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Home My WebLink About02-05-08 , -' .-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 Decedent's Last Name Suffix (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Social Security Number Date of Birth Decedent's First Name MI Spouse's First Name MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 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 SHOULD BE DIRECTED TO: Name Number FILL IN APPROPRIATE OVALS BELOW _ 1. Original Return c:::> 2. Supplemental Return c:::> 4. Limited Estate ~ 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received c:::> c:::> 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required c:::> 8. Total Number of Safe Deposit Boxes fY) First line of address / 0 ? Ur11\'€R Second line of address City or Post Office State n e. 1I) C. U. tl"I b E- r p f\ REGISTER o~ ~LS USE QM..Y t'J -;-', ~I Pl ro I en -0 3 rv DirE FILED ZIP Code o Correspondent's e-mail address: '(3 "\ H (' \ -..\ vi ~ l-- (' (j) r:o (Y\ c, A ~T i \\ e.. '\ 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 information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ,,~ \~ d_'-l-OQ- ADDRESS CJ IA n f\ n 11 \0\ '~\...!-~.LL-V \~Q. \~ \UU)\Cpl~?C.L,\/OIO SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 --.J d\A --.J 15056052048 REV-1500 EX Decedent's Name: 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) c:::> 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_ 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 Side 2 L 15056052048 c::> 15056052048 .-J ""',.".,,~ '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF ) --\ A?-.e.... \ c.- - (Y\" n \ u. YY\ FILE NUMBER o 0 ~ '~9 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, DESCRIPTION VALUE AT DATE OF DEATH e- \ """"\ ; t.... e.- of' <,:. ~ fH~ \<- ~~~\' (\ ~ L" D l; (g 9 - L\ .~ \ - "3 \'4. ~:J. ',', TOTAL (Also enter on line 5, Recapitulation) $\ -:;). ::t ;).. -I '/ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) . _~.!.J~:~_ ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER 0-0&3 ~ \--\ ~ '2. e.J t. {Y\ ~ (\ I U. YY\ Debts of decedent must be reported on Schedule I. ITEM NUMBER A. FUNERAL EXPENSES: DESCRIPTION AMOUNT 1. r Q, -r"" e. (Yl 0 I[ -'i .~ '""-'--' e ~- ~ \ \..\ () P'\ --{, (9 'f e....~ ,'I Woo c\ C.e ("{'- e...~ A 'V '-I 0~/~ <3~ ~qb c:ru B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) ,IV fl Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State _ Zip Year(s) Commission Paid: 2, Attorney Fees .JV l;f 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant A/I? Street Address City State _ Zip Relationship of Claimant to Decedent 4. Probate Fees t-"---..\>e..A A~j CTi A/f1 ~w ~ 3. C1l.) 5. Accountant's Fees 6. Tax Return Preparer's Fees Nit 7. TOTAL (Also enter on line 9, Recapitulation) $ L ~y". ~~ <.3 (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 )~ A '--~\ t.- m, (\\\AyY\ FilE NUMBER DOf..o'?J~ Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH e.....;\ \ L..-e. Y\ 5 B A- f\ k V1\ f\ S\ '€- y- ~ 'ft ~ eX 5 :l ~ I) "3 ~ {; 0 t ,;- 10 \ \ 0 L/ :t24 q"y I TOTAL (Also enter on line 10, Recapitulation) $ '~ ~ '-\ as. L-\ \ (If more space is needed, insert additional sheets of the same size) " REV-'S" EX+ (9-00* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF \ )..\ ~ <... e- FILE NUMBER oo(o~S C-- m~ (\l\.,l'(Y\ 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 [include outright spousal distributions, and transfers under See, 9116 (a) (1.2)] Q ~~ h.i-e., C1;O ~O 1. "In A 'I \. A. '(\ )<. <L ~ <' e. r -=s- (L ..f'\. ("'\ ~ ~ "'1.. -r ~ ^ Q./"- r0 A '(\ G" A rJ( cLT~cSkle( /O'?6 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 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - 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) ',~\\ I, //,/ ~~/ ~h ~ -' ::-- ~~~ PARTHEMORE Funeral Home & Cremation Services, Inc. A Family Tradition Of Caring@ Mrs. Marian J. Keener 107 Bunker Hill Road New Cumberland, P A 17070 6/28/2007 For the services of Hazel C. Minium 1303 Bridge Street P.O. Box 431 New Cumberland, PA 17070 (717) 774-7721 (Fax) 774-5546 www.parthemore.com We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please 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. L ____"!"erm~__ Net 30 Due Date 7/28/2007 Account # 2007054.0 Description Amount _ SERVICES & MERCHANDISE Memorialization Funeral Service Grouping 5,500.00 Total Services and Merchandise 5,500.00 Gilbert W. Parthemore, Founder CASH ADVANCE ITEMS Death Notice, Harrisburg Patriot 18 Certified Copies of Death Certificates Hairdresser Clergy Honorarium Organist Honorarium Flowers, Casket Spray Rabena's Wardrobe Service, Pressing 187.83 108.00 40.00 150.00 100.00 175.00 12.50 Gilbert 1. Parthemore, Supervisor Stephen K. Parthemore, CFSP Bruce R. Parthemore, Pre- Need Coordinator, CPC Total Cash Advances 773.33 Professional Memberships: NFDA · PFDA DCFDA · CCFDA 0'""\ I . s'J ~ t\W G~ The Rule You Know. The People You TrUST Total Payments/Credits Balance Due $6,273.33 $-723.00 $5,550.33 "1t9reenlJJool1 :Rlemorin! €emeterp, lfnt. :i.:9~~~?~~ SINCE 1896 John and Peggy Barket 22 VPT Road Tower City, Pennsylvania Phone: 717.647.7333 DATE: June 30,2007 17980 RE: INVOICE: RU.r ial 1001 Bill To: Marian Keener 107 Bunker Hill Rd. New Cumberland, Pa. 17070 DESCRIPTION . . AMOUNT Remove Tombstone with Base which is over the last space on this Lot,Remove Foundation, after burial recement new foundation and replace Tombstone. Foundation size 66"in. X 18' In. 1188sq. ln @.35<t $415.00 . - Open and close grave $4"75.00 Total $890.00 . . TOTAL $890.00 - I Make all checks payable to Greenwood Memorial Cemetery, Inc. Payment DUE UPON RECEIPT. If you have any questions concerning this invoice, please call John Barket. Prices subject to change without notice. Unpaid balances after thirty (30) Days subject to penalties. THANK YOU FOR YOUR BUSINESS! -------~ '~ / -..... u.... u. u.........:. c.. :.:.~.:.:.:. .~. :'.: _...:.: .~.:.:............... u..... _... _.......... u............................ u..... Detach here. QnJy this top portion and your payment should be included in the envelope. Make your check payable to Credit Card Services. Account Number: 52403800 01561104 Billing Period: 05/17/07 - 06/16107 CITIZENS BANK MASTERCARD PLATINUM You can avoid finance charges on Purchases if you ilay the entire New Balance by the Payment Due Date for every billing cycle. This grace period does not apply to Balance Transfers. Cash Advances or Previous Balance. See the back of your statement for details about your "GRACE PERIOD". BALANCE SUMMARY Previous Balance Payments and Credits Cash Advances Purchases and Other Charges Total FINANCE CHARGES $ 2,721.36 500.00 0.00 0.00 28.06 + + + New Balance - .... ,". - - ,. .~.... . - .. - ~ - - .. ", - ~..... - ... ,. - - ". - .. - . - - .~ - - - - - .. - - ... -. # - - - - - - ... - - - - - - - - - - .. - - - - - ~ - - - - . - .:.. - - .- - - -. - - - - ,- -.. - - - $ 2,249.41 ACCOUNT ACTIVITY Trans Date Post Date Reference Number Transaction Description Amount PAYMENTS AND CREDITS OS/24 OS/24 75545147144000394321699 06/13 06/13 75545147164000212323955 PURCHASES AND OTHER CHARGES Payment Received Thankyou Payment Received Thankyou 200.00 (-) 300.00 (-) 06/15 06/15 06/15 06/15 PURCHASE FINANCE CHARGE PURCHASE FINANCE CHARGE 0.90 27.15 FINANCE CHARGE SUMMARY Average Dally Balance Dally Periodic . Rate* Corresponding ANNUAL PERCENTAGE RATE* Periodic FINANCE CHARGE Days In Billing Cycle: 31 Purchases Cash Advances Balance Transfers $81.12 $0.00 $2,460;61 .03559% .06384% :03559% 12.99% 23.30% 12.99% $0.90 $0.00 $27.15 . This rate may vary. See reverse for important information. ANNUAL PERCENTAGE RATE 13.24 % Transaction fees are included In the Annual Percentage Rate and may cause It to appear Inflated. Account Number: 5240 3800 0156 1104 Page 1 of 6 ~:E Citizens Bank 1-888-910;.4100 Call Citizens' Phone Bank anytime for account information, current rates and answers to your questions. 