HomeMy WebLinkAbout10-30-07 (2)
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15056051047
REV-1500 EX (06-05)
PA Department of Revenue '*
Bureau of I ndividual Taxes .
PO BOX 280601
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
County Code Year
File Number
Date of Birth
Decedent's Last Name Suffix
Decedent's First Name
MI
(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
<=)
2. Supplemental Return
<=)
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
<=)
<=) 4a. Future Interest Compromise (date of
death after 12-12-82)
<=) 7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
<=) 10. Spousal Poverty Credit (date of death <=) 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
8. Total Number of Safe Deposit Boxes
4. limited Estate
<=)
-
<=)
=~
.f---
.0;-
Correspondent's e-mail address:
Under penalties of perjury, I declare that I have examined this retum, 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.
P E FOR FILING RETURN DATE
~ ftJ. d ()
Side 1
L
15056051047
15056051047
--.Jq
r-
--1
15056052048
REV-1500 EX
Decedent's Name: M A \0\
RECAPITULATION
So 1'\
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 1'3) . . . . . . . . . . . . . . . . . . . . . . . . 14.
TAX COMP,UTATION . 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 .O~
16. Amount of Line 14,tfl~ble
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
19. TAX DUE.. .... . . ., .. .. . .. . . . .. . . .. .. ... . .. .., ... ... .. .... . . . .,. .. 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
"
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Side 2
15056052048
Decedent's Social Security Number
15.
16.
17.
18.
c::>
15056052048
--1
REV-1500 EX Page 3
File Number
Decedent's Complete Address:
DECEDENT'S NAME h
STREET~~f-77~I ,---1-C--b~ ofL_____n___~_________ H____ __m_________~~____
---------LLJ< 1 y\ cy ttt'~$----_-------~-------~----------.
CITY
o
1-----
, ZIP
0,50
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
Od~J.~D
==----~--fL5- ~4 3----
Total Credits ( A + B + C ) (2)
:11: bD
3. InterestlPenalty if applicable
D. Interest
E. Penalty
----------------- -- Total Interest/Penalty (D + E)
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.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE,
(3)
(4)
(5) 4 Cfb/ifb
(5A)
(58) J.{ ~~,~D
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.
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QU~STIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decE!dent 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 ~
d. receive the promise for life of either payments, benefits or care? ...................................................................... D ~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?' .............................................................................................................. D ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D ~
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 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 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 be~eficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfElf'S 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 thedeced,ent'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.
~._~."., '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF ~ 11 FILE NUMBER
r'\ A \', r . '- 0 n S 0 {)
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.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ITEM
NUMBER
1.
DESCRIPTION
f} D 1000 i 00 Cen\~ \e:~'('e- (}-1 {)e.~05 \\ w,1-h
C () m M e.rt;e. ~ fP.)" .
VALUE AT DATE
OF DEATH
10, 7 11.33
TOTAL (Also enter on line 5, Recapitulation) $ (f) 1 J} f "3 3
(If more space is needed, insert additional sheets of the same size)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF __ FILE NUMBER
hA~~ ~_ JO~r\e,on
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SCHEDULE F
JOINTLY-OWNED PROPERTY
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
A. \ . ~ <;~ 0 ~\<.. I" 1-< If\'~ s A ~rt\s bAl)1hre~
'.J vd'T
K.e~1U\ \ C:.s ~ V t" ~ ~ ft . 170 S Ie>
B. ~ \J 0. \ \~ 5'0~D<f1.--\<.. S f1 V't-- ~ bA- lJ r~ n:~
c.
JOINTLY.OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY 'kOF DATE OF DEATH
ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. c..o MM.e.. ~Cte- ~ P\ ~\<.. -Yo! ~ a '5' 0
~10tlClt C.e-ItT ,~\ c ~\e- o -r v~ t> So ,'1"' 1 J../ "tf, ;)..0 oo~ :3 7.3 -;).,/0
~j RJ. C b In 1\1 ~r c--e. ""BA-1\'lt< ~ 0.0 J 3 ) 9 6 '1 'if 5' :3 J.j3 ~ .crl so1c J 11/ 'Ll:J"
TOTAL (Also enteron line 6, Recapitulation) $ 6'i.s'J... 0 "
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (10-06.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
_MAR'-f 1. Jf9~'(\son
Debts of decedent must be reported on Schedule I.
FILE NUMBER
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
Co v\<. h,-U\ FuY\er-C1-..\ H(?fl\.e..
"2>0 rv ,c~es..,V\v, <2>,. .
