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Home My WebLink About03-17-08 ~ --.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 Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT o a ~ 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 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 Daytime Telephone Number FILL IN APPROPRIATE OVALS BELOW _ 1. Original Return <::) 2. Supplemental Return c:::::) 4. Limited Estate c::> 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received c::> First line of address Second line of address State 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 ; .J --.J , ',) DATE FILED ._ C) Correspondent's e-mail address: k E..R.Lif s-lfi<<P C6P1C4SI. /llcl- 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 p~eparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPO IBLE FOR FILING RETURN ADDRESS '~ :197 f.R-AeJ/ (CJ/(fl/ ~ d (5l/;.edtob?J SIGNATURE OF PRE PARER OTHER THAN REPRESENTATIVE f/,,; / ?..l..2 r ADDRESS DATE PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 --.J .-J 15056052048 REV-1500 EX Decedent's Name: Decedent's Social Security Number I Co 3 3 Cl.Y ~ '3C( 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/Sec 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. o 0 0 O.d 0.0 Q 0.0 (] q 5-9 ~ (j O. 6 G. 9 5" 'it .(}o ? .3 (;] .0 0 . J :? &J .0 (J / ;,. I Y .0 0 . / ~I Y.o 0 TAX COMPUTATION - SEE INSTRUCTIONS FOR'APPLlCABLE 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 .0U 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 " . 15. i)/J.o<) 16. . 17. 18. . 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT b_~ V -2 c--7f/ /j / /' t/ Side 2 15056052048 . 5'-/ . f / . . -5'1 ~Y I c:::> 15056052048 .-J r REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME Od G -() 1077 File Number ;2 STREET ADDRESS tlnfZ tEllJ Ln 5~IW yY\ 'S+ ALAi3n . m S;171f25!1tV__nSt fll f C- -. STATp ff ZIP /7(/S-j- CITY Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 5-'/ Y I 3. Interest/Penalty if applicable O. Interest E. Penalty o Total Credits ( A + B + C ) (2) Total Interest/Penalty ( D + 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. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESilONS 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 IZI b. retain the right to designate who shall use the property transferred or its income; ............................................ D r;Q c. retain a reversionary interest; or..........................................".............................................................................. D g} d. receive the promise for life of either payments, benefits or care? ...................................................................... D ~ 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 ~ 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 PS. 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 transfe~s 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-l508 EX. (1-97) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF CI A I f-fJ E..- FILE NUMBER rY\ 5fj:\u{3 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. .:r rJ f c. (( ~ Sf- DESCRIPTION C/iLGk,'#f 56 - 0 ~ /7 - J / / ~ 50 - 0390- J~9Y 3/5 () (f0 7~ 7;1, tj VALUE AT DATE OF DEATH 't / /d,5}? '/ / Y'I C; ( I /~/5' 7/. ~ 51lt//J/q S /l eel 3 cO P A) G 811AJk f,{). i3(J" S~S c;l.J6 fN! S pa.<!y If f' /I, / J,?, 5' J TOTAL (Also enter on line 5, Recapitulation) $ . (If more space is needed, insert additional sheets of the same size) Total Banking Statement PNC Bank For the period 12/09/2006 to 01/09/2007 EST OF ARLENE M STAUB DECD TERRY E STAUB EXTRX 531 W SIMP,SON ST MECHANICSBURG PA 17055-3765 Relationship Overview Bank Deposit Accounts Description Interesl Checking Performance Money Market. Celtificate( s) Of Deposit Total Deposils Account Number 50-0417-3112 50-0390-3494 Total of 1 Senior Choice Plan Interest Checking Account Summary Account number: 50-0417-3112 Balance Summary Beginning balance 4,917.64 Deposits and other additions .94 Checks and other deductions 738.00 Average monthly balance 4,318.04 Interest Summary Annual Percentage Yield Earned (APYE) 0.25% Number of days in interest period Average collected balance for APYE 32 4,318.04 Activity Detail Deposits and Other Additions Date Amount Description 01/09 .94 Interest Payment Online and Electronic Banking Deductions Date Amount Description 1~15 738.00 Direct Payment - Reversal US Treasury 303 XXXXX6677D Ending balance 4,180.58 Charges and fees .00 Interest Paid this period .94 ~PNCBANK Primary account number: 50-0417-3112 Page 1 of 3 Number of enclosures: 0 ~ For 24-hour banking, and transaction or interest rate information, sign on to "It PItJC Bank Online Banking at pnc.com. For customer service call 1-888-PNC-BANK between the hours of 6 AM and Midnight ET. Para servicio en espanol, 1-866-HOLA-PNC Moving? Please contact us at 1-888-PNC-BANK ~ Write to: