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Home My WebLink About11-16-07 (2) ....J 15056051047 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 Year File Number INHERITANCE TAX RETURN RESIDENT DECEDENT 2 1 o 7 00315 Date of Birth 201188984 03 9 200 7 o 4 2 7 1 9 2 6 Decedent's Last Name Suffix Decedent's First Name MI LEV E S QUE D 0 ROT H Y M (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 c:::;::) 4. Limited Estate c:::;::) 3. Remainder Retum (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 'R 1. Original Return c:::;::) 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) c:::> 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 ~ULD BE DIRE@D TO: Name Daytime Telepho~ber -.I =:n I~ i-;l~ Z rT10 7 1?~~~J;;8 ~2 8r~ ~ REGISTER ~ m~USE C8l)\ :i.J ::-S -.J C) () C' ,~, 0 -.- "oJ 0-"- 11 :x .,- =R ~~ :n ;~~~ 0 ~-i (; m - . ~ .9!"J c:::> 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received .JL 8. Total Number of Safe Deposit Boxes ti K E I T H O. B R E N N E.MA N Firm Name (If Applicable) S N E L B A K E R & B R E N N E MAN, P C First line of address 4 4 WE S T M A N S T R E E T Second line of address City or Post Office State ZIP Code DATE FiLED M E C H A N I C S BUR G P A 1 705 5 Correspondent's e-mail address: I declare that I have examined this retum, including accompanying schedules and statements, and to the best of my knowledge and belief, lete. laratlon of pr parer 0 than the personal representative is based on all information of which preparer has any knowledge. RETURN . , ExeCJ~ tor.__._.._~~._-~:~:.!.:!i4t- PA 17055 ~ DATE II. 1~/o? SIG Main Street, Mechanicsburg. PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 -.J 0/ ~ 15056052048 REV-1500 EX Decedent's Name: Dorothy M. Levesque 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 undi;:fec. 9116 (a)(1.2) X .0_ 7 9 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 15. 16. 17. 18. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056052048 2 0 1 Decedent's Social Secu rity Number 1 8 8 9...J3.__~_ . . 1 ,9 3 9 .8 8 7 ,3 4 7 . 7 1 6 ,2 2 9 .4 2 3 ,7 1 0 .5 5 1 5 .0 0 3 ,7 2 5 5 5 91 7 9 1 .4 6 1 7 9 1 .4 6 4 ,1 3 0 .6 2 4 , 1 3 0 .6 2 C::::l 15056052048 ---I REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-07-00315 DECEDENT'S NAME Dorothy M. LeVesque STREET ADDRESS 20 North 12th Street CITY I STATE I ZIP Lemoyne PA 17043 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 4,130.62 3,900.00 195.00 Total Credits ( A + B + C ) (2) 4,095.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( 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) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5) (5A) (5B) 35.62 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. 35.62 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 lXJ b. retain the right to designate who shall use the property transferred or its income; ............................................ D lXJ c. retain a reversionary interest; or.......................................................................................................................... D lXJ d. receive the promise for life of either payments, benefits or care? ...................................................................... D IX] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. D lXJ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D lXJ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ lXJ 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 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. REV-1508 EX+ (8-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Dorothy M. LeVesque FILE: NUMBER 21-07-00315 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 2. Refund, prescription expense payment VALUE AT DATE OF DEATH $ 350.00 1,400.50 1. DESCRIPTION Miscellaneous personalty, furniture and furnishings 3. U.S. Savings Bond - $50.00 58.38 4. Refund - Manorcare Nursing Home 131 . 00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 1,939.88 REV-1509 EX+ (6-98* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTlY-OWNED PROPERTY ESTATE OF FILE NUMBER Dorothy M. LeVesque 21-07-00315 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 A. Ray K. LeVesque ADDRESS RELATIONSHIP TO DECEDENT 213 North Market Street Mechanicsburg, PA 17055 Son 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 DECEDENT'S INTEREST 1. A. ':>/15/2OCJ) Commerce Bank Checking Account No. $14,695.41 50% 7,347.71 513174441 TOTAL (Also enter on line 6, Recapitulation) $ 7 , 347 . 71 (If mDre 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 FILE NUMBER Dorothv M. LeVesque 21-07-00315 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 INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT ANO DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE OATE OF TRANSFER. ATTACH A COPY OF THE DEEO FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. Bankers Life and Casualty Company annuity 13,834.55 100% - $13,834.5 Policy No. 7,761,996. Transferee: Ray K. LeVesque, son. Date of transfer: March 9, 2007 (date of death) 2. Bankers Life and Casualty Company annuity 72,394.87 100% - 72,394.8 Policy No. 7,760,270. Transferee: Ray K. LeVesque, son. Date of transfer: March 9, 2007 (date of death) TOTAL (Also enter on line 7 Recapitulation) $ 86,229.42 5 7 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06l_ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Dorothy M. LeVesque FILE NUMBER 21-09-00315 Debts of decedent must be reported on Schedule L ITEM NUMBER A FUNERAL EXPENSES: 1. DESCRIPTION AMOUNT B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Waived Street Address City State _Zip Year(s) Commission Paid: 2. Attorney Fees to Snel baker & Brenneman, P. C. 2,400.00 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 to Register of Wills 84.00 6. Accountant's Fees , filing fees, reserve T~OOK~f~x Advertise a. Cumberland Law b. The Sentinel: miscellaneous Estate expenses, 5. 