5 1 US259 BR303 HAZEL C MINIUM 20 N 12TH ST APT 111 LEMOYNE PA 17043 Checking Account Statement . OF 3 Beginning June 06, 2007 through July 05, 2007 Checking SUMMARY Balance Calculation Previous Balance Checks Withdrawals Deposits & Additions Current Balance 4,408.50 566.23 - 5,638.88 - 3,019.38 + 1,222.77 = HAZEL C MINIUM MARIAN KEEN ER Green Checking 610069-431..3 Previous Balance TRANSACTION DETAILS Checks. There is a break in check sequence Check # 991 992 Withdrawals A TM/Purchases Date Amount 06/06 06/06 06/08 06/11 06/11 06/11 06/18 06/18 06/18 06/22 06/26 Other Withdrawals 8.56 5.82 32.28 80.17 15.98 ..11-43 bZ.96 14.54 12.71 31.95 21.87 Date Amount 06/07 06/07 06/15 06/22 07/03 1,990.00 71. 16 371.43 26.02 2,882.00 Amount 300.00 25.97 Date 06/.13 06/18 Check # 993 994 Amount 40.26 200.00 Description MMC Purchase - 999999 Mcdonald's F7928 Lemoyne PA ~1MC Purchase - 999999 Karns Quality Foodlemoyne PA MMC Purchase - 999999 Lawrence Chevroletmecnani Urgpa MMC Purchase - 999999 Weis Markets #125 Camp Hill PA MMC Purchase - 999999 CVS Pharmacy #1622lemoyne PA MMC Purchase - 999999 CVS Pharmacy #1630camp Hill PA MMC Purchase - 999999 Weis Markets #125 Camp Hill PA MMC Purchase - 999999 CVS Pharmacy #1622lemoyne PA MMC Purchase - 999999 Glenn Miller -Seer Lemoyne PA MMC Purchase - 999999 CVS Pharmacy #1622lemoyne PA MMC Purchase - 999999 Weis Markets #125 Camp Hill PA Description Holiday 2 Rent 070607 755323 Liberty Mutual Payment 070607 Ao228819015760 Bankers Life 357 Ins Prem 070613 900167637070615 Verizon Paymentrec 062207 7177319854911 Debit Memo Deposits & Additions Date Amount DeSCription 06/29 1,067.00 US Treasury 220 VA Benefit 062907 03668110 10 10 06/29 137.38 Benefit Payments Pensions 070629 000001812702002 Member FDIC 9 Equal Housing Lender <:;pp rpvpr~p ~irlp for imnort;:mt infnrm::ltion Date 06/.25 06/15 4,408.50 o Total Checks 566.23 o Total Withdrawals 5,638.88 REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME _____\-\~~_~~__~___0)\ ni__\L\__0l__ ... STREET ADDRESS _ __2Q.. ---.D____L~ ~_ ... ~ L____A.fL_"-~nl_._________.._____ CITY Le.<y\ C \ /1 ~ I STATE I p.f+ . ------r Zi p i \;DLf3 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount Total Credits ( A + 8 + C ) / ~ (2) V \~ \J (4) C:/ ~\' 4A)V (58/' (3) (1 ) 3. Interest/Penalty if applicable D. Interest E. Penalty _________d____~________________ TotallnteresUPenalty (0 + E) 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. 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. 8. Enter the total of Line S + SA. This is the BALANCE 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;.......................................................................................... D g] b. retain the right to designate who shall use the property transferred or its income; ............................................ D gj c. retain a reversionary interest; or.......................................................................................................................... D 121 d. receive the promise for life of either payments, benefits or care? ...................................................................... D lliJ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. D ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D I2l 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 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 PS. 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. ~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. ..., ,,~_;f~ ~~ 1 '. .-;, ,.,5", ' ~,...i:"~.; ~~,..:,.y,""" -~,. .,I'---*-'":~ 1;~;'--- ~A~.^+...,.t, ,.,:.;,. ~~". ~~~, . ~.~~ ~: , .,'" ,;,..,.::':::..:)"': r ~.-ij;4T~' ", ~~'- ..... 4C .~:!-..... ", .. :~. -0- :-.??' :'.- ......{~.::.Gl ~:.;;.: f/) : ~/ _),J' __..'" ,~:::~, ~~ -;;;.-'-~;~ \~ \, .. ;,:~ ~~ ~ ~. " " ~ '~ .", ~ '~ ~l ==- - - - ~ -=== ~ -::- - ~ ...;.- - - ::::::: ..:;::" -Z - :::::: -::;:" ::- - - - :;::::;. -- - -:::- - - -:::- l \ , !,' ,-,:-r. r;, .\. \ t.... , I , \ l'il\\~ t't.'\l, - 'j \,\'1. \2' \ \ 'c j-C>\l (,.e ,)J'\ \~.,.,). . .. _ _, ("{_,j \0\ Osv.~J\N ':) '., -JU\\ \ 1\" ~."..' r " ," (') ('\ \~Jr-\',' ~ '-- ' v\)'", ' ~ \ .. \ \ \ i. \ t ... ' J ~ ,,'~ ., 'j \ \ \ r f) c" (! ..) \ . ~ ~ d:' ,0 ~31 ~ ~.~ ~ ~. j ~ 1-'} '~ ex? ~ ~ fl r!j ~ \\ u ? ...,,?" ".,.) ~ .. \ \ \ \ 1 "