Customer Service PO Box 609 Pittsburgh PA 15230-9738 e. Visit us at pne.com iii TOO terminal: 1-800-531-1648 For hearing impaired clients only Deposit Balance 4,180.58 4,184.41 1,215.72 9,580.71 Est Of Arlene M Staub Deed Terry E Staub Extrx Please see the Activity Detail section for additional information. As of 01/09, a total of $.94 in interest was paid this year. There was 1 Deposit or Other Addition totaling $.94. There was 1 Online or Electronic Banking Deduction totaling $738.00. FORM953R.l005 Total Banking Statement Q For 24-hour information, sign on to PNC Bank Online Banking on pnc.com. Account number: 50-0417-3112 - continued Daily Balance Detail Date Balance 12/09 4,917.64 For the period 12/09/2006 to 01/09/2007 EST OF ARLENE M STAUB DECD Primary account number: 50-0417-3112 Page 2 of 3 Date 12/15 Balance 4,179.64 Date 01/09 Balance 4,180.58 Enrol1 your PNC Bank Visa Check Cam in Visa Extras and earn points towanls great rewards like dinner out, shopping, travel and more. See 'our local PNC Bank branch or www.nc.comror oner details. Want extra protection when banking online? We've got you coven:d. PNC is pleased to announce an added layer or security ror PNC Bank Online Banking. i\ Personal SeCluity Image and Caption, and Security Questions, now help us to know it is real1y you when you sign on to Online Banking and help you to know it's really us. So you can relax. Your account is now protected hy an added layer 0 I' security. To learn more about security and al1 that PNC does to protect your identity and account inronnation, see PNC Security Assurance at www.pnc.com/go/ security assurance. IMPORTANT ACCOUNT INFORMATION Supplement to the Account Agreement l'or Personal Checking and Savings Accounts The inl'onnation in this supplement amends certain inl'onnation in your Account Agreement l'or Personal Checking and Savings Accounts (Agreement). AI1 other infonnation in the Agreement, as amended, continues to apply to your account. Please review the rollo\ving inl'onnation and retain it with your records. EfI'ective 3/1/07 INTEREST PAYMENT AND BALANCE COl\1PUTATION Perl'onnance Money Market accounts included in Premiwn, Choice, WorkPlace Premium, WorkPlace Choice, Senior Premium and Senior Choice Plans Your Interest Rate and Annual Percentage Yield will no longer can)' a guarantee of70% ofthe Index Rate, but wil1 be set at our discretion 1'01' the balance tiers below. \Ve may change these rates and yields at any time without notice to you. You can see your branch or cal1 1-888-762-2265 tar rate inlonnation. $1,000 - $24,999.99 $25,000 + Choice Plan Performance Money Market Account Summary Account number: 50-0390-3494 Est Of Arlene M Staub Decd Terry E Staub Extrx Balance Summary Beginning Deposits and Checks and other Ending balance other additions deductions balance 4,172.14 12.27 .00 4,184.41 Average monthly Charges balance and fees 4,172.52 .00 Interest Summary Annual Percentage Number of days Average collected Interest Paid Yield Earned (APYE) in interest period balance for APYE this period 3.41% 32 4,172.52 12.27 Please see the Activity Detail section for additional information. As of 01/09, a total of $12.27 in interest was paid this year. REV-1511 EX+ (12-99)' . ~:.1~~_ ~ SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A DESCRIPTION FUNERAL EXPENSES: ;J; / ;, AI f L /l., ,cll/V C /</11 fI<I/J1 f ~ Iifi ~/JJ /J#te- If Sd 1 IJ. 13/l/)-}/)?(J/lt ,4/c- /)1,; , M //'1 Sj?/f fJ If /7(}t5 I/II c. 1. 5' [ ~ -Af/A cl+td 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. Attorney Fees 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 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) AMOUNT /3 c,~, 0 () Iml co -11- M, HoIIinSJer Funeral Home & Crematory, Ine. Eric L. HoIlinSJer. Supervisor December 12, 2006 Clayton J. Staub 397 Peach Glen Road Gardners, P A 17324- The Funeral Service for Arlene M. Staub 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. 1. PROFESSIONAL SERVICES Services of Funeral Director/Staff. . . . . . . 3850.00 FUNERAL HOME SERVICE CHARGES SELECTED MERCHANDISE: Casket. . . . . . . . . . . . . . . . . . . . . . . . . Econovault. . . . . . . . . . . . . . . . . . . . . . . . THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THATYOUHAVESELECTED . . . . . . . . . . . . . 3850.00 2195.00 995.00 7040.00 Cash Advances Opening Grave. . . . . Cemetery Equipment. . . Newspaper Notices - Sentinel 1\.J......ur........o....~- l'..T,.....:^,",-:- DflIi"nt .. ~W.'~r.u.i"""'''' .. ."'............... ... -.."......... 600.00 325.00 91.00 1000 Ciergy'Mass Offering, . _ Certified Copies of the Death Certificate. Flowers. . . . . . . . . . . TOTAL CASH ADVANCES AND SPECIAL CHARGES . 10(1" 0(' 72.00 125.00 1323.00 Total Total Cost. TOTAL AMOUNT DUE 8363.00 8363.00 501 NORTH BALTIMORE AVENUE. MOUNT HOLLY SPRINGS. PENNSYLVANIA 17065 · (717) 486-3433 · FAX (717) 486-3215 www.hoIIin~erfuneraIhome.com