HomeMy WebLinkAbout01-16-07
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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21 06
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
00916
NUMBER
COMMONWEALTH OF PENNSYlVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17128-0801
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
EVANS, RUTH R.
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DATE OF DEATH (MM-DD-YEAR)
DATE OF BIRTH (MM-DD-YEAR)
09/20/2006
11/01/1924
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
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fgI 1. Original Return
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4a. Future Interest Compromise (date of death after
12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
10. Spousal Poverty Credit (date of death between
1
o 3. Remainder Return (date of death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
1 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Soh 0)
4. Limited Estate
6. Decedent Died Testate (Attach copy
of Will)
9. Litigation Proceeds Received
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THIS' SEC110NMUST BE 'COMPi.EfEO:Altc'
AME
JERRY R. DUFFIE
IRM NAME (If applicable)
JOHNSON, DUFFIE, STEWART & WEIDNER
ElEPHONE NUMBER
717/761-4540
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
OFFICIAL USE ONLY
I
209-16-6109
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WillS
SOCIAL SECURITY NUMBER
COMPLETE MAILING ADDRESS
P. O. BOX 109
LEMOYNE, , PA 17043-0109
(1 ) None
(2) None
(3) None
(4) None
(5) 148,141.33
(6) 96,678.00
(7) None
(8)
(9) 21,334.38
(10) 870.77
OFFICIAL USE ONLY
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241;819.33
Ul
(11 )
22,205.15
222,614.18
(12)
13. Charitable and Govemmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(13)
(14)
222,614.18
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15.Amount of Line 14 taxable at the spousal tax rate, x .00 (15)
or transfers under Sec. 9116(a)(1.2)
z 222,614.18 .045 (16)
0 16.Amount of Line 14 taxable at lineal rate x
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II. 17.Amount of Line 14 taxable at sibling rate x .12 (17)
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0
0
S 18. Amount of Line 14 taxable at collateral rate x .15 (18)
19. Tax Due (19)
10,017.64
10,017.64
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
;opyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
MANOR CARE
1700 MARKET ST.
CITY
ISTATE PA
IZIP 17011
CAMP HILL
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
9,000.00
473.68
Total Credits (A + B + C)
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E)
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
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
Ir'~~ ,
(1 )
10,017.64
(2)
9,473.68
(3) 0.00
(4)
(5) 543.96
(5A)
(58) 543.96
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;.................................................................................. ~ I
~: ~::::~ ~h;e~~~~i~~:~s:~:~es~~~..~~.~.I~ .~~~ .~~~.:.~.~.~.~.~.~~~~~~~~~~. .~.~ .i.t.~.~~~~~~::::: ::::::::: :::::::::::::::::: :::::
d. receive the promise for life of either payments, benefits or care?..............................................................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?........... ...................................................... ................................... ............ ...... 0
o
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3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?.........
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ...................... .............. ...................... .......... ..................................................
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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 retum, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of
pre parer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
CHARLES W. EVANS
~
225 SOUTH 17TH STREET
CAMP HILL, PA 17011
ADDRESS
ADDRESS
P. O. BOX 109
LEMOYNE" PA 17043-0109
~~''P~(uQlJ1il$1
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DATE
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For dates of death on or after July 1, 1994 and before January 1, 1995, the taxrate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. 99116 (a) (1.1) (i)J.
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. 99116 (a) (1.1) (ii)]. The statute does not exemDt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure
of assets and filing a tax return 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-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% [72 P.S. 99116 (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 .5. 99116
1.2) [72 P.S. 99116 (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. 99116 (a) (1.3)]. A sibling is defined,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
~(Q)L9W
JLa~t Will aub \!Ce~tameut
OF
RUTH R. EVANS
I, RUTH R. EVANS, of Borough of New Cumberland, Cumberland County, Pennsylvania,
declare this to be my last will and revoke any will previously made by me.
I.
