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Home My WebLink About09-04-07 --.J 15056051058 REV-1500 EX (06-05) PA Deparbnent of Revenue '*' Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0001 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICIAL USE ONLY ~ouno/ Code Year INHERITANCE TAX RETURN RESIDENT DECEDENT File Number 21 07 0164 Date of Birth 456-78-9644 02106/2007 01/12/1948 Decedent's Last Name HAGAN Decedent's First Name MI MARY R (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 ta') 1. Original Return c;:::) 2. Supplemental Return c;:::) 4. Limited Estate c;:::) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required c;:::) 4a. Future Interest Compromise (date of death after 12-12-82) c;:::) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) C::l 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 ()aytime Telephone Number r~-:; . ,...-, .. C')" (717) 737-34fr5o --' . ~q 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes THOMAS E. FLOWER REGiSTER'6F'V9it~'USE . 111 I ....1 r Firm Name (If Applicable) SAlOIS, FLOWER & L1NDSA 2109 MARKET STREET ) First line of address -0 Second line of address c" ZIP Code C'1 CO City or Post Office State DATE FILED CAMP HILL PA 17011 Correspondent's e-mail address: Under penalties of pe~ury, 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. :: A:SS E OF PERSON~~R~~:N~.u u__" _____...___.__u___ .d___11$-DZtil______ THOMAS E. FLOWER, ADMINISTRATOR, 2109 MARKET ST., CAMP HILL, PA 17011 ---_.._~-----,._--------_.._._- - ._------_.__._----~~---~~-_._-- '---.--.---------------- SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS SAlOIS, FLOWER & LINDSAY, 2109 MARKET ST., CAMP HILL, PA 17011 PLEASE USE ORIGINAL FORM ONLY L 15056051058 Side 1 15056051058 --.J ...J 15056052059 REV-1500 EX Decedent's Name: MARY R HAGAN 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) <::::) Separate Billing Requested. . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested.. . . . . .. 7. 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 & 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 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 X.O_ 17. Amount of Line 14 taxable at sibling rate X .12 10,388.20 18. Amount of Line 14 taxable at collateral rate X .15 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 15056052059 Side 2 15. 16. 17. 18. Decedent's Social Security Number 15056052059 32,081.03 32,081.03 11,912.30 9,780.53 21,692.83 10,388.20 0.00 10,388.20 1 ,246.58 '* .-J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENTS NAME MARY R HAGAN STREET ADDRESS 3 MARILYN DRIVE 64 DECEDENTS SOCIAL SECURITY NUMBER 456-78-9644 CITY CARLISLE STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 1 ,246.58 1,430.00 62.33 Total Credits (A + B + C ) (2) 1,492.33 3. Interest/Penalty if applicable D. Interest E. Penalty 0.00 0.00 Total Interest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) 0.00 245.75 0.00 0.00 0.00 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. 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 [KJ b. retain the right to designate who shall use the property transferred or its income; ............................................ D [KJ c. retain a reversionary interest; or.......................................................................................................................... D [iJ d. receive the promise for life of either payments, benefits or care? ...................................................................... D [iJ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. D [KJ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D [KJ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ [KJ 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 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 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 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)]. 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)]. 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 EX+ (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF MARY R HAGAN FILE NUMBER 21-07-0164 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1 Suburban Propane, refund 2 UMH Properties, returned security deposit 3 cash 4 American Express travele(s check 5 Household goods and furnishings, net auction proceeds 6 2003 Toyota Matrix, 65,000 miles, sale proceeds 7 PA Slate Bank checking #10300176 8 PA State Bank savings #21300157 VALUE AT DATE OF DEATH 236.59 400.00 11.62 100.00 2,219.00 9,200.00 17,322.17 2,591.65 .. TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) ... 32,081.03 REV-1511 EX+ (12-99>. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF MARY R HAGAN FILE NUMBER 21-07-0164 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: GORMAN-SCHARPF FUNERAL HOME, PROFESSIONAL SERVICES AND CREMATION FUNERAL - FLOWERS, URN DRAPE, HONORARIA, MEMORIAL LUNCHEON, ETC. 1,557.11 1,104.91 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 6,500.00 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 97.00 5. Accountant's Fees 6. Tax Retum Preparer's Fees 7. JIM, DONNA GORDON - PACK HOUSEHOLD ITEMS FOR AUCTION 440.00 8. JESSICA WOOD - MAID SERVICE TO CLEAN RENTAL MOBILE HOME 50.00 9. CASSIUS MULLEN AUTO REPAIR, REPAIRS TO MATRIX PRIOR TO SALE 1,907.21 10. PUBLISH ESTATE NOTICES, CLJ (75), CARLISLE SENTINEL (166.07) 241.07 11. TAX RETURN FILING FEE 15.00 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 11,912.30 REV-1512 EX+ (12-03) * COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21-07-0164 ESTATE OF MARY R HAGAN Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, Including unrelmbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 1,528.68 44.52 AMERICREDIT, PAY OFF AUTO LOAN PPL, ELECTRIC BILL KINETIC IMAGING 2 3 15.60 4 PENN CREDIT CORP 57.00 5 CAMP HILL FIRE CO, AMBULANCE WEST SHORE EMS, AMBULANCE 635.00 6 102.29 7 HOSPITAL OF THE U. OF PENN STATEWIDE TAX RECOVERY NEPHROLOGY ASSOCIATES OF CENTRAL PA 121.67 8 71.00 9 29.50 10 CARLISLE CARDIOLOGY ASSOCIATES 96.06 11 EDWIN A ABRAHAMSON & ASSOC., JUDGMENT DEBT CLINICAL PRACTICES OF THE U. OF PENN 6,153.67 392.76 12 13 CAMP HILL EMERGENCY PHYSICIANS 17.50 14 NCO FINANCIAL SYSTEMS 357.28 15 HOLY SPIRIT HOSPITAL 158.00 9,780.53 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (6-98* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF MARY R. HAGAN FILE NUMBER 21-07-0164 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 INCLUOE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO OECEOENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLEl VALUE 1. FEDERAL CIVIL SERVICE RETIREMENT ANNUITY PAYABLE TO "CYNTHIA A. BROWN - FRIEND" DECEDENT'S "CSF" NUMBER IS 3-068-923 ADMINISTRATOR DOES NOT KNOW IDENTITY OF BENEFICIARY OR AMOUNT OF RETIREMENT ANNUITY PAYABLE TO BENEFICIARY TOTAL (Also enter on line 7 Recapitulation) $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-l513 EX+ (9-00) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF MARY R HAGAN FILE NUMBER 21-07-0164 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS ~nclude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)) 1 Mr. Richard W. Hagan, 7902 Mulchins Way, Piano, TX 75024 brother .5 2 Mr. Michael F. Hagan, 1940 4th Street, Apt. #2, Sparks, NV 89431 brother .5 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed. insert addiUonal sheets of the same size) Feb 26, 2007 RE: Mary Hagen To Whom It May Concern: This letter states that at date of death (2/6/07) her accounts had the following balances: #21300157 savings $2,591.65 #10300176 checking $17,322.17 T7~YY\ ~ Ann':::! Asst. Comm. Office Manager 717-243-3189 1 North Hanover Street Carlisle, PA 17013 717.243.3189 fax717.243.9649 pastatebank.com