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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17128-0601
I FILE NUMBER
21
. C;;OUNIY ~OI:)I; '(EAR
SOCIAL SECURITY NUMBER
07
00746
NUMBER
198-30-2635
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGI~TERnOF WILLS
SOCIAL SECURITY NUMBER
-rr:=;-Remal"derRetum-(date of death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
o
8. Total Number of Safe Deposit Boxes
2100 Longs Gap Road
Carlisle, PA 17013
(1 )
(2)
None
None
o 4a. Future Interest Compromise (date of death after
12-12-82)
6. Decedent Died Testate (Attach copy 0 7. Decedent Maintained a living Trust (Attach
at Will) copy of Trust)
g. litigation Proceeds Received 0 1 D. Spousal Poverty Credit (date of death between 0 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
. ._......1~:~..).-91and1-1-95). . . '._
[II:IIS SI:CTI0"",.,USTBE COMPLETED..AI,.L.CQj;I"eSPQI\IDENCE. ANDCQNFIDENTIAL-Totii INFORa.4ATION-SI:IOI!LD B!O~I'lEC'I~!l IQ:
NAME COMPLETE MAILING ADDRESS
Stephen L. Bloom
PIRM NAME (It applicable)
Stephen L. Bloom, Esquire
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
I Adler, Ruth I
relATE -Of-DEATH (MM:OD-YEAR)
(3) None
(4) None
------. ----
(5) 3,820.86
----.-"----- ----
(6) 52,720.07
(7) None
(9) 16,188.60
(10) 35.62
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
>> BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH<<
Copyright 2000 form software only The Lackner Group, Inc.
DATE OF BIRTH (MM-DD-YEAR)
07/31/2007
09/12/1915
15.Amount of Line 14 taxable at the spousal tax rate, x .00 (15)
or transfers under Sec. 9116(a)(1.2)
z 40,316.71 .045 (16)
0 16.Amount of Line 14 taxable at lineal rate x
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CL 17.Amount of Line 14 taxable at sibling rate x .12 (17)
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~ 18. Amount of Line 14 taxable at collateral rate x .15 (18)
19. Tax Due (19)
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. (IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
"-rn1'
10
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LJ 2. Supplemental Return
20. ~
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
1. Original Return
4. Limited Estate
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~ELEPHONE NUMBER
I 717/249-7717
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
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(8)
fj6,540.93
(11 )
16,224.22
40,316.71
(12)
(13)
(14)
40,316.71
1,814.25
1,814.25
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET' ADDRESS
110 Hollenbaugh Road
CITY
STATE PA
ZIP 17015
Carlisle
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
1,814.25
1,800.00
90.71
Total Credits (A + B + C)
(2)
1,890.71
3. InterestlPenalty if applicable
D. Interest
E. Penalty
TotallnterestlPenalty (D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 1 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. (5)
A. Enter the interest on the tax due. (SA)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B)
0.00
76.46
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:
a. retain the use or income of the property transferred;..................................................................................
b. retain the right to designate who shall use the property transferred or its income;.......
c. retain a reversionary interest; or..................................................................................................................
d. receive the promise for life of either payments, benefits or care?.............................................................
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?................................. .............................. ......................................................
Yes No
~ I
o ~
o ~
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IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of perjury, I declare that I have examined this relum, including accompanying schedules and statements, and to the best of my knowledge and belief, It is true. correct and complete Declaration of
er~arer other than. the eersonal representative is based on..all in~rrnaticJ". of which_prepa~_has~l.k~"-wle_d2"
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
Don;:(J~ IY\ . .~
. -
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN
. Ricbard K ~:r .... ~~
~7:~REP:i?~~RES-ENfuIVE
Stephen L. Bloom
DATE
110 Hollenbaugh Road
Carlisle, PA 17015
4/~'8iT~-'
ADDRESS
187 McAllister Church Road
Qarli~leJ.PA 17Q15
//. /3-07
ADDRESS
DATE
2100 Longs Gap Road
Carlisle, PA 17013
<1/~~/DI
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 3% [72 P.S. g9116 (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 0%
[72 P.S. g9116 (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 0% [72 P.S. g9116 (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 4.5%, except as noted in 72 P.S. g9116
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 12% [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.
ADDITIONAL Personal Representatives
Estate of Ruth 1. Adler- SS# 198-30-2635
...............................................................................
Under penalties of perjury, the undersigned declare that they have examined this return,
including accompanying schedules and statements, and to the best of their knowledge and belief,
it is true, correct and complete.
Signature
x.tnU.)~ !2tkm~
Name
Address Line 1
Address Line 2
City, State, Zip
Doris Jane Adams
57 Bears School Road
Date
Carlisle, P A 17015
9bt/o 7
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEAlTH OF PENNSYL VANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Adler, Ruth I
FILE NUMBER
21 - 07 - 00746
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
1
2
3
DESCRIPTION
Members 1st Federal Credit Union - Checking Account #161577-11
Cash on Hand
TOTAL (Also enter on Line 5, Recapitulation)
VALUE AT DATE OF
DEATH
3,620.86
200.00
3,820.86
.
