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Home My WebLink About10-10-07 -1 15056041147 REV-1500 EX (06-05) PA Department of Revenue Bureau of Individual Taxes PO BOX.280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICIAL USE ONLY . County Code INHERITANCE TAX RETURN 21 RESIDENT DECEDENT Year File Number 07 0544 Date of Birth 185035439 05232007 04161916 Decedent's Last Name UNDERKOFFLER Suffix Decedent's First Name ADA MI B (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 IS! 1. Original Return 0 2. Supplemental Return 0 4. Limited Estate 0 4a. Future Interest Compromise (date of death after 12-12-82) IS! 6. Decedent Oied Testate 0 7. Decedent Maintained a Living Trust (Attach Copy of Will) (Attach Copy of Trust) 0 9. Litigation Proceeds Received 0 1 0 Spousal Poverty Credit (date of death . between 12-31-91 and 1-1-95) 3. Remainder Return (date of death prior to 12-13-82) o 5. Federal Estate Tax Return Required o 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (Attach Sch. 0) ~ORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: ame Daytime Telephone Number JEAN D SEIBERT 7172369301 Firm Name (If Applicable) WION, ZULLI AND SEIBERT REGISTE~;~ WILLS t;l~ ONLY" Cj (' , " --..I c.:::: First line of address 109 LOCUST STREET Second line of address --" City or Post Office HARRISBURG State PA ZIP Code 17101 \-) . _:~.J D;6.T~ FILED ~'; (...J . wzs@mindspring.com 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 OR FILING RETURN DATE Gerald L. Underkoffler (7 -S--Z1Jt') 17257 Jean D Seibert 109 Locust Street, Harrisburg, PA 17101 L Side 1 15056041147 15056041147 -1 --.J 15056042148 REV-1500 EX Decedent's Name: UNDERKOFFLER, ADA B 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) 0 Separate Billing Requested............. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) 0 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. Decedent's Social Security Number 185035439 26,038.19 69,921.08 95,959.27 ---- -----. ----- 6,026.42 227.29 6,253.71 89,705.56 ----_.-..,._._~----~~-_. -_._...._~--~._--------_._._--~._-- 89,705.56 TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, of transfers under Sec. 9116 (a)(1.2) X ~ 16. Amount of Line 14 taxable at lineal rate X .045 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 15. 89,705.56 16. 17. 18. 19. Tax Due....... ................. ......................................................................... .................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. L Side 2 15056042148 4,036.75 4,036.75 o 15056042148 --.J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 - 07 - 0544 Underkoffler, Ada B -- ~- -- - -- ----- ----- STREET ADDRESS 129 Walnut Bottom Road - --_..~._--._---_..._--_.__._._. ...~-_.- -----._----,------- CITY Shippensburg -------.~-- -----~~TSTATEn -------,zlfj----------- PA I 17257 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1 ) 4,036.75 3,835.46 ---'---- 201.84 3. InteresUPenalty if applicable D. Interest E. Penalty Total Credits (A + 8 + C) (2) 4,037.30 TotallnteresUPenalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. 8. Enter the total of Line 5 + SA. This is the BALANCE DUE. (3) (4) (5) (SA) (58) 0.00 0.55 0.00 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;.................................................................................. I.J b. retain the right to designate who shall use the property transferred or its income;.................................... IJ c. retain a reversionary interest; or.................................................................................................................. [J d. receive the promise for life of either payments, benefits or care?.............................................................. [I 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?................................................... ................................................. .................. 