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Home My WebLink About05-15-07 -.......--. -- ...J 1505b041125 REV-1500 EX (06-05) PA Depal1menl of Revenue. ~~r:~:~~":~ual Taxes INHERITANCE TAX RETURN Harrisbulll, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICIAL USE ONLY County Code Year 2 1 0 6 File Number 087 1 Date of Birth 208505883 o 8 3 1 2 0 0 6 1 1 1 5 1 9 5 6 Decedenfs Last Name R 0 S e n b err y Suffix Decedenfs First Name Randy MI L (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 00 1. Original Return o 4. Limited Estate 00 o 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received o D o 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required o 2. Supplemental Return D 4a. Future Interest Compromise (date of death after 12-12-82) D 7. Decedent Maintained a Living Trust (Attach Copy of Trust) D 10. Spousal Poverty Credit (date of death 0 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. All CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number 8. Total Number of Safe Deposit Boxes H . Ant h 0 n y Firm Name (If Applicable) A dam s 717 532 327 0 First line of address REGIS11;RpF WILLS U@NLY ":......::: c.:'::J "c-O -..J ," :''l .::J :::r:. Q -< Second line of address lJ 4 9 W est Ora n 9 e Street "'"', , '~ :"") .- --- .'... ../, City or Post Office S hip pen s bur 9 State ZIP Code ,..1 N '--QATe FILED . . PA 17257 UI Correspondent's e-mail address: Under penalties of peljury, I declare that I have examined this return, including accompanying schedules and statemenls, and to the best of my knowledge and beIlef, it is true, correct and complete. OecIaration of preparer o1her than the personal representative is based on an information of which preparer has any knoWledge. SIGNATUR OF ';4S0N ~NSI FOR FIL G RETURN DATE ADDRESS / /) /t/ /72S-7 SIGNATURE 0 ADDRESS . {., 4- 57 Side 1 L 15056041125 1505b041125 ...J -------....- - ~ ....J 15056042126 REV-1500 EX Decedent's Social Security Number 208505883 Decedent's Name: Randy L. Rosenberry RECAPITULATION 1. Real estate (Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 2. Stocks and Bonds (Schedule B) .................................. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages & Notes Receivable (Schedule D) ........................ 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5. 6. Jointly OWned Property (Schedule F) D Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Np.n;Probate Property (Schedule G) U Separate Billing Requested. . . . . .. 7. 1 3 4 8 6.8 3 9. Funeral Expenses & Administrative Costs (Schedule H) ................ 9. 34407.35 47894.18 39321.09 8. Total Gross Assets (total Lines 1-7) ........................... 8. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . ...........10. 11. Total Deductions (total Lines 9 & 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 39321.09 8573.09 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ..... . . ... ........14. 8 5 7 3. 0 9 TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X.O _ o . 0 0 15. O. 0 0 16. Amount of Line 14 taxable 8 5 7 3 . 0 9 3 8 5 . 7 9 at lineal rate X .04L 16. 17. Amount of Line 14 taxable o . 0 0 O. 0 0 at sibling rate X .12 17. 18. Amount of Line 14 taxable o . 0 0 O. 0 0 at collateral rate X .15 18. 19. Tax Due .. .. .. . .. ... ..... . ... ...... ... . . ..... . . ......... 19. 3 8 5. 7 9 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT D Side 2 L 15056042126 15056042126 ....J REV-1500 EX Page 3 File Number 21 06 0871 CITY Shippensbur STATE PA ZIP 17257 Tax Payments and Credits: 1. Tax Due (Page 2 Une 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 385.79 Total Credits (A + 8 + C) (2) 3. InterestlPenalty if applicable D. Interest E. Penalty TotallnterestIPenalty ( 0 + E) If Une 2 is greater than Une 1 + Une 3, enter the difference. This is the OVERPAYMENT. Fill In oval on Page 2, LIne 20 to request a refund. 0.00 5. If Line 1 + Une 3 is greater than Une 2, enter the difference. This is the TAX DUE. (3) (4) (5) (5A) (58) 0.00 0.00 385.79 4. A. Enter the interest on the tax due. 8. Enter the total of Une 5 + 5A. This is the BALANCE DUE. 385.79 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; ...................................................................... D 00 b. retain the right to designate who shall use the property transferred or its income; ............................... D 00 c. retain a reversionary interest; or ................................................................................................ D 00 d. receive the promise for life of either payments, benefits or care? ....................................................... D 00 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... 00 D 3. Did decedent own an 'in trust for" or payable upon death bank account or security at his or her death? ......... D 00 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................. D 00 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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 three (3) percent [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 zero (0) percent [72 P.S. ~9116 (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 zero (0) percent [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 four and one-half (4.5) percent, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)1. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. ~9116(a)(1.3)1. 