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REV.l!>OO Il:'i 16-001
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21-05
REV-1500
OFFICIAL USE ONLY
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
193 52
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Zeigler, Ja:rres A.
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
05-17-05 01-16-58
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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NUMBER
9264
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Attach copy 01 Will)
o 9. Litigation Proceeds Received
\1JC2. Supplemental Return
o 4a. Future Interest Compromise (date 01 death after 12-12-82)
07. Decedent Maintained a Living Trust (AttachcopyofTrust)
o 10. Spousal Pove~ Credit (date 01 death between 12-31-91 and 1-1-95)
o 3. Remainder Return (date 01 death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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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)
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)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
TELEPHONE NUMBER
(717) 236-8000
COMPLETE MAILING ADDRESS
P.C.
P. O. Box 984
Harrisburg, PA 17108
OFFICIAL USE ONLY
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
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14. Net Value Subject to Tax (Line 12 minus Line 13)
(1)
(2)
(3)
(4)
(5)
1,946.44
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(7)
(8)
(9)
(10)
27.00
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(12)
(13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
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1.9~. 44
27.00
INSOLVENT
INSOLVENT
x.O_ (15)
x.O_ (16)
x .12 (17)
x .15 (18)
(19) ..
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
Decedent's Complete Address:
STREET ADDRESS
1395 Letchworth Road
CITY Camp Hill I STATE PA I ZIP 17011
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
INSOLVENT
Total Credits (A + B + C ) (2)
3. Interest/Penalty if applicable
D. Interest
E. Penalty
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.
INSOLVENT
A. Enter the interest on the tax due.
(5)
(5A)
.......
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
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
a. retain the use or income of the property transferred;.......................................................................................... 0
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0
c. retain a reversionary interest; or.......................................................................................................................... 0
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0
No
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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 penallies of pe~ury, I declare that I have examined this retum. including accompanying schedules and statements. and to the best of my knowledge and belief, ij 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 R~E W. FIlllt. ~~ 0 A
ADDRESS 1 racy i. telg!er, Mhf[IrlJ{r:L"rl.x.
6309 Stanford Court, ~chanicsburg, PA 17050
E E SENTATIVE
/~JDATE /
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ADDRESS
PA 17108
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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 exemot 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: " "; ,;L;(~
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 ad~ptiye parent,
or a stepparent of the child is 0% [72 P.S. ~9116(a)(1.2)]. .",.;'"~;~'~~'y;;;~'i;?')~~f.
e Tho Ia> rn" ;m",,'" 00 .e 00' ,,'"' of 'ao,fu~ 10 o<1o'.e ""oitl,1" d~$:~~.~!~;~&~~i,~~.~c~~~lJ;t!~~~='~il~l!il;
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
James A. Zeigler
FILE NUMBER
21-05-0534
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointJy-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
.
VALUE AT DATE
OF DEATH
2.
Central Pennsylvania Teansters Pension Food
(retirerent inco:rre plan - death distribution)
Internal Revenue Service (2005 tax return refund)
630.44
1,316.00
TOTAL (Also enter on line 5, Recapitulation) $ 1,946.44
(If more space is needed, insert additional sheets of the same size)
-R'EV-1511 EX+ (12-99) .
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
FILE NUMBER
21-05-0534
James A. Zeigler
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
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
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. Cumberland County Register of Wills (Short Certi"ficates) 12.00
8. Ctnnberland Cmmty Register of Wills lfi1ing of Supplemental
Retum) 15.00
TOTAL (Also enter on line 9, Recapitulation) $ 27.00
Debts of decedent must be reported on Schedule I.
(If more space is needed, insert additional sheets of the same size)