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation?...................................................................................................................... x I IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. No I-xl ._1 IxJ Ii] f.':-1 I ~J x i IX 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. 99116 (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. 99116 1.2) [72 P.S. 99116 (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. 99116 (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. *' .- .~.~~.------.L SCHEDULE D I MORTGAGES & NOTES RECEIVABLE i L__.__ _______ ------r=. --. ---.-..----.---- ---- i FILE NUMBER _ -___u_i 21 - 07 - 0544 ----~"-_.-.._.__.__.._- COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Underkoffler, Ada B All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER --~---"------"-- - -------.-------...-------- . --,._-------------- ---.-----------.--..--...--- ..- DESCRIPTION VALUE AT DATE OF DEATH 26,038.19 1 Note from Joseph and Amy Underkoffler to Ada B. Underkoffler -~--- ..---..-------.--- --_._-_.._-.._-~-..__..---.._._-----_._.._-_..-.._.__.,.-.-----....--- TOTAL (Also enter on Line 4, Recapitulation) 26,038.19 *' SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Underkoffler, Ada B FILE NUMBER 21 - 07 - 0544 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 DESCRIPTION VALUE AT DATE OF DEATH 1,859.19 1 F&M Trust Checking Account No. 34-97704 2 Acrrued interest to date of death 0.52 3 F&M Trust Money Market Account No. 70-71167 66,670.78 4 Acrrued interest to date of death 198.03 5 06-22-07 Rothermel Funeral Home Refund 484.68 6 07-19-07 Outlook Pointe Senior Care Refund 634.00 7 08-20-07 Hershey Foods Health Care Plan B Refund 36.13 8 08-20-07 F&M Trust Refund for overcharged on check printing 37.75 9 TOTAL (Also enter on Line 5, Recapitulation) 69,921.08 . SCt-EDU..E H FLtERAL. EXPENSES & ADMNIS1RATIVE COS1S COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Debts of decedent must be reported on Schedule I. -------~--_._~._._- -_..~.~-~._.~_.._--_._.- ITEM NUMBER FUNERAL EXPENSES: ------ A. 1 Gingerich Memorials FILE NUMBER 21 - 07 - 0544 ESTATE OF Underkoffler, Ada B DESCRIPTION 700.80 AMOUNT 2 j Hoss - funeral luncheon I I 572.72 B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Social Security Number(s) I EIN Number of Personal Representative(s): Street Address City Year(s) Commission paid Attorney's Fees Wion, Zulli & Seibert State Zip 2. 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant 4,000.00 Street Address City Relationship of Claimant to Decedent State Zip 4. Probate Fees Register of Wills 248.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1 Advertising 209.50 Sentinel TOTAL (Also enter on line 9, Recapitulation) 6,026.42 *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Underkoffler, Ada B 2 Cumberland Law Journal 3 I Patroit News - Ad for wheelchair I Check Printing charge Schedule H Funeral Expenses & Mninistrative Cos1s continued 6 Reserve for copies, postage, long distance telephone calls, notary fees i FILE NUMBER 21-07-0544 75.00 58.65 61.75 25.00 75.00 4 5 Advertising for Medical Equipment Page 2 of Schedule H . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Underkoffler, Ada 8 Include unreimbursed medical expenses. ITEM NUMBER SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS I FiLE NUMBER [21_ - 07 - 0544 - ._---~-_._---~-._..- -'--~-'-"-_.__.,- DESCRIPTION - -----.-------.------. --... --.. ----- ..--- 06-06-07 CP02 - Wheelchair rent --...-------.-----------.----.------ -.-.-....--.. 2 06-06-07 Chase Card - prescriptions 3 07-19-07 West Shore EMS . --,.. ---._---._-------- --------------..-...----.--------..----- TOTAL (Also enter on Line 10, Recapitulation) AMOUNT 36.54 132.10 58.65 227.29 REV-1513 EX+ (9-00) . SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Underkoffler, Ada B FILE NUMBER 21 - 07 - 0544 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) -r I NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY __ ____.n SHARE OF ESTATE (Words) TAMOUNTClF E-ST ATE -l n(~J I I I I. 