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Home My WebLink About07-25-07 --.J 15056051047 REV-1500 EX (06-05) PA Department of Revenue . Bureau of Individual Taxes lllro PO BOX 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICIAL USE ONLY County Code Year File Number INHERITANCE TAX RETURN RESIDENT DECEDENT 2- / 0(0 o /Cy ()(:, Date of Birth / ~-:J / ~ .~ ? ff~ 0.8 22 2. 6 (){;. t) bIZ I 7'2. ~ Decedent's Last Name Suffix Decedent's First Name MI SilL L L EHI1IV ?ah/J YNE' Lv' (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 _ 1. Original Return c::> 4. Limited Estate c::> 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required c::> 2. Supplemental Return c::> c::> c::> 4a. Future Interest Compromise (date of death after 12-12-82) c::> 7. Decedent Maintained a Living Trust (Attach Copy of Trust) c::> 10. Spousal Poverty Credit (date of death c::> 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 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received --L 8. Total Number of Safe Deposit Boxes ~ CL1 of E If? J;. Vi?.R D 7'.; . 7r1" 8' Ca..........~~8 ..1) C~-;O --..J REGISTER~~~LLS r- ONLY Firm Name (If Applicable) - .,..,....,......, h) Ul First line of address ~/1{)1 C-f)/(Lj5LE 1\ OA P Second line of address :J~J ---{ C) City or ~ vst Office GARP/Y}.;/c5 State ZIP Code -.J DATE FILED ?A /7 )'2:1 Correspondent's e-mail address: 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 DATE n__ 2- '2 .- ~ 7 Av,-, ([. I " DATE 7~Z-'3 - ~ 7 /7Y2..~ . PREPARER~ER THAN REPRESENTATIVE ADDRESS . -- '/ 7> .-r- ~ . . ~ y ~/ C:::.~,. // 5' /(0 /f7 ~ ~ d f C;; ~'J r--cl;, ,AI? r ,J". /7~ - PLE~SE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 -1 --.J 15056052048 REV-1500 EX Decedent's NameS;/ ELL!; /1 AN: If,!) f'1-{A Y ~ E W; 1~$lg~5'8'8 RECAPITULATION /' Decedent's Social Security Number 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. 2 5;36 6. Jointly Owned Property (Schedule F) C=> Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) C=> Separate Billing Requested. . . 6. . 7. . 8. Total Gross Assets (total Lines 1-7). . 8. 11 Total Deductions (total Lines 9 & 10). .......... 11. 2 5':.3 0.72 g oD2.6 ~ 2- Y80..39 / / 2 .8". 3.D 8" ~. 752.36) 9. Funeral Expenses & Administrative Costs (Schedule H). 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . . . 10. 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. . 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 .0_ . 16. Amount of Line 14 taxable at lineal rate XO _ . 17. Amount of Line 14 taxable at sibling rate X .12 . 18. Amount of Line 14 taxable at collateral rate X .15 . 15. . 16 . 17. . 18. . .... . 19. . 19. TAX DUE. . . . . . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT c::::> Side 2 L 15056052048 15056052048 --.J REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENTSNAM:;W ELL If /'1 A /V J;f ~~Z1 Y/J/[ STREET ADDRESS !J / M V V AI TA / // f 1/? E E fv/,/ / Lor g CITY S/: //VG5 , r z'P/7d& 5- Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InteresUPenalty if applicable D. Interest E. Penalty Total Credits ( A + B + C ) (2) TotallnteresUPenalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + l.ine 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, 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. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (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 No a. retain the use or income of the property transferred;...................................................................................... D ~ b. retain the right to designate who shall use the property transferred or its income; ........................................... D ~ c. retain a reversionary interest; or....................................................................................................................... D !Xl d. receive the promise for life of either payments, benefits or care? .................................................................. D IKJ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. D I25J 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ............ D IXI 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ D ~ 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 PS. 39116 (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. 99116 (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 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. 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 four and one-half (4.5) percent, except as noted in 72 P.S. 39116(1.2) [72 PS. 39116(a)(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. 39116(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-l508 EX. (1-97) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ShpPPpmnn, Rr.mn!:ln~ leI 210601006 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 NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH Ca-6h ~ 21.00 Checking account PNC Bank 51-4040-5504 511.62 f'lo{U.E..e home 1,500.00 Automogi.E..e - 1989 P.E..ymouth 400.00 f'li-6c. pe~-6ona.E.. p~ope~ty (ija~d Sa.E..e) 98. 10 TOTAL (Also enter on line 5, Recapitulation) $2. 530. 7 2 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Sheffeman, Romayne W. FILE NUMBER 21 06 01006 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Hoffinge~ lune~af Home $8,386.00 B. ADMINISTRATIVE COSTS: 1 . Personal Representative's Commissions Name of Personal Representative(s) Street Address City_ State _ Zip Year(s) Commission Paid: 2. Attorney Fees J. Wa~d Coope~ 175.00 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 228.69 5. Accountant's Fees 6. Tax Return Preparer's Fees Dean Hottman 13,00 7. TOTAL (Also enter on line 9, Recapitulation) $ 8, 802. 6 9 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) ,. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Sheffeman, Romayne W. FILE NUMBER 21 06 01006 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Che6apeake H06pitaf $ 952.00 Homeowne~6 ~n6U~ance (lo~emo6t) 109.00 7h~ivent 10.00 7efephone 6.69 ~et-td 410.20 Lot ~entaf 992.50 TOTAL (Also enter on line 10, Recapitulation) $ 2, 480. 39 (If more space is needed, insert additional sheets of the same size)