1,000.00 7. grant of Letters Testamentary Journal: $ 75.00 151.55 Total: 226.55 TOTAL (Also enter on line 9, Recapitulation) $ 3, 710.55 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dorothy M. LeVesque FILE NUMBER 21-07-00315 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. 2006 Pennsylvania Income Tax due: $ 15.00 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 15.00 REV-1513 EX+ (9-00) SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF D . M L<>Ve.'?nue NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] Ray K. LeVesque 213 North Market Street Mechanicsburg, PA 17055 son NUMBER I RELATIONSHIP TO DECEDENT Do Not List Trustee(s) 2. Thor M. LeVesque 1101 A1dwe11 Drive Redmond, VA 23225 grandson FILE NUMBER 21 07 00315 AMOUNT OR SHARE OF ESTATE 1/2 residue of Estate 1/2 residue of Estate 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 (If more space is needed, insert additional sheets of the same size) TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ of: JAMES M. BACH Attorney-At-Law LAST WILL AND TESTAMENT FOR DOROTHY M. LEVESQUE __ ___.I =.-- - .. -~~ ~..~...., .L......,.L ~ "~'J..LJ~" J.. 1. UCICUY reVOKe, cancel and annul all my former Wills and Testaments, including codicils thereto, by me at any time made, and declare this alone to be my LAST WILL AND TESTAMENT. AS TO SUCH ESTATE IT HAS PLEASED GOD TO ENTRUST ME WITH IN THIS LIFETIME, I DISPOSE OF THE SAME AS FOLLOWS, VIZ: ITEM 1. I direct that my Executors hereinafter named, pay and discharge all of my just debts, funeral and testamentary expenses. ITEM 2. I order and direct that I be buried in a lot that I own situated at the Rolling Green Cemetery, Camp Hill, Pennsylvania. ITEM 3. All the rest, residue and remainder of my entire estate, wheresoever situate, and whatsoever it may consist of, I give, devise and bequeath, absolutely, and in fee, to my dearly beloved son RAY K. LEVESQUE and my dearly beloved grandson THOR M. LEVESQUE, share and share alike, per stirpes. ITEM 4. I nominate and appoint RAY K. LEVESQUE as Executor of this my LAST WILL and TEST AMENT. Should the Executor herein named fail to qualify or cease to act as Executor, then I appoint THOR M. LEVESQUE as Executor in his stead. ~~ 1>7 )l~~J DORO Y M. LEVES Page 2 of 3 purposes, whether or not such property passes under this LAST WILL, shall be paid by my Executor out of my residuary estate. ITEM 7. I grant to my personal representatives herein named, in addition to, but not in limitation of those powers vested by law, to be exercised without prior application to or approval of any court, the power and authority to retain indefinitely any property, to invest and reinvest any assets or the proceeds derived from the sale of assets, although said investments may not be of the character prescribed by law, to sell, convey, assign, transfer and encumber any property, to pay, settle or compromise all claims, to make distribution or divisions in cash or in kind, and in general to exercise all powers in the Page 3 of 3 I i ! r~ E 111; 1') f,t ii"', t.:f I:';; \~;~~1" t: ",; ~~:t iJ:: t: ('1.-,' r; ~. ;~'; " u~ ,;':' " ;'\;' i:i: t:; r.. I... C f., /; ~: r ~;i' i: ! :\ fi !~ I' ( management of any property hereunder which any individual could exercise in the management of similar property owned in his own right, and to execute and deliver any and all instruments and to do all acts, which may be deemed necessary and proper. /fl~~ M Lr~.u) D, OTHY M. LE l SQUE ~A~~f~% ~ rfJ~ ARAB J. OBERTS SUZ6 E T. POWER WILL; that I signed it willingly; and that I signed it as my free and voluntary act for the purpose therein expressed. ~;r4tli~\ :. ~~h, ~ JM1fs M. BACH, ESQUIRE NOTARY PUBLIC Mechanicsburg, P A 17050 My Commission Expires: 05/13/03 Sworn to or affirmed and acknowledged before me, by: , the TEST A TRlX thi.s 12th day of April, 2001. NOfAllAl, ... JAMs M.!AOt ~ NrIc ~r..~~ ~~(~~~~ 1k.y 1:J.. 200$ "'- ----===--.." '"",',. MOf$Al.~__..I...IL ";-';~~M.~' ~"O;., ~~t~~lJ,~ ,., ~ =~-",....."'. ~ _~~-:-;~.,,"'Gr;'~".,,'~""- . AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA) ) ss COUNTY OF CUMBERLAND ) We, SARAH J. ROBERTS and SUZANNE T. POWER, the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the TEST A TRIX sign and execute the instrument as his LAST WILL; that the TEST A TRIX signed it willingly and that he executed it as his free and voluntary act for the purpose therein expressed; that each witness in the hearing and sight of the TEST A TRIX signed the WILL as witnesses; and that, to the best of our knowledge, the TESTATRIX was, at the time, 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn to or affirmed and acknowledged before me, by: SARAH J. ROBERTS and SUZANNE T. POWER, witnesses, this 12th day of April, 2001. r; WITNESS: I ,l/., ,. YCl,:Ie-Z.t,' SARAH . ROBERTS WITNESS: ~~ r; P""'-"J SUlA!,' NE T. POWER 4-t~ J ES M. BACH, ESQUIRE OTARY PUBLIC Mechanicsburg, P A 17050 My Commission Expires: 05/13/03