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Home My WebLink About02-23-07 REV-1500 EX (6-00) Rev-1500 OfFICIAL USE ONLY '\ COMMONWEALTH OF ..... ............. .... ... ..................O'...........O'.O'.....O'.. ....O'...O' ..O'.O'...O'.O'.... ..O' ...... ..O' PENNSYLVANIA FILE NUMBER DEPARTMENT OF REVENUE DEPT. 280601 INHERITANCE TAX RETURN 06 HARRISBURG, PA 17128-0601 21 - 0503 RESIDENT DECEDENT County Code Year Number DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER I- Z HESS John H. 181-07-7308 W Cl DATE OF DEATH (MM-DD-YEAR) DATE OF 81RTH (MM-DD- YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH W U March 7. 2006' REGISTER OF WillS w Cl (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER N/A .!! x 1. Original Return 2. Supplemental Return 3. ~rnalnder Return (dale 01 death prior \012- - - I-- .Jt:fII~ 4. Limited Estate 4a. Future Interest Comprise (dIlle of dealh aIler 12-12-82) 5. Federal Estate Tax Return Required 1'[0 ~ e.2 - - Lo...- o ~Ul 6. Decedent Died Testate (Attach copy of Will) 7. Decedent Maintained a Living Trust (AlI8cIIa copy ot TRIll) 8. Total Number of Safe Deposit Boxes < - = 10. Spousal Poverty Credit(dIlleotdtNllh between 12.31-111 and 1.1.15) 011. Election to tax under Sec. 9113(A). 9. Litigation Proceeds Received - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: C NAME COMPLETE MAILING ADDRESS Q;) 109 Locust street ~ Jean D. Seibert, Esquire 8- FIRM NAME (If Applicable) Harrisburg, PA 17101 In ~ Wion, Zulli & Seibert 8 TELEPHONE NUMBER 717-236-9301 (1) :0 0 1. Real Estate (Schedule A) $0.00 k::: OFFIOIiOa. USE ONL Y-J .--0 ~ ~jQ r::-- :n 2. Stocks and Bonds (Schedule B) (2) $0.00 :'~ ~;? ~ '-i.;'_O 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) $0.00 i- s:: ~ N r ;s.~ . --.'- --J Z ::r,)X W :::,-:=:) 4. Mortgages & Notes Receivable (Schedule D) (4) $0.00 L ~-'I ::""' '_) C-..... 0 $o.ooE'? ~Tl -0 ___.J -.'j I- 5. Cash, Bank Deposits & Misc. Personal Property (Schedule E) (5) :l: - ::<.01 <( . ::IJ r:'i' C) . --i r,-\ ...J 6. Jointly Owned Property (Schedule F) (6) $25,380.06~ ::> D Separate Billing Requested en I- ~ w c.. 7. Inter-Vivos Transfers & Misc. Non~Probate Property (7) $O.OO! <( ... ....... ..... ... ... ... .... .... .... ............ .......... () (Schedule Gar L) W 8. Total Gross Assets (total Lines 1-7) (8) $25,380.06 ~ 9. Funeral Expenses & Administrative Costs (Schedule H) (9) $6,431.00 ! 10. Debts of Decedent, Mortgage Liabilities & Liens (Schedule I) (10) <- $8,995.06 11. Total Deductions (total Unes 9 & 10) (11) $154'606 12. Net Value of E$tate (Line 8 minus Line 11) (12) $9,954.00 13. Charitable and Govemrnental Bequests/See 9113 Trusts for which an election to tax has not been (13) !l:OOO made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) $9,954.00 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of line 14 taxable at the spousal tax Z rate, or transfers under Sec. 9116 (a)(1.2) x (15) $0.00 - 0 ~ 16. Amount of line 14 taxable at lineal rate $9,954.00 x .045 (16) $447.93 - ~j 17. Amount of line 14 taxable at sibling rate x .12 (17) $0.00 0- ~ 18. Amount of line 14 taxable at collateral rate x .15 (18) $000 0 () 19. Tax Due (19) $447.93 20.0 > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < Decedent's Complete Address: STREET ADDRESS Hampden 48 Messiah Village CITY I STATE IZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) $447.93 ~,~ nn ~" ~7 Total Credits (A + B + C) (2) $447 37 3. Interest/Penalty if appliCable D. Interest E. Penalty Total Interest/Penalty (0 + 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. (3) $0.00 (4) $0.00 (5) $0.56 (5A) $0.00 (5B) $0.56 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: a. retain the use or income of the property transferred; b. retain the right to designate who shall use the property transferred or its income; c. retain a revisionary interest; or 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 on year of death without receiving adequate consideration? 