I direct that all my legal debts and funeral expenses, including my gravemarker and all
expenses of my last illness, shall be paid from my residuary estate as soon as practicable after
my decease as a part of the expense of the administration of my estate.
II.
I bequeath my household goods and personal effects and other tangible personalty of a
like nature (not including cash or securities), together with any existing insurance thereon, to my
children, COLLETTE R. KELLY and CHARLES W. EVANS, to be divided between them by my
Executor with due regard to their personal preferences in as nearly equal shares as practical.
III.
bequeath all my jewelry to my daughter, COLLETTE R. KELLY, provided she shall
survive me.
IV.
I devise and bequeath the residue of my estate of every nature and wherever situate as
follows:
A. I bequeath the sum of Ten Thousand ($10,000.00) Dollars or ten (10%) percent of
my residuary estate, whichever is less, to my son, THOMAS F. EVANS.
B. One-half (1/2) of the balance thereof to my daughter, COLETTE R. KELLY.
C. One-half (1/2) of the balance thereof to my son, CHARLES W. EVANS.
V.
Should any of my issue entitled to a share of my estate not have attained the age of
twenty-three (23) at the time of distribution to him or her, I devise and bequeath the share of each
such issue to M&T BANK, of Harrisburg, Pennsylvania, IN SEPARATE TRUST, to hold, manage,
invest and reinvest the share so received, and any accumulation of income thereon, and to use
and apply the income and principal or so much thereof as, in Trustee's sole and absolute
discretion, may be necessary or appropriate for such issue's support or education (including trade
school and college education, both graduate and undergraduate) without regard to his or her
parent's ability to provide for such support or education, or to make payments for these purposes,
without further responsibility, to such issue or to such issue's parent or to any person taking care
of such issue. Any principal or income not no applied shall be distributed to such issue absolutely
when he or she attains the age of twenty-three (23). If he or she dies before attaining the age of
twenty-three (23), the Trust shall terminate and such share shall be distributed to his or her
personal representative.
VI.
I direct that all taxes that may be assessed in consequence of my death, of whatever
nature or by whatever jurisdiction imposed, shall be paid out of my residuary estate as a part of
the expense of the administration of my estate.
VII.
I appoint my son, CHARLES W. EVANS, Executor of this, my last Will. Should my son,
CHARLES W. EVANS, fails to qualify or ceases to act as Executor, I appoint my daughter,
COLLETTE R. KELLY, Executrix of this, my last Will.
2
VIII.
I direct that my Executor, Trustee, and their successors, shall not be required to post bond
for the faithful performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this:J /, t"iJ
A~il ,2004.
f
day of
~g.F~'
(SEAL)
Signed, sealed, published and declared by the above-named Testatrix, as and for her Last
Will and Testament, in the presence of us, who, at her request, in her presence and in the
presence of each other have hereunto subscribed our names as witnesses.
//] .
'1r~ f'd,t ~,,(U;n
3
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
: ss:
COUNTY OF CUMBERLAND
I, RUTH R. EVANS, Testatrix, whose name is signed to the foregoing instrument, having
been duly qualified according to law, do hereby acknowledge that I signed and executed the
instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free
and voluntary act for the purposes therein expressed.
RUT~ .a~
Sworn or affirmed to and acknowledged before me, by RUTH R. EVANS, the Testatrix,
this .;. c.a ~ day of ~~ , 2004.
NOTARIAL SEAL
DIANNE LENIG, Notary Public
Lemoyne Borough Cumberland Co.
My Commission Expires Dec. 21, 2005
..C"~ ~
Notary Public ( "G"~
4
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
we,~{.:t ~~ \..~ "-.. and ~ --{{~~...-.......,...,., the witnesses whose
names are signed to he foregoing in~trument, being duly qualified according to law, do depose
and say that we were present and saw the Testatrix sign and execute the foregoing instrument as
her Last Will and Testament; that she signed willingly and that she executed it as her free and
voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the
Testatrix signed the Will as witnesses; and that to the best of our knowledge, the Testatrix was at
that time at least 18 years of age, of sound mind and under no constraint or undue influence.
