HomeMy WebLinkAbout12-13-07
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REV"500 EX (6-00,
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21 07
0347
COUNTY CODE YEAR
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
COPPENS DIANE MARIE
NUMBER
DATE OF DEATH (MM-DD-YEAR)
03/17/07
DATE OF BIRTH (MM-DD-YEAR)
02/14/64
SOCIAL SECURITY NUMBER
163-60-2125
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
COPPENS DANIEL J.
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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~ 1. Onginal Return
o 4. Limited Estate
o 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after 12-12.82)
o 7. Decedent Maintained a Living Trust (Attach copy ofTrust)
o 10. Spousal Poverty Credit (date of death between 12.31-91 and 1-1-95)
o 3. Remainder Return (date of dealh prior 1012-13-82)
o 5. Federal Estate Tax Return Required
8. Totai Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
KARL M. LEDEBOHM, ESQUIRE P.O. BOX 173
FIRM NAME IlfApplicable) NEW CUMBERLAND, PA 17070-0173
TELEPHONE NUMBER
(717) 938-6929
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)
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IX:
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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)
(1)
(2)
(3)
(4)
(5)
104,851.94
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24,272.87
(6)
2,740.05
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131,86~.86
(7)
0.00
(9)
(10)
(8)
17,159.26
88,013.82
(11)
(12)
(13)
105,173.08
26,691.78
0.00
\.0
(14)
26,691.78
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
Z 15. Amount of Line 14 taxable at the spousal tax
0 26,691.78 x.oL
i= rate, or transfers under Sec. 9116 (a)(1.2) (15)
~ 16. Amount of Line 14 taxable at lineal rate x.O_ (16)
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0- 17. Amount of Line 14 taxable at sibling rate x .12 (17)
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0 18. Amount of Line 14 taxable at collateral rate x .15 (18)
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>< 19. Tax Due (19)
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20.0
0.00
0.00
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
. Decedent's Complete Address:
STREET ADDRESS
813 NORTH WALNUT STREET
CITY MECHANICSBURG I STATEpA I ZIP 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
0.00
Total Credits ( A + 8 + C ) (2)
0.00
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenally ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
Make Check Payable to: REGISTER OF WILLS, AGENT
(5A)
(58)
0.00
0.00
0.00
0.00
0.00
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.
8. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
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;.......................................................................................... 0
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0
c. retain a reversionary interest; or..... ......................................... ...................................... ................................. ..... 0
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ................................................... ..................................... .................... ............ ~
No
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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 infonnation of which preparer has any knowledge.
SIG JURE O~ PERSON RSlf'ONSIBLE FOR FILING RETURN
ac..-JI L ~.
ADDRESS
813 NORTH
SIGNATUR F.
DATE
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ADDR S
P. . BOX 173, NEW CUMBERLAND, PA 17070-0173
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DATE
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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. 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 ;s 0% [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 0% [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 4.5%, 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 12% [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 EX+ (6-98)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF
DIANE MARIE COPPENS
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.
FILE NUMBER
21-07-0347
ITEM
NUMBER
1.
DESCRIPTION
813 NORTH WALNUT STREET, MECHANICSBURG, PA 17055
(Fair market value based upon assessment of 92,060.00 at a common Jevel
ratio of 87.8%)
VALUE AT DATE
OF DEATH
104,851.94
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
104,851.94
REV-1!;08 EX+ (6-98)
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
DIANE MARIE COPPENS
FILE NUMBER
21-07-0347
ITEM
NUMBER DESCRIPTION
1. MISCELLANEOUS CLOTHING
2. WEDDING RING AND BAND
Indude 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.