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? c=J C8::J IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Yes ~ B No ~ E8 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 cOl'llllete. DecI tion of preparer other than the personal representative is based on all the information of which preparer has any knowledge. SIG SIBLE F FILING RETURN dcrf7 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. g9116 (a) (1.1) (ii)]. The statute does not exemot 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. ~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. g9116(1.2) [72 P.S. s9116(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. s9116(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. REV-1509 EX + (1-117)(1) COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDEIIT DECEDENT SCHEDULE F. JOINTLY -OWNED PROPERTY ESTATE OF John H. Hess FILE NUMBER If an asset was made joint within one year of the decedent's date of death, It must be reported on Schedule G. SURVMNG JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Barbara Shade 6911 Chatham Drive Harrisburg, PA 17111 Daughter B. C. . JOINTL y-oWNED PROPERTY: ITEM LETTER DATE DESCRIPTION OF PROPERlY DATE OF DEATH %OF DATE OF DEATH FOR JOINT MADE Indude name of f1nanciallnstllution and bank account number or slrrilar Identifying number. DECO'S VALUE OF NUMBER TENANT JOINT Attach deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. Certificate of Deposit at PNC Bank $5,706.77 50.0% $2,853.38 2. A Checking account at PNC Bank $11,185.97 50.0% $5,592.99 3. A Joint Brokerage Accounts at Janney Montgomery Scott: $16,000 FHLMC 2643 UA - value remaining $1,991.77 50.0% $995.88 $10,000 FHLMC 1163 JA - value remaining $814.54 50.0% $407.27 $10,000 FNMA 04-29UA - value remaining $447.60 50.0% $223.80 $8,000 FHLMC 2864 DB - value remaining $6,109.37 50.0% $3,054.69 $11,000 FHLMC 2891 KG - value remaining $8,554.66 50.0% $4,277.33 $5,000 FHLMC 2892 KG - value remaining $3,930.78 50.0% $1,965.39 $9,000 FNMA 0499 NC - value remaining $6,504.32 50.0% $3,252.16 $8,000 FHLMC 2991 LA - value remaining $5,514.34 50.0% $2,757.17 TOTAL (Also enter on line 6, Recapitulation) $25,380.06 . . (If more space IS needed, Insert additional sheets of the same size) REV.1Sll EX + (1-97)(1) COMMONWEAL THOF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DeCeDeNT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF John H. Hess FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: . 1. Cocklin Funeral Home $5,831.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s) I EIN Number of Personal Representative(s) Street Address City State Zip - Year(s) Commission Paid: 2. Attomey Fees - Wion, Zulli & Seibert $575.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip - Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Filing fee $25.00 TOTAL (Also enter on line 9, Recapitulation) $6,431.00. . . (If more space IS needed, Insert additional sheets of the same size) REV.1512 EX + (1-97X1) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF John H. Hess SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS FILE NUMBER Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT $1,324.00 1. 3-20-06 Messiah Village 2. 3-20-06 Messiah Village $49.15 3. 3-28-06 Messiah Village $6,201.25 4. PSERS - prorated retirement payment refund $1,420.66 TOTAL (Also enter online 10, Recapitulation) (If more space is needed, insert additional sheets of the same size) $8,995.06 REV-1513 EX + (9..cO)) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF John H. Hess FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not L..t Trust"(.) OF ESTATE I. TAXABLE DISTRIBUTIONS [Include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Barbara Shade Daughter 100% 6911 Chatham Drive Harrisburg, PA 17111 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. 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)