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-1508!X + (8-98) * SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Randy L. Rosenberry FILE NUMBER 21 06 0871 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolntly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH 2,421.83 PNC Checking Account 50-0454-3873 2. Mobile Home 11,065.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 13486.83 REV-1510 EX + (6-98) . SCHEDULE G INTER.VIVOS TRANSFERS & MISC. NON.PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Randy L. Rosenberry FILE NUMBER 21 06 0871 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INClUDE TIE NAIotE OF lME TRANSFEREE, 1llEIR R8.ATION8HIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE NUMBER TIE MTE OF TRAN8FER ATTACHA COPY OF TIE DEED FOR RENo. ESTATE. VALUE OF ASSET INTEREST PF APPI.ICASlE) VALUE 1. Mony Life of America transferred to mother 37,407.35 100. 3,000.00 34,407.35 TOTAL (Also enter on line 7 Recapitulation) $ 34 407.35 (If more space is needed. insert additional sheets of the same size) REV-15118<+(12-99) * SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Randy L. Rosenberry FILE NUMBER 21 06 0871 Debts of decedent mUlt be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1, 2. 3. FUNERAL EXPENSES: ,Spring Hill Cemetary-opening grave site Fogelsonger-Bricker Funeral Home 'Revered Arnold Fleagle-funeral service 300.00 2,314.00 50.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Sandra Rosenberry SocIal Security Number(s)JEIN Number of Personal Represenlative(s) Street Address City Slate Zip Year(s) Commission Paid: 2. Attorney Fees H. Anthony Adams 3,000.00 3. Family Exemption: (If decedenfs address is not the same as c1aimanfs, attach explanation) Claimant Street Address City Slate Zip Relationship of Claimant to Decedent 4. Probate Fees 143.00 5. Acoountanfs Fees 6. Tax Return Prepare!'s Fees 7. SME (final months lot rent) 256.00 8. Chambersburg Hospital (illness with last 6 months) 17,333.00 9. Cumberland Valley Medical (illness with last 6 months) 153.00 10. Mohammed AI (illness within last 6 months) 184.09 11. Chambersburg Imaging Association 69.00 12. Keystone Medical 184.00 13. Intemal Revenue Service (Prior Debt Lien) 3,000.00 14. Internal Revenue Service (taxes due prior to death for 2006) 12,335.00 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 39 321.09 an IV . osen IrTY 21 06 0871 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(l) OF ESTATE I. TAXABLE DISTRIBUTIONS pnclude ~ht s~sal distributions, and transfers under Sec. 9116 (a (1. )] 1. Sandra Rosenberry Lineal 8,573.09 10 Howard Avenue Shippensburg, PA 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 II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ ''''-''''''';. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF R d L R be SCHEDULE J BENEFICIARIES FILE NUMBER (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT KNOW ALL MEN BY THESE PRESENTS, that I, RANDY LEE ROSENBERRY of Pennsylvania being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament hereby revoking all prior wills and codicils by me at any time heretofore made. ARST: I direct the payment of all my legal debts, funeral expenses including my grave marker and all expenses of my last illness, state, federal estate and inheritance taxes and administration costs shall be paid as soon as may be conveniently done follOWing my decease leaving all specific bequests free of tax to the legatee. SECOND: I give, devise and bequeath all my property be it real, mixed or personal, to Sandra E. Rosenberry. THIRD: I nominate and appoint Sandra E. Rosenberry, as the Executrix of this my Last Will and Testament. If she should fail to serve or be unable to serve, then in either of those said events, I nominate and appoint, Jacob B. Rosenberry, as the Executor of this my Last Will and Testament. IN WITNESS WHEREOF, I, RANDY LEE ROSENBERRY to this my Last Will and Testament set my hand and official seal, this d C1 day of Oe c 2005. ~~EAl) RANDY LEE OSENBERRY Sworn to and subscribed, declared and Published by Randy Lee Rosenberry, as his Last Will and Testament, and so Done in the presence of we the Witnesses, who sign at his request, And in his presence, and in the presence Of each other. ~~ COMMONWEALTH OF PENNSYLVANIA: :SS COUNTY OF CUMBERLAND I, Randy Lee Rosenberry, whose name is signed to the foregoing instrument, having been duly qualified according to taw, do hereby acknowledge that I signed it willingly; and that I signed it as my free and voluntary act for the purpose therein expressed. ~\ rl. ;f~i l- Randy Lee~nberry U Sworn to and acknowledged, before me, By Ra~y~ Rosenberry, the Testator, This day of ~f~'v>Ir 2005. ~~- '"Notary Public . Notarial Seal H. Anthony Adams. Notary Public Shippensburg Boro. Cumberland County My Commission Expires May 1 5.. 2006 Member, Pennsylv9.nia AsSOClaliooot Notaries , " " COMMONWEALTH OF PENNSYLVANIA: :SS COUNTY OF CUMBERLAND WE, Darlene M. Bigler and Sharon Coleman Adams, the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we saw the Testator sign and execute the instrument as his Last Will and Testament; that he signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator signed the Will as witnesses, and that to the best of our knowledge and belief the Testator was at the time at least eighteen (18) or more years of age and of sound mind and under no constraint or undue influence. Q{M~ /7J.13iL ~~aL Sworn to and subscribed before me by, Darlene M. Bigler anQ ~t}aron COI~n Adams The witnesses, this ~day of &N\.~ 2005. \~~ Notary Public Notarial Seal H. Anthony Adams, Notary Public Shippensburg Boro, Cumberland County My Commission Expires May 15, 2006 Member, PennsylVania Association of Notaries