L-
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and
Sworn or affirmed. to and subscribed to before me by ~
~ ..(l~~ witnesses, this
~ to-- \. __ ' 2004.
~ ~~~..J...
;;> \a "-~ day of
~.""'"
Notary Public ~~"'
:227459
NOTA.RIAl SEAL
DIANNE lENIG, Notary Public
lemoyne Borough Cumberland Co.
My Commission Expires Dec. 21, 2005
5
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF EVANS, RUTH R.
FILE NUMBER
21 - 06 - 00916
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 Household Goods - items from assisted living residence at nursing home. 250.00
2 Jewelry - adeemed 0.00
3 M& T Bank - Checking Account No. 28850912 - Date of death balance, plus accrued interest. 10,923.16
4 M& T Investment Group - Account No. 1104329502 - 58,756.92
Date of death balance
5 Prudential Mutual Fund - Account No. 03535338711 - 1,628.09
Date of death balance
6 Wachovia Securities - Account Numbers - 3042-1788 76,021.68
Date of death balance
7 East Pennsboro Ambulance - refund 80.00
8 Verizon - refund 5.49
9 HCR - ManorCare - refund 288.69
10 United Security Assurance - premium refund - Nursing Home Insurance 180.30
11 FIA Card Services - refund 7.00
TOTAL (Also enter on Line 5, Recapitulation) 148,141.33
.
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
EVANS, RUTH R.
I FILE NUMBER
21 - 06 - 00916
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
Charles W. Evans 225 S. 17th Street Son
A Camp Hill, PA 17011
Collette R. Kelly 98 16th Street Daughter
B New Cumberland, PA 17070
JOINTLY OWNED PROPERTY:
LETTER DATE ~~SCRIPIIO~~F PROJIERn DATE OF DEATH %OF DATE OF DEATH
ITEM Include name 0 lnanClallns I u Ion an tlan account number DECD'S VALUE OF
NUMBER FOR JOINT MADE or similar identifying number. Attach deed for jointly-held real VALUE OF ASSET
TENANT JOINT INTEREST DECEDENT'S INTEREST
estate.
1 A 01/20/2000 M&T Bank - Certificate of Deposit No. 10,068.96 5,034.48
31003913918438
2 A 01/19/2000 M&T Bank - Premium Interest Account No. 14,127.59 7,063.80
950265344
3 B 10/08/1996 Members 1st Federal Credit Union 642.46 321.23
Checking Account No. 162816-11
4 B 10/07/1996 Members 1 st Federal Credit Union 2,906.62 1,453.31
Savings Account No. 162816-00
5 B 10/08/1996 Members 1st Federal Credit Union 14,428.28 7,214.14
Money Manger Account No. 162816-05
6 B 10/08/1996 Members 1 st Federal Credit Union 1 ,400.43 700.22
Certificate No. 162816-40
7 B 10/08/1996 Members 1st Federal Credit Union 1,400.43 700.22
Certificate No. 162816-41
8 B 12/27/1996 Members 1 st Federal Credit Union 5,586.11 2,793.06
Certificate No. 162816-43
Total of Continuation Schedule(s)
TOTAL (Also enter on line 6, Recapitulation) 96,678.00
.
SCHEDULE F
JOINTLY-OWNED PROPERTY
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
EVANS, RUTH R.
I FILE NUMBER
21 - 06 - 00916
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
JOINTLY OWNED PROPERTY
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM In lude name of financial institution and bank account number DATE OF DEATH
NUMBER FOR JOINT MADE or similar identifying number. Attach deed for jointly-held real VALUE OF ASSET DECD'S VALUE OF
TENANT JOINT e' ate. INTEREST DECEDENT'S INTEREST
9 B 12/27/1996 Members 1st Federal Credit Union 5,586.11 2.793.06
Certificate NO. 162816-44
10 A 05/05/2004 1,968 Shares - General Electric Company 68,604.48 34.302.24
Common @ $34.86 p/sh.