V~l\~\\Jqv~ \ ~CL. l'10\ ~
FloWi~~1 "\~\~{f" \ M.\'OC,
t Te, "^ ,,,tv\. k\ 5'\ f'J \'\ ~r~
3fo?i~.D7
~ ~O
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
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 ~ e. ~ l ~ \" t II-- ,,~ OJ d \.>
'1101{, D 6
5. Accountant's Fees
6.
Tax Return Preparer's Fees (; (0 1l:- ( '(L; A. D ~ c: l c: E ll. G. - IT
J 1./1'7' G G CA rn A ~ I V) ST .
'~b'vt.T ~T ~VC-l~ f) 31.J<\6~
Q. oO.QC>
7.
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
"'I ;). '3 ;).~ 01
REV-1512 EX+ (12-03)
.
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
1.
"l "1'6 ,00
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
17%',v 6
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REGISTER OF WILLS CERTIFICATE OF GRANT OF LETTERS
CUMBERLAND County, Pennsylvania
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No. 2007-00785 PA No. 21- 07-0785
Estate Of: MARYIJOHNSON
t;:,,",'t'I. M,(idJr L.I/1;1'1
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Late Of:
HAMPDEN TOWNSHIP
CUMBERLAND COUNTY
., . ,"'X
Deceased
Social Security No: 201.42.6701
WHEREAS, on the 22nd da}' of .';ugust 2007 an instrument dated
August 11th 1981 was admitted to prd::ate as the last will of
MARY I JOHNSON
(First. Middle. LBSO
la te of HAMPDEN TOWNSHIP, CUMBERLAND COunry,
who died on the 15th day of August 20D~ and,
WHEREAS, a true copy of the ~,'iJ11 as probated is annexed hereto.
THEREFORE, I, GLENDAFARNERSTRASBAUGH Register of wills in and
for CUMBERLAND County, in the Commorwealth of Pennsylvania, hereby
certify that I have this day granted L,et tel'S TESTAMENTARY to:
JUDITH A SCHORK
who has duly qualified as EXECUTORfRIXI
and has agreed to administer the estate according to law, all of which
fully appears of record in my 'Office at CUMBERLAND COUNTY COURTHOUSE,
CARLISLE, PENNSYL VANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the sea
of my office on the 22nd day of August 2007.
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CA .~ ......
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* * NOTE * * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)
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tNOLD, SLIKB & BAYLEY
A1TOR.NEYS AT LAW
..oe NA...'" .'1'..1:'1'
:.UfP HIU,P.....TLVAXU t7011
LAST WILL AND TESTAMENT
OF
MARY 1. JOHNSON
I, MARY 1. JOHNSON, of the Borough of Dillsburg, York
County, Pennsylvania, declare this to be my Last Will and
Testament, hereby revoking any will previously made by me.
I - I direct the payment of all my just debts and
funeral expenses out of my estate as soon as may be practical
after my death.
II - I devise and bequeath all the rest, residue
and remainder of my estate of whatever nature and wheresoever
situate unto my issue per stirpes.
III - I appoint my daughter, Judith A. Schork,
Executrix of this my Last Will and Testament. Should my said
daughter, Judith A. Schork, fail to qualify or cease to act as
such, then I appoint my granddaughter, Lisa R. Gilbert, to act
in this capacity. Neither of my personal representatives shall
be required to post bond in this or any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
on this, the 11th day of August, 1981.
~~.~
Mary .~~hn on
(SEAL)
Pagel
~
N.~> sealed, published and declared by Mary I. Johnson,
"Testatrix therein named, on this and one (1) other sheet of
paper as and for her Last Will and Testament in our presence,
who, in her presence, at her request and in the presence of
each other, have hereunto subscribed our names as attesting
witnesses.
Nfla".# ~....IYI
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Ad res r
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A res' /
LD, SLIK.E Be BAYLEY
ATTOR.NEYS AT LAW
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KJLL,Pan.YLVAJU'" ITOII
Page 2
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COMMONWEALTH OF PENNSYLVANIA)
5S.
COUNTY
OF
CUMBERLAND)
l~, the undersigned, the testatrix and the witnesses,
respectively, whose names are signed to the foregoing instrument,
being first duly sworn, do hereby declare to the undersigned
authority that the testat ri~igned and executed the instrument
as h erLast Will and that she had signed willingly (or willingly
directed another to sign for h e~, and that s he executed it as
h erfree will and voluntary act for the purposes therein
expressed, and that each of the witnesses, in the presence and
hearing of the testat rixsigned the will as witness and that to
the best of their knowledge the testat rix was at that time
eighteen years of age or older, of sound mind and under no
constraint or undue influence.
~ ~.~
~ Testatrix)
~....~ ~... ~
Witness
~ """H./~-".' ~
Witness
Subscribed, sworn to and acknowledged before me by the
testat rix, and subwibed and swo;:a to before me by both
witnesses, this /1- day of ~~ ' 19$1( .
