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Home My WebLink About10-10-07 -.J 15056051058 REV-1500 EX (0&-05) PA Department of Revenue *' Bureau of I ndividual Taxes PO BOX 280601 Harrisburg, PA 17128-0001 ENTER DECEDENT INFORMATION BELOW So~a~.~~~ty_~umber Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year 21 07 File Number 0570 Date of Birth , 177-24-7003 OS/27/2007 Decedenfs Last Name Suffix Decedenfs First Name MI Olive M Humbert (If Applicable) Enter Surviving Spouse's Information Below ~~~:l;l~str-JiJrne .__ ..... _..~ Suffix ~~l;lE"~~i~Name MI ~EOLJ~'~~~_aln~ecurity Num~~E THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW S> 1. Original Return <::) 4. Limited Estate <::::) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required <::::) 2. Supplemental Return C=> C=> <::::) 4a. Future Interest Compromise (date of death after 12-12-82) c::::> 7. Decedent Maintained a Living Trust (Attach Copy of Trust) Cj 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 SECnON MUST BE COMPLETED. ALl CORRESPONDENCE AND CONFIDENTIAL TAX INFORMAnON SHOULD BE DIRECTED TO: Name Da}'ti.'l1.~_,.el~pho."_~ r-J~.l1ll:>er 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes ca> J. Robert Stauffer Firm Name (If Applicable) , (717) 766-9673 ________.._.__...___.____~.LcJ.__~__ , ,--- RiGI5TER"OF~LLS-U51i~LY . i! First line of address Market Square Building t,__' Second line of address -.-j :~_-.J i I City.or.Pol;lt C>ffice Mechanicsburg State ZIP Code ~ _ , -f ; DATE FILED - i L-...-...-...--..-.-..-------..-.-..---(.,.;l-.-.-._. PA 17055 Correspondent's e-mail address: Under penalties of perjury, I declare that I have examined this retum, including acoompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer au- than the personal representative is based on all information of which preparer has any knowledge. 5IG~URE 9f P=iRSO RES7~SI FOR FIL G RETJlRN DATE _~_Ll, _~~ /d-,r-117 ADD E55 Z' . . 102 James Street, Leola, PA 17540 51 /Ii. P. EPA~E ER T EPRE5ENTATIVE DATE / - t7 7 Chanicsburg, PA 17055 PLEASE USE ORl~INAL FORM ONLY L 15056051058 Slcte 1 15056051058 ..-J ~ ~ 15056052059 REV-1500 EX Decedenfs Social Security Number Olive Decedent's Name: M Humbert , 177-24-7003 __._____.i 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. 8,850.19 6. Jointly Owned Property (Schedule F) c:> Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) c:> Separate Billing Requested.. . . . . .. 7. 8. Total Gross Assets Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 8,850.19 9. Funeral Expenses & Administrative Costs (Schedule H). . . .. .. . . . . . . . . . . . . .. 9. 2,842.95 10. Debts of Decedent, Mortgage liabilities. & Liens (Schedule I). . . . . . . . . . . . . . . . 10. 93,724.52 11. Total Deductions (total Lines 9 & 10)................................... 11. 96,567.47 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. ! -86,717.28 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 18. Amount of Line 14 taxable at collateral rate X .15 -86,717.28 15. 16. 17. 18. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C) L 15056052059 Side 2 15056052059 ---I RE\lJ.1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME Olive M Humbert STREET ADDRESS 875 Messiah Village f~_!'-\I.mb!lL_~_---~~ 10570 DECEDENT'S SOCIAL SECURITY NUMBER 177-24-7003 CITY Mechanicsburg STATE ZIP PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Une 19) 2. CreditslPayments A. Spousal Poverty Creed B. Prior Payments C. Discount (1) Total Credits ( A + B + C ) (2) 3. InterestlPenalty if applicable D. Interest E. Penalty 4. TotallnterestlPenalty ( D + E ) 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. (3) (4) (5) (5A) (5B) 0.00 5. If Line 1 + Une 3 is greater than Une 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. 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;.......................................................................................... 0 ~ b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 ~ c. retain a reversionary interest; 01'.......................................................................................................................... 0 Xi] d. receive the promise for life of either payments, benefits 01' care? ...................................................................... 0 !il 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" 01' payable upon death bank account or security at his 01' her death? .............. 0 !if 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ,~f~I1~;~I~~~;'~ 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)}. The tax rate imposed on the net value of transfers to or for ttle 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. EFORM>1 00472-0900 o PNCBAN< Your account was DEBITED for the following reason: D Check # posted on IX! Closed account 5000000441 D Branch adjustment (branch name) D Service charge error D Other: encoding error _ posted to incorrect account AMOUNT $ 7 1063.54 ~ Account Number FilelD 5000000441 040 PNC Bank, National Association FOR BANK USE ONLY Branch #/Dept. # Date 0000041 06/12/2007 o OLIVE M HUMBERT E 350 MESSIAH CIR B MECHANICSBURG, PA 17055-8620 I T Prepared By (PRINT Name) JEFF WINEKA Customer's Advice of Charge G PNC"BAN< (1411 ~t 'YANICStiURG (U41) , LAST MAIN STREET l'IEC: IANICSBURG PA 17055 Cashbox 10 AM * Deposit Check 11 :48 .:IN 12 2007 Account " ,liUer Tran Amou;"l, XXXXXX0048 $7,063.54 W/S 10 WWSHC.l' 4 Sequence Number I)00Si Batch 401 Thi, deposit or payment ;s accepted subject 'u ver ification and to th.; ,1es end regulations of 'la'-lo fnr th', udnk. Deposits ~d) rO' De aVd1 J - C im ,ediate withdrawal ~ece . ',,'ulC Dc held Ull q verified with your sta~ I~". . REV-150~ EX+ (6-98) '*' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Olive M. Humbert FILE NUMBER 21-07-0570 Indude the proceeds of litigation and the date the proceeds were received by the estate. All properly jolndy~ with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. PNC Bank Checking Account #5000000441 DESCRIPTION VALUE AT DATE OF DEATH 2. PEBTF Ambulance Service, Refund 7,063.54 880.44 3. Messiah Village, personal fund 906.21 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 8,850.19 . REVo151\ EX+ (12099>* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAl EXPENSES & ADMINIS1RATIVE COSTS ES'fATE OF Olive M. Humbert fILE NUMBER Debts of decedent must be reported on Schedule L ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Malpezzi Funeral Home 550.89 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Richard Humbert Social Security Number(s)/EIN Number of Personal Representative(s) 205-26-3372 Street Address 102 James Street 450.00 City Leola Year(s) Commission Paid: 2008 .StatePA Zip 17540 2. Attorney Fees 500.00 3. Family Exemption: (If decedent's address is not the same as c1aimanfs, 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. The Sentinel, estate notice 8. Cumberland Law Journal, estate notice 9. West Shore EMS, Ambulance Service 10. Register of Wills - Filing Fee 11. Register of Wills - Filing Account 83.00 158.62 75.00 880.44 15.00 130.00 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 2,842.95 . REV-1512 ~+ (12-03) . COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE UABlU11ES, & UENS ESTATE OF Olive M. Humbert FILE NUMBER 21-07-0570 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. State Employees Retirement System, Overpayment 113.63 2. Department of Public Welfare, Medical Assistance 93,610.89 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 93,724.52