3. 2006 KIA SPORTAGE (545 miles - purchase price is reflected)
VALUE AT DATE
OF DEATH
120.00
300.00
21,800.00
1,817.78
46.00
189.09
4. FINAL PAYCHECK FROM PINNACLE HEALTH
5. REFUND FROM THE LOMIS COMPANY
6. REFUND FROM THE LOMIS COMPANY
7. UNLIQUIDATED WRONGFUL DEATH/NEGLIGENCE CLAIM PENDING
( A SUPPLEMENTAL RETURN WILL BE FILED AS NEEDED)
unknown
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
24,272.87
REV-'S09 EX+ (6-98.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
DIANE MARIE COPPENS
FILE NUMBER
21-07-0347
SURVIVING JOINT TENANT(S) NAME
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
A. DANIEL J. COPPENS
ADDRESS
RELATIONSHIP TO DECEDENT
813 NORTH WALNUT STREET
MECHANICSBURG, PA 17055
SPOUSE
B.
C.
JOINTLY-OWNED PROPERTY:
LEITER 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 DECO'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTlY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 9/26/96 DEPOSIT ACCOUNT HELD AT WACHOVIA BANK, N.A. 5,480.10 50 2,740.05
(BANK STATEMENT ATTACHED AS EXHIBIT A AND MADE
PART HEREOF)
TOTAL (Also enter on line 6, Recapitulation) $ 2,740.05
(If more space is needed, Insert additional sheets of the same size)
REV-'510 EX+ (6-98.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
DIANE MARIE COPPENS
FILE NUMBER
21-07-0347
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.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RElATIONSHIP TO DECEDENT AND
NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPliCABLE) VALUE
1. Prudential Retirement Account Plan No.: 300047 23267.21 100% 72 P.S. 0.0
Beneficiaries: Daniel J. Coppens (spouse), Section
John Kubeika (nephew) and Candice Gill (niece) 9111(r)
2.
Liberty Mutual Life Insurance policy no.: SA3-830-0501228-01 30000.00 72 P.S. 0.0
Beneficiary: Daniel J. Coppens (Spouse) Section
9111(d)
TOTAL (Also enter on line 7 Recapitulation) $ 0.0
(If more space is needed, insert additional sheets of the same size)
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REV-1511 EX+ (12-99)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
DIANE MARIE COPPENS
FILE NUMBER
21-07-0347
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. MALPEZZI FUNERAL HOME ( itemization is attached as exhibit "B" and made part hereo~ 7,874.82
2. Gingrich Memorials - Grave marker. 810.00
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B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City State _Zip
Year(s) Commission Paid:
2. Attomey Fees 4,000.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 3,500.00
Claimant DANIEL J. COPPENS
Street Address 813 NORTH WALNUT STREET
City MECHANICSBURG State ~Zip 17055
Relationship of Claimant to Decedent SPOUSE
4. Probate Fees 310.00
5. Accountant's Fees
6. Tax Return Preparer's Fees 165.00
7. FINAL LIVING INCOME TAX RETURNS TO JOHN COX, CPA
7. INHERITANCE TAX REVIEW TO TOM FLOWER, ESQUIRE 80.00
8. ESTATE PUBLICATION FEE TO THE SENTINEL 164.44
9. ESTATE PUBLICATION FEE TO CUMBERLAND LAW JOURNAL 75.00
10. FEE TO REGISTER OF WILLS TO FILE FIRST & PARTIAL ACCOUNT AND ADVERTISE 180.00
a
TOTAL (Nso enter on line 9, Recapitulation) $ 17,159.26
(If more space is needed, insert additional sheets of the same size)
REV-1:t12 EX+ (6-98)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
DIANE MARIE COPPENS
FILE NUMBER
21-07-0347
Include unrelmbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1. CHASE HOME FINANCE, P.O. Box 830016, Baltimore, MD 21283-0016
MORTGAGE ON PROPERTY AT 813 NORTH WALNUT STREET (SET FORTH ON
SCHEDULE A)
2. CHASE AUTO FINANCE
MAl LCODE AZ. 1196
201 NORTH CENTRAL AVE.,
PHOENIX, AZ. 85004
(LIEN ON 2006 KIA SPORT~GE SET FORTH ON SCHEDULE E)
VALUE AT DATE
OF DEATH
61018.94
18720.42
3. DISCOVER BANK ACCT. #6011 0021 80674095
C/O MICHELE MEHAN
WELTMAN WEINBERG & REfS CO. L.P.A
175 SOUTH THIRD STREET. SUITE 900
COLUMBUS, OH 43215
614.56
4. Chambers Hill Fire Swatara EMS
5. OSL DBA ORTH INSTITUTE OF PA
6. QUANTUM IMAGING & THERAPEUTIC ASSOCIATES
7. Quest Diagnostics
8. PharMerica
9. Hetrick Center PC
10. Pinnacle Health Hospital
11. Riverside Anesthesiologists
50.00
286.00
170.00
49.00
747.56
17.27
657.00
700.00
1196.31
12. 2007 COUNTYITOWNSHIP REAL ESTATE TAX FOR PROPERTY AT
813 NORTH WALNUT STREET, MECHANICSBURG, PA 17055
13. 2007-2008 SCHOOL REAL ESTATE TAX FOR PROPERTY AT
813 NORTH WALNUT STREET, MECHANICSBURG. PA 17055
423.57
14. Interest payments on mortgage loan set forth in item 1 above for April through
December 2007.
