paid with the Pennsylvania Inheritance Tax return tD be filed by the decedent's representative. [] The abDve infDrmatiDn is incDrrect and/Dr debts and deductiDns were paid by YDU. YDU must cDmplete PART ~ and/Dr PART ~ belDw. 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 COMMONWEALTH OF PENNSYLVANIA OEPARTMENT OF REVENUE BUREAU OF INOIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 INFORMATION NOTICE AND TAXPAYER RESPONSE FILE ACN DATE NO. 21 05-0953 06104327 02-07-2006 REV-1545 EX AFP '09-001 EST. OF TIMOTHY P MOSES S.S. NO. 210-40-2099 DATE OF DEATH 10-15-2005 COUNTY CUMBERLAND TYPE OF ACCOUNT [X] SAVINGS o CHECKING o TRUST o CERTIF. JANET L MOSES 330 HOLLOW BROOK DR CARLISLE PA 17013 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 o~ 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 Commonweal~h of Pennsylvania. Questions may be answered ~y calling (717) 787-B327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 33037-05 Date 05-04-1996 Established Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due x 6,792.54 16.667 1,132.11 .00 .00 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 ill 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. 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 I 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 TAXPAYER SIGNATURE 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 05-0953 06104329 02-07-2006 REV-154! EX AFP 109-00l EST. OF TIMOTHY P MOSES S.S. NO. 210-40-2099 DATE OF DEATH 10-15-2005 COUNTY CUMBERLAND TYPE OF ACCOUNT [XJ SAVINGS o CHECKING o TRUST o CERTIF. JANET L MOSES 330 HOLLOW BROOK DR CARLISLE PA 17013 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 ~ay be answered by calling (717) 787-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 33037-00 Date 04-01-1983 Established Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due x 7,534.45 16.667 1,255.77 .00 .00 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 ill 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. [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. [] 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 @] 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 PART [!J DATE PAID DEBTS AND DEDUCTIONS CLAIMED 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 :i;.l"l , I?~" :/;:1 .i'i:l ;1::'::::21 ~hj - [ ~~ ,!;~ ~:; lS=l ["'~9 ~O .f5f ~.~Q ~:~ t() ~4i ,,~ u ,5 '" o ~ .~ .J g .g ~t~ r.r; !.... ~ ~ g SViZo:;:Z o;-o...::iop....... a 2 ~b ~ ~ :u J:Q r \,() 0.) g;v., ~ NE )<'10""" ......Z0..~ I..~~ r- '91 :~ ;?:: ,,~ 1 ,-....=.-.... ~~LJ.~I . t=r4 ~s'ld . '- ' t-=~=.,~;J :,'. ,9' :y/ " 1::~4 :1 r I I I I I I I on o ..... .... ..... ;:, .... bil = ;;; = r..< s o u o u g. ;i ~ <n '" Q) ... "0 "0 -< 'l:I .S .. ., Q.. .... 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