~cft1u~
OLD, SLIKR & EAYLBY
ATTOkNEYS AT l"'"
Thelma S. McCauslin, Notary Public
My Commission Expires July I. 1984
Camp-Hill, PA Cumberland County
tp RJl..L,Pt..-..-STLVAK"U. 110U
Cocklin Funeral Home, Inc.
30 N. Chestnut Street
Dillsburg, P A 17019
(717)432-5312
September 13, 2007
Mrs. Judith A. Schork
16 Kings Arms
Mechanicsburg, P A 17050-
The Funeral Service for Mrs. Mary I. Johnson
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
(A) OUR SERVICE:
Cremation Option # 10 . . . . . . . . . . $2500.00
FUNERAL HOME SERVICE CHARGES $2500.00
SELECTED MERCHANDISE:
White Cultured Marble. . . . . . . . . . . . . . . . . . . .
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THATYOUHAVESELECTED . . . . . . . . . . . . .
Cash Advances
Death Certificates.
Cemetery Opening
Death Notice. .
Cutting date on stone.
Cumberland Co. Coroner Auth..
Cemetery Tent. . . . . .
TOTAL CASH ADVANCES AND SPECIAL CHARGES .
Total
Total Cost .
. . . . . . . . . . . . . . . . . . . .
SUB-TOTAL
INITIAL PAYMENT / DISCOUNT / CREDITS
TOTAL AMOUNT DUE
The unpaid balance over 0 days is subjected to a 0.50 % service charge per month - 6.0000 % per annum.
Mrs. Mary I. Johnson
Page 1
$215.00
$2715.00
$42.00
$300.00
$276.07
$150.00
$25.00
$180.00
$973.07
$3688.07
$3688.07
0.00
$3688.07
Page 2 of 2
Date
09/05/2007
Account
513190785
0184021NY1 N00001846
I c,L\,e'n,.o 10
MARY I, JOHNSON
PH. 717-691.839'
'6 KJNGS ARMIS
MECHANICSSURG. PA 17050
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C:;;;;;/;;t;i;/'Jt~--r---' '-~~O~RS til 'E':-':'
..Bank .......'u.tl.Ao..eonwm.v....."
... 18<116 YFs-ooo..
993
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Check 993, $94.00 Date Presented 08/24/2007
Commerce
"Bank
Commerce Bank/Harrisburg N.A.
P.O BOX 4999
Harrisburg, Pennsylvania 17111.0999
1.888-937-0004 . ..
-.-: --
018402INY1NOOOOl846
MARY I JOHNSON
JUDITH A SCHORK
16 KINGS ARMS
MECHANICSBURG PA 17050
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We're here 7 days a week, 24 hours a day at 1-888-937-0004.
50 PLUS CHECKING
0513190785
Statement Balance as of 08/07/07
. Plus 1 Deposits and other Credits
Li!sS 1 Checks and other Debits
Statement Balance as of 09/05/07
Transactions By Date
Date
Description
Debit
Credit
Balance
09/05/07 INTEREST PAYMENT
$0.40
$3,345.91
$3,346.31
iCheck Transactions
I
Number
Date
Amount
Number
Date
Amount
Number Date
Amount
.993.'
08/24
$94.:00
Items denoted with an "E" are electronic entries and will not have a check image.
Interest Summary
002 Cycle
NOTE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION
Page 1 of 2
M..m....r "'nil":
Cotntnerce
e' ~an.l-- AmBrica's Most Convenient Banks
Dl ft 1-888-937-0004
commercepc.com
Balance infonnation reftects transactions through 6'00 PM th t b' d
and other items ere received for deposit sUbject to :::P':ViS::~e;s~yu, So, meCodeposils ~ay not ba available for immediate withdrawal. Checks
n. orm mmerclal Code or any applicable collection agreement.
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(VW1'S
63 ~ 10;48AM 09/06/07
lImE Deposit Withdrawal
c:. 301950
184 HAMPDEN CENTER
$10,711.33
::;
BR-17
3.3MM 4/07 AC
Commerce
e' ~-n,l-- America's Most Convenient Banks
~ ft 1-888-937-0004
commercepc.com
Balance information reftects transactions through 6:00 PM on thet business dey. Some deposits mey not ba evailable for immediate withdrawel. Checks
and other items are received for deposit subject to the provisions of the Uniform Commercial Code or any applicable collection agreement.
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09'/06/07
c. HH22SQ
Time Deposit Withdrawal
184 HAMPDEN CENTER
$7;464.2D
BR-17
3.3MM 4/07 AC
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