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
- ---
--------...__.-----
ESTATE OF
Adler, Ruth I
I FILE NUMBER
21 - 07 - 00746
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
Donna M. Stine
ADDRESS
110 Hollenbaugh Road
Carlisle, PA 17105
A
JOINTLY OWNED PROPERTY:
ITEM LETTER DATE Ilnclude name ott~~~16I~~h~tlSfl~.f~,gpb~nccount number
NUMBER FOR JOINT.JMOADNET ~or similar identifying number. Attach deed for jointly-held real
TENANT I estate.
__ ___... .____ __ __ __ __ ..____n _______
1 A 108/28/1996 Members 1st Federal Credit Union - Savings
I Account #161577-00
2
A
06/04/1998 Members 1 st Federal Credit Union - Certificate of
Deposit #161577-57
3
A
>one year Bank of America - 60 Month Fixed Term CD
#68100100996389
4
A
06/04/1998 Members 1 st Federal Credit Union - Investment
Savings Account #161577 -05
5
A
06/04/1998 Members 1st Federal Credit Union - Certificate of
Deposit #161577-40
6
A
06/04/19981 Members 1st Federal Credit Union - Certificate of
1 Deposit #161577-53
1
06/04/1998 I Members 1st Federal Credit Union - Certificate of
I Deposit #161577-54
7
A
8
A
06/04/1998 Members 1 st Federal Credit Union - Certificate of
! Deposit #161577-55
1
RELATIONSHIP TO DECEDENT
Daughter
DATE OF DE TH % OF
A DECO'S
VALUE OF ASSET IINTEREST'
154.04
DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
77.02
10,039.04 5,019.52
45,162.12 22,581.06
4,902.301 2,451.15
5,026.47 2,513.24
10,039.04! 5,019.52
10,039.04i 5,019.52
10,039.041 5,019.52
ITotal of Continuation Schedule(s)
TOTAL (Also enter on line 6, Recapitulation)
52,720.07
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Adler, Ruth I
SCHEDULE F
JOINTLY-OWNED PROPERTY
continued
FILE NUMBER
21 - 07 - 00746
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
JOINTLY OWNED PROPERTY
ITEM LETTER
NUMBER FOR JOINT
TENANT
DESCRIPTION OF PROPERTY
DATE In~lude name of financial institution and bank account number
~t~~ orjsimilar identifying number. Attach deed for jointly-held real
I ~~~.
% OF DATE OF DEATH
DATE OF DEATH DECO'S VALUE OF
VALUE OF ASSET 'INTERESTIDECEDENT'S INTEREST
9
A
'06/04/1998 Members 1st Federal Credit Union - Certificate of
Deposit #161577 -56
10,039.04!
5,019.52
Page 2 of Schedule F
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SCHEIll..E H
FUNERAL EXPENSES &
ADNINSTRATIVE COSlS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Adler, Ruth I
FILE NUMBER
21 - 07 - 00746
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER FUNERAL EXPENSES:
A. Hoffman-Roth Funeral Home, Inc.
AMOUNT
DESCRIPTION
2
Funeral Luncheon Food
3
Carlisle Memorial Service, Inc. - Tombstone
B.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
1.
Social Security Number(s) / EIN Number of Personal Representative(s):
2.
3.
Street Address
City State Zip
Year(s) Commission paid
Attorney's Fees Stephen L. Bloom, Esquire -- Stephen L. Bloom
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant Donna M. Stine
Street Address 110 Hollenbaugh Road
4.
City Carlisle State PA
Relationship of Claimant to Decedent Spouse
Probate Fees Register of Wills of Cumberland County
17015
Zip
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1
Legal Notice - The Sentinel
Total of Continuation Schedule(s)
TOTAL (Also enter on line 9, Recapitulation)
9,088.92
177.60
536.00
2,500.00
3,500.00
115.00
137.03
134.05
16,188,60
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Adler, Ruth I
Schedule H
Fu1eraI Expenses &
Aaninis1rative Cos1s ca1Iinued
FILE NUMBER
21 - 07 - 00746
2
Legal Notice - Cumberland Law Journal
3
Postage
75.00
10.25
48.80
4
Advertisement - The Sentinel
Page 2 of Schedule H
..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Adler, Ruth'
Include unreimbursed medical expenses.
ITEM
NUMBER
1
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
Members 1st Federal Credit Union - VISA Acct. #4121449991615779
DESCRIPTION
, FILE NUMBER
21 - 07 - 00746
TOTAL (Also enter on Line 10, Recapitulation)
AMOUNT
35.62
35.62
REV.1513 EX+ (9-00)
..
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Adler, Ruth I
. FILE NUMBER
21 - 07 - 00746
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
RELATIONSHIP TO
DECEDENT
Do Not List Trustee(s}
AMOUNT OR SHARE
OF ESTATE
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1
Donna M. Stine
110 Hollenbaugh Road
Carlisle, PA 17015
i Daughter
1/3 Residuary
2
Richard E. Adler
187 McAllister Church Road
Carlisle, PA 17015
Son
1/3 Residuary
3
Doris Jane Adams
57 Bears School Road
Carlisle, PA 17015
Daughter
1/3 Residuary
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
IA. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
. BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS