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HomeMy WebLinkAbout11-01-07 (3) o .-J 15056051058 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 INHERITANCE TAX RETURN . 'Ii RESIDENT DECEDENT ~ OFFICIAL USE ONLY County Code Year 0& File Number 0%:::>'"---'1 Date of Birth 195-07 -9378 08/29/2006 05/04/1918 Decedent's Last Name Suffix Decedent's First Name MI Dyblie Harry G (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WillS FILL IN APPROPRIATE OVALS BELOW ce> 1. Original Return c:::> 2. Supplemental Return c:::> 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return ReqUired 4. Limited Estate 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. Litiga!ion Proceeds Received 8. Total Number of Safe Deposit Boxes Patricia D. Arcuri , (717) 542-9642 Firm Name (If Applicable) REGISTER OF WilLS USE OKI.:Y i .._-,) First line of address City or Post Office State ZIP Code 950 Gleneagles Drive Second line of address York Pa 17404 Correspondent's e-mail address: 1/ Yo /Ce ;P'/l. DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051058 15056051058 ....J l~\ ~ -.J 15056052059 REV-1500 EX Decedent's Name: Harry G Dyblie 195-07 -9378 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) c::::; 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 45 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 15056052059 Side 2 L Decedent's Social Security Number 0.00 0.00 0.00 0.00 85,098.02 13,010.20 0.00 98,108.22 7,215.87 4,843.64 12,059.51 86,048.71 0.00 86,048.71 15. 16. 3,872.19 17. 18. 3,872.19 15056052059 -.J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME Harry G Dyb/ie STREET ADDRESS 1700 Market Street DECEDENT'S SOCIAL SECURITY NUMBER 195-07 -9378 CITY Camp Hill STATE Pa ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 3,872.19 3,250.00 171.05 Total Credits (A + 8 + C ) (2) 3,421.05 3. InterestJPenalty if applicable D. Interest E. Penalty TotallnterestJPenalty ( 0 + 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) 3,421.05 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (58) 451 .14 13.43 464.57 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;.......................................................................................... Iil 0 b. retain the right to designate who shall use the property transferred or its income; ............................................ Iil 0 c. retain a reversionary interest; or.......................................................................................................................... 0 [i] d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [i] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. Iil 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. Iil 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 Iil 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 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. g9116(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. .REV-1502 f'X+ (6-98) SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER JI/9~~ yr;;. JJy gLIC o? / -t/? - t/ K~-,/ All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH none 0.00 TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF JI/l/Z.~ y FILE NUMBER C;. .J)Yt3Lle d/-cJ? - O?sy All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION None: The decedent was the joint owner of certain municipal bonds disclosed on schedule F VALUE AT DATE OF DEATH 0.00 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 REV-1508 EX+ (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF t//l121! Y ~,..2> YBL/E: 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. FILE NUMBER 02/-tJt:, - o~sy ITEM NUMBER DESCRIPTION 1 Miscellaneous clothing 2 Miscellaneous furniture (lived in a nursing home) 3 Photographs and military service medals 4 Casette Recorder and tapes 5 Suit Case 6 Cane and Walker 7 Bulova Wristwatch 8 Telephone, lamp, portable tv VALUE AT DATE OF DEATH 25.00 450.00 25.00 10.00 5.00 10.00 5.00 15.00 D 37,353.02 50,200.00 9 M&T Bank Account (#15004211801756) opened 12/10/04 at Queen Street Branch, York, Pa, title as O~+rii"i-:':l n /!,.,.."r-i.. /J.TJ:).J~,.nl Ov:hHQ 10 M&T Bank COD (12 mos) opened 7/14/06 title Patricia D. Arcuri ATF Harry Dyblie LE..5S ~ tJpO, ~O GIFT EX. CLU.51 ~Ai TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 80,098.02 15'; iP! '1, ocL.. REV-1509 EiX+ (6-9B* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF Harry G. Dyblie FILE NUMBER 21-06-0854 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A Patricia D. Arcuri 950 Gleneagles Drivwe Daughter B. C JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A. 04/29/99 Checking Account M&T Bank #~1 (Highland Park Branch) 10,258.33 50 5,129.16 ::P./~?/)371 2 A 04/29/99 Morgan Stanley Custodial Acct, 410-051698 Morgan Stanley, H-burg, Pa 15,560.10 50 7.78005 3 A 04/29/99 Liquid Asset Morgan Stanley #410-051698 201.97 50 100.99 TOTAL (Also enter on line 6, Recapitulation) $ 13,010.20 (If more space is needed, insert addHional sheets of the same size) REV-1510 E;X+ (6-98) to '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF I-I/l,e IG .y FILE NUMBER 6' / -e::Jt - t:' 9 ~y- 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. t;,. ..J) 'I eLl € DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RElATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. Disclosure has been made on other schedules TOTAL (Also enter on line 7 Recapitulation) $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99)* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Harry G. Dyblie FILE NUMBER 21-06-0854 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUN I:RAL I:XPI:NSI:S: Parthemore Funeral Home, New Cumberland, PA asset reported-amount shown reflects actual sums Notice, York Daily Record Notice, Patriot Relationship of Claimant to Decedent State !PA B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Patricia D. Arcuri Social Security Number(s)/EIN Number of Personal Representative(s) Street Address 950 Gleneagles Drive 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant City 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Administratrix Notice, Carlisle Sentinel 8. Funeral luncheon, Radisson, Camp Hill, PA 9 Nonna's Restaurant, New Cumberland, PA-pre-viewing meal for out of town family 10 Olde Town Florist, New Cumberland, PA TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of the same size) REV-1512 EX' (12-03) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF Harry G. Dyblie FILE NUMBER 21-06-0854 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. Holy Spirit Hospital, Camp Hill, PA service on 6/02/06 28.00 2. Holy Spirit Hospital, Camp Hill, PA corrected billing for 5/15/05 service 241.05 3. Moffitt-Smith Furniture, Mechanicsburg, PA for repair of chifferobe 938.10 4. Phi/haven, Mt. Gretna, PA for psychiatric services at Manor Care Nursing Home, Camp Hill, PA 37.72 5 AT&T Universal Card 545.00 6 Reimburse Social Security for final month 7 Holy Spirit Hospital, Camp Hill, PA service on 02107/06 1,302.00 251.77 8 Legal consultation regarding estate planning and regarding lawsuit 1,500.00 9 Decedent is defendant in personal injury lawsuit in Cumberland County at Case NO. 06-4069 Civil Samantha Baker v Harry Dyblie and decedent is represented by Dickey, McCamey and Chilcote, Camp Hill, PA TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 4,843.64 REV-1513 EX' (9-00) SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Harry G. Dyblie FILE NUMBER 21-06-0854 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Nol List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (12)] Patricia Dyblie Arcuri, 950 Gleneagles Drive, York, PA 17404 Daughter 100 % 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 additional sheets of the same size)