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REV-1500 EX + (6-00)
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REV -1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
OFFICiAl USE ONLY
FILE NUMBER
21 -06 1 0 0 1
CiiUNTVCOOE --vEAA- - - NUMBfR- -
SOCIAL SECURITY NUMBER
Olson Florence, M.
DATE OF DEATH (MM.DD.Year)
DATE OF BIRTH (MM-DD-Year)
3 1 2 - 1 8 - 7 9 8
THIS RETURN MUST BE FILED IN DU L1CA TE WITH THE
REGISTER OF WILLS
10/02/2006 02/09/1920
(IF APPLICABlE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
o 1 Original Return
o 4. Limited Estate
[R] 6. Decedent Died Testate (Attach copyofWiU)
o 9. Litigation Proceeds Received
SOCIAL SECURITY NUMBER
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 of Trust)
o 10. Spousal Poverty Credit (date of death between 12.31.91 and 1.1.95)
o 3. Remainder Return (date of eath prior to 12-13-82)
o 5. Federal Estate Tax Return Required
Q... 8. Total Number of Safe Dep sit Boxes
o 11 Election to tax under Sec. 9113(A) (Attach Sch 0)
THIS SECTION Ml1STSECOMPLETED.ALLCORRESPONDENCEANDCONFIDENTIA L 'rAxINFORMATIONSOOUI.DBEDIR . T
NAME COMPLETE MAILING ADDRESS
John H. 8rou'os Es uire 4 North Hanover Street
FIRM NAME (If Appicabl3)
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TELEPHONE NUMBER
717-243-4574
Carlisle, PA 17013
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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)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
OFFI~~ U E ONLY
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19,950.97
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(6)
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(7)
(8)
19,950.97
(9)
(10)
1,168.30
881.12
(11)
(12)
(13)
2 049.42
17,901.55
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
(14)
17,901.55
X _(15)
X _(16)
X 12 (17) 0.00
17,901.55 X 15 (18) 2,685.23
(19) 2,685.23
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
>;>.... BESO~EtOANSWE~AI..I...QIJEStIONSONREVERSESIDE.ANDRECHECK.MATH...<<..
Decedent's Complete Address:
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STREET ADDRESS 1 Langsdorf Way
CITY I STATE I ZIP
Carlisle PA 17015
Tax Payments and Credits:
1 Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
2,685.23
3. InteresVPenalty if applicable
D. Interest
E. Penalty
Total Credits (A + 8 + C ) (2)
TotallnteresVPenalty (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)
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. (5A)
8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
0.00
2,685.23
2 685.23
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;.................................... ................. .......... 0 [IJ
b. retain the right to designate who shall use the property transferred or its income;. ........................ ..... 0 ~
c. retain a reversionary interest;.or........... .................................................. ............................. 0 [iJ
d. receive the promise for life of either payments, benefits or care?................................................. 0 lID
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?........................................ .............................. 0 00
3. Did decedent own an "in trust for' or payable upon death bank account or security at his or her death?... .... 0 00
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation?..................................................... ....................... .............. 0 [ID
ADDRESS
Under penal/es of pe~ury, I that I have examined this retum, incuding accompanying schedules and statements, and to the best of my knowledge and belef, it is true, correct and complete. i
r n the personal representative is ba~.Qfl1Ifinformation of which preparer has any knowledge
N RESP IBL OR F URN
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF T E RETURN.
CJ
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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 s
[72 P.S. ~9116 (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. ~91 6 (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 a licable 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, anjdoptive parent,
or a stepparent of the child is 0% [72 P.S. ~9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedenrs lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedenrs siblings is 12% [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Secti 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1.508 EX + (6-~
,./ 'aw
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Ols n F orence M.
FILE NUMBER
21 06
Include the proceeds of litigation and the date the proceeds were received by the estate.
All rty. . tI d 'th' ht f . h' t b d' IdS h d I F
100
prope Jom y-owne WI rig o survivors Ip mus e ISC ose on C e u e .
ITEM VA U E AT DATE
NUMBER DESCRIPTION ( F DEATH
1. Orrstown Bank, Carlisle, PA 19,789.02
2. Cumberland Crossings Petty Cash Account 161.95
TOTAL (Also enter on line 5, Recapitulation) $ 19950.97
(If more space IS needed, Insert additional sheets of the same size)
REV-1511 EX + (12-99)
..
COMMONWEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Olson Florence. M.
FILE NUMBER
21
06
1001
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
'\MOUNT
1.
2.
FUNERAL EXPENSES:
Hetrick Cremation Services
Postages to send documents
36.00
6.30
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s) Dan Barney
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
State
Zip
Year(s) Commission Paid:
2.
3.
Attorney Fees John H. Broujos, attorney, 4 N. Hanover Street, Carlisle PA 17013
Family Exemption (If decedent's address is not the same as claimant's, attach explanation)
Claimant
975.00
Street Address
City
State
Zip
Relationship of Claimant to Decedent
4.
Probate Fees
119.00
5.
Accountant's Fees
6.
Tax Return Preparer's Fees
7.
Register of Wills: Filing Inheritance Tax
15.00
8.
Register of Wills: Filing Family Settlement Agreement
17.00
TOTAL (Also enter on line 9. Recapitulation) $
1,168.30
(If more space IS needed, Insert additional sheets of the same size)
REV-~512 EX + (6-98)
'*
SCHEDULE.
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Olson Florence M. 21 06 1001
Include unreimbursed medical expenses.
ITEM VAll E AT DATE
NUMBER DESCRIPTION 0 DEATH
1. Cumberland Crossings 679.50
2. Continuing Care Rx 201.62
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TOTAL (Also enter on line 10, Recapitulation) $ 881 .12
(If more space is needed, insert additional sheets of the same size)