'I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers , under Sec. 9116 (a) (1.2)] 1 I Gerald L. Underkoffler, 301 North Prince . Street, Shippensburg, PA 17257 Step-Son 1/3 2 Joanne M. Lytle, 1 Hollinger Lane Elizabethtown, PA 17022 Step-Daughter 1/3 3 Linda Crider, 54 West Broad Street, Souderton, Step-Daughter PA 18964 1/3 !Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet II. NON-TAXABLE DISTRIBUTIONS: fA. 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 0.00 ~-_'~--_"_----~._---,.~_.,____ '.________n_________ _.,_.__...., LAW OFFICES ~!l~. & Q/akt DAVID A. WION FRANCIS A. ZULLI JEAN D. SEIBERT 109 LOCUST STREET P.O. BOX 1121 HARRISBURG, PENNSYLVANIA 17108-1121 (717) 236-9301 (717) 232-1488 FAX (717) 236-6100 Email: wzs@mindspring.com .. 1. 4'lf1fJ7 VICTOR A. BIHL OF COUNSEL 113 EAST MAIN STREET HUMMELSTOWN, PA 17036 (717) 566-2501 Estate of ad&-. 6 ~ ~C'f:J~4'; . Date of Death ';11b./f- ;;3, -ijJ?{1 7 d- IctL dcl-L. J!:5A.O'nA..L.. :?' YLdL-J$-;f~./L.J Checking Accounts: Number Date Opened Balance at Date of Death Int. to Date of Death Joint Owner, if any Savings Accounts: Number Date Opened Balance at Date of Death Int. to Date of Death Joint Owner, if any Certificates of Deposit: Number Date Value at Date of Death Int. to Date of Death Joint Owner, if any Maturity Date Interest Rate Interest Paid Quarterly, Semi-Annually, etc. Debts: 1 :3t..1- q 'l70L-} ~~ J~~I~~ ~ 0 . 51- IN tH \J I Dl.LAc.. A-eL-r 1 1 F ~ M l(u..~+. Name of Bank or Savings Association Date: & 112...1al 2 (M~~\l.L-\~ '10- "-'/Ilo'l &Co. <0 10. ~~ J qg. 03 IlJl)l v I uUA-U MCf 2 2 Others: 3 3 3 J((lhQkl ~&urYJ Signature an Title of Bank or Savings Association Official \<6J...v e. V\. ~D CA...\i is ~~ PI oc~s~4 C\ftrQ~\'.^^a..M.~1R.. I- (. U TVU.&+.. "..---<--_s 1'Inst ~Till nuh ijtesmmeut of ADA B. UNDERKOFFLER 11 eittg of ~ounb ~ittb, over eighteen years of age, QJld a resident of the State of Florida, I make, pub1ish and declare this instrument to be my Last Will and Testament, hereby revoking all wills and codicils previously made by me. ~it9t, the expenses of my funeral, buria~ or other disposition of my remains I may have directed, my just debts, and the costs of administering my estate shall be paid out of the residue of my estate. ~etottb, I give and devise all the rest, residue, and remainder of my property of every kind and wherever situated, as follows: To my husband, LEROY H. UNDERKOFFLER, or if he does not survive me, then to my stepchildren, LINDA CRIDER, JOANNE M. LYTLE and GERALD L. UNDERKOFFLER, or to the survivors of them. * * * C,:,.' WIritb, My~sonal Representative has full power and authority to sell, transfer and convey any property in m:Yestate, real or personal, upon such terms and conditions as my Personal Representative deems best. No bond shall be required of my Personal Representative. My husband, LEROY H. UNDERKOFFLER, My stepson, GERALD L. UNDERKOFFLER, if the person first appointed fails to qualify or ceases to act. shall.be my Personal Representative. shall be my Personal Representative !wtt Imn ~trtm inhirlltmg gentler sJraU indubr all B'nbrn aub mplm -'raIl indube plUTaI, d. fire andul uquitrt... ~tt ~ihtellll ,-qereof, I have hereunto subscribed my name and affixed my seal on this date of Auqust <; 1994. ,2 .i/~ 2.:;: ;;:i l&tf.i i-:{Pt-'I../ ADA B. UNDERKOFFLE~ . Testator e ~ e lIerehtt ([erlifll, that the foregoing instrument was, on the date thereof, signed, published and declaredby the above named Testator, as said Testator's Will in our presence, and we, at Testator's request, in Testator's presence and in the presence of each other, have signed our names as witnessess, on the same date. (-->i?l,A<:r~/ n /-lr;;l'/n;rl y;d~r~~'^-Lflld~ , of Pinellas County, Florida. , of Pinellas County, Florida. 6572 Seminole Bmllp.vRrrl. ~"ItA Q ........_ T ___1 "_-4_.._ .,<3(V\ .~_:_ ~..___.. ........._ . ~ :t>~e 2\000