11 B 05/05/2000 1,968 Shares - General Electric 68.604.48 34,302.24
Company Common @ $34.86 p/sh
Page 2 of Schedule F
.
SCHEDULEH
FUNERAL. EXPENSES &
ADMNlSlRATIVE COSTS
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF EVANS, RUTH R.
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER FUNERAL EXPENSES:
A. 1 Parthemore Funeral Home - funeral expenses
DESCRIPTION
2
Catholic Cemetery Association - interment charges
B.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
CHARLES W. EVANS
1.
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address 225 SOUTH 17TH STREET
City CAMP HILL State PA
Zip 17011
2.
Year(s) Commission paid
Attorney's Fees JOHNSON, DUFFIE, STEWART & WEIDNER --
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
State
Zip
4.
Probate Fees
Register of Wills - Cumberland County
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1
Cumberland Law Journal- advertise letters
Total of Continuation Schedule(s}
TOTAL (Also enter on line 9, Recapitulation)
FILE NUMBER
21 - 06 - 00916
AMOUNT
10,249.70
1,060.00
3,100.00
6,200.00
314.00
75.00
335.68
21,334.38
*'
Schedule H
Funeral Expenses &
Administrative Costs continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF EVANS, RUTH R.
FILE NUMBER
21 - 06 - 00916
2
The Patriot-News - Advertise Letters
130.68
3
Members 1 st FeU - charge to drill safe deposit box - keys were lost.
100.00
4
Register of Wills - file Inventory & Inheritance Tax Return
30.00
5
Reserve for close-out costs.
75.00
Page 2 of Schedule H
.
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIOENT DECEDENT
ESTATE OF EVANS, RUTH R.
FILE NUMBER
21 - 06 - 00916
Include unreimbursed medical expenses.
ITEM DESCRIPTION AMOUNT
NUMBER
1 Verizon - final bill - decedent's account 8.36
2 NeighborCare - decedent's final prescription charges. 599.26
3 West Shore EMS - decedent's account balance 263.15
TOTAL (Also enter on Line 10, Recapitulation) 870.77
:EV-1613 EX+ (9-00)
.
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
EVANS, RUTH R.
I FILE NUMBER
21 - 06 - 00916
RELATIONSHIP TO AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DECEDENT OF ESTATE
Do Not List Trustee(s)
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1 Collette Kelly - 98 16th Street Daughter One-half household
New Cumberland, PA 17070 goods & personal
effects; jewelry;
one-half residue.
2 Charles W. Evans Son One-half household
225 S. 17th Street, Camp Hill, PA 17011 goods & personal
effects; one-half
residue.
3 Thomas F. Evans - Deceased - 02/15/2006
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropria e, 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
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
SUBJECT: Estate of Ruth R. Evans
No. 21-06-00916
20;]7! i "
10 0' I.~
FROM I t, /,;:.': 05
JOHNSON, DUFFrU.L.l:t..s;f.....E..\ 'fNA.. .... RT &.
WEIPNEIt'j.c, (.
Attorneys at LaW
P.O. Box 109
Lemoyne, P A 17043
(717) 761-4540
Fax: 717 761-3015
DATE: January 12, 2007
TO Register of Wills Office
Cumberland County Courthouse
1 Courthouse Square
Carlisle, PA 17013-3387
Enclosed for filing in the above-captioned Estate are the following:
1. Original Inventory.
2. Original and copy of Inheritance Tax Return.
3. Check in the amount of $30.00, filing charges.
4. Check in the amount of $543.96, Inheritance Tax.
Envelope to forward the receipts to me.
Thank you.
SIGNED: Cind Hubler, Estate Administration Parale al
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