2241.91
15. Interest payments on vehicle loan set forth in item 2 above
791 .28
16. Homeowner's insurance to State Farm Fire and Casualty Company for property at 813
N. Walnut Street, Mechanicsburg, PA 17055 (Set forth on Schedule A)
330.00
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
88,013.82
REV-4513 EX. (9-00) *'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
DIANE MARIE COPPENS
FILE NUMBER
21-07-0347
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS Unclude outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2))
DANIEL J. COPPENS SPOUSE 100%
813 NORTH WALNUT STREET
MECHANICSBURG, PA 17055
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 $ 0.00
(If more space is needed, insert additional sheets of the same size)
rax Transmittal
4/20/2007 4:05 PM PAGE
2/003
Fax Server
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'WAcHovtA
Reference ID: 201 5620
Wachoyia Bank N.A.
Balance Confirmation Services
POBox 40028
Roanoke, VA 24022-7313
April 20, 2007
KARL M LEDEBOHM
ATTORNEY AT LAW
POBOX 173
NEW CUMBERLAND, P A 17070
SUBJECT: Verification / Confinnation of Account and Balance Information provided for:
Customer: DIANE MARIE COPPENS (SSN# 163-60-2125)
Date of Death: March 17,2007
Deuosit Account Information
Account
Type
Account
Number
Date of Death
Balance
Average
Balance.
Date
Openw
9/26/1996
Maturity Interest Accruw ITD Date
Date Rate Interest Interest Paid C106ed
CHECKING 1014140223004
LEGAL TTILE: DIANE M COPPENS
DANIEL J COPPENS
$5,480.10
NA
. Due to system limitations, we can only provide a twelve month average balance on depository accounts.
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A
Michael J. Malpezzi, Owner · Jeremy J. Shartzer, Funeral Director
8 Market Plaza Way · Mechanicsburg, PA 17055 . Phone: (717) 697-469t
March 22, 2007
Daniel J. Coppens
813 North Walnut St.
Mechanicsburg, PA 17055
The Funeral Service for Diane Marie Coppens
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can.
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.
1. PROFESSIONAL SERVICES
Services of Funeral Director/Staff
FUNERAL HOME SERVICE CHARGES
SELECTED MERCHANDISE:
Steel Gasketed Casket
Sentinel Burial Vault
Register, Folders, Acks.
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED
AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN
ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES.
CASH ADVANCES
Cemetery Equipment
Certified Death Certificates
Newspaper Notices - Patriot
Newspaper Notices - Out of Town
Clergy/Mass Offering
Flowers
TOTAL CASH ADVANCES AND SPECIAL CHARGES
Please
$3865.00
$3865.00
$1985.00
$1095.00
$68.00
$7013.00
$140.00
$120.00
$152.52
$82.00
$150.00
$217.30
$861.82
SUB-TOTAL $7874.82
INITIAL PAYMENT / DISCOUNT / CREDITS
TOTAL AMOUNT D..Ur.E tr.T - - - -- -$. 7874~82-
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