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Home My WebLink About03-20-08 --.J 15056041147 REV-1500 EX (06-05) PA Department of Revenue Bureau of Individual Taxes PO BOX.280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Sodal Security Number Date of Death OFFICIAL USE ONLY County Code Year File Number *' INHERITANCE TAX RETURN RESIDENT DECEDENT 2 1 0 8 631Lj Date of Birth 177243149 12182007 05121930 Decedent's Last Name Suffix Decedent's First Name BORNEISEN EDNA MI M (If Applicable) Enter Surviving Spouse's Information Below Spouse's I.ast Name Suffix Spouse's First Name MI Spouse's Sodal Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW I!J 1. Original Return 2. Supplemental Return D D 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Talx Return Required B. Litigation Proceeds Received D D D D 4a. Future Interest Compromise (date of death after 12-12-82) D [K] D 4. Limited Estate B. Decedent Died Testate (Attach Copy of Will) 7 Decedent Maintained a Uvlng Trust . (Attach Copy oITrus!) 8. Total Number of Safe Deposit Boxes 1 o. ~~~::~ ~~~3'f.~g~:~N~~~e5r death D 11. Election to tax under Sec. 9113(A) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number RICHARD L. WEBBER, JR. ESQUIRE 7175327388 Firm Name (If Applicable) WEIGLE & ASSOCIATES, P.C. .--:- ..-.~. ;. .) REGISTER OF'WI;~LS USE ON.L Y First line of address r',J C_' 126 EAST KING STREET Second line of address DATE FILED L . City or Post Office State ZIP Code 17257 SHIPPENSBURG PA Correspondent's e-mail address:rwebber@weigleassociates.com 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. S.IG~TURE.. OF PERSON R~PQNSIBLE FOR FILING RETURN J ~:~EI ..v~LCI.1\..0 ..J.,Jff\d\A.C~~ Alana G. Moriarty ~~O ~ ADDRESS . 18 Briarcliffe Drive, Shippensburg, PA SIGNATURE OF PREPARE,: OTHER THAN REPRESEjITATIVE .\.-./ ( {/'--..- -- / ADDRESS 17257 Richard L. Webber, Jr. Esquire DATE }/s/c'15 126 East King Street, Shippensburg, PA 17257 Side 1 L 15056041147 15D56041147 --.J \--b --.J 15056042148 REV-1500 EX Decedent's Name: E d n a M B 0 r n e i s e n Decedent's Social Security Number 177243149 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) ................ 6. Jointly Owned Property (Schedule F) D Separate Billing Requested ............. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) D Separate Billing Requested............. 7. 8. Total Gross Assets (total Lines 1-7)....................................................................... 8. 5. 2,835.28 2,835.28 525.42 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, of transfers under Sec. 9116 (a)(1.2) X .00 16. Amount of Line 14 taxable at lineal rate X .045 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 0.00 15. 934.97 16. 0.00 17. 0.00 18. 19. Tax Due................. .................................................................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side2 L 15056042148 1,374.89 1,900.31 934.97 934.97 o . 0 0 42.07 o . 0 0 o . 0 0 42.07 D 15056042].148 --.J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME Edna M Borneisen STREET ADDRESS 101 North Prince Street File Number 21-08- Shippensburg I STATE PA lZIP 17257 CITY Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 42.07 0.00 Total Credits (A + B + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box 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. (3) (4) (5) 42.07 (5A:, (5B) 42.07 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS Yes o o o o o 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? ...................................................................................................................... 0 ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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?......... .................. ............. ....... ............. ......... ...... ............................ ................ No ~ ~ ~ ~ ~ ~ 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)l. 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 survivin!~ spouse is zero (0) percent [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 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)[72P.S.S9116(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. S9116 (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-1508 EX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETLRN RESIDENT DECEDENT Borneisen, Edna M FILE NUMBER 21-08- ESTATE OF Indude 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 DESCRIPTION 1 Highmark - Premium Refund VALUE AT DATE OF DEATH 269.37 2 Norman H. Bricker - Refund 2.565.91 TOTAL (Also enter on Line 5, Recapitulation) 2.835.28 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) . REV-1151 Ex::....[12-99) *' SCHEDULE H FUNERAL EXPENSES & ADMINISTRA liVE COSTS CCll.iMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Borneisen, Edna M D~bts of decedent must be reported on Schedule I. FILE NUME~ER 21-08- ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s): Street Address City State Zip - Year(s) Commission paid 2. Attorney's Fees Weigle & Associates, P.C. 500.00 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. A=untant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 25.42 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 525.42 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1502 EX+ (6-98) SCHEDULE H.B7 OTHER ADMINISTRATIVE COSTS continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Borneisen, Edna M FILE NUMBER 21-08- ESTATE OF ITEM NUMBER DESCRIPTION AMOUNT 1 Alana Moriarity - Reimbursement for certified mail 10.42 2 Cumberland County Register of Wills - Filing fee for inheritance tax return 15.00 Subtotal 25.42 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B7 (Rev. 6-98) R'!v-1512 EX+ (6-98) SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALlH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIOENT DECEDENT Borneisen, Edna M FILE NUMEIER 21-08- ESTATE OF Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Millennium Pharmacy Systems East - Medicine 28.55 2 Shippensburg Health Care Center 1.346.34 TOTAL (Also enter on Line 10, Recapitulation) 1,374.89 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) REV-1513 EX+ (9-00) . SCHEDULE .. BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUME:ER 21-08- NUMBER Borneisen, Edna M NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116(a)(1.2)] RELATIONSHIP TO DECEDENT Do Not List Trusteelsl SHARE OF ESTATE AMOUNT OF ESTATE (Words) ($$$) I. Dennis L. Kennedy 350 North Mountain Road Newville, PA 17241 Son One Third (1/3) Alana G. Moriarty 18 Briarcliffe Drive Shippensburg, PA 17257 Daughter One Third (1/3) Donna R. Richardson 23 Spring Street Shippensburg, PA 17257 Daughter One Third (1/3) Total 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 311.65 311.66 311.66 934.97 Form PA-1500 Schedule J (Rev. 6-98) 0.00 Copyright (c) 2002 form software only The Lackner Group, Inc. !~ ~.~ t:~ ~;I l'.r: D~r", ,',i " ~ : i 5..i,'- J'tl .. I'~.',",!' g , C:J ;j; 0 . ru ,0 .;1, = [~ . II:) [f'LJXE RBF - U-J - Ln o U-J lP .. .' g Ii:l ~[f :'~~ , , ~ f "'I~ ~I w~ '" (..) en"lJ~ ;!;o~z "lJ' "'0 ;:g (ll ::E ... Zom~ xen, ~c.> -I;::" cc.>;:o;;)> :oo>zZ ~ G) "lJ en :x: ~ -I"' :0 mIlD -I~ " ~ .~GHMARK. Date: 02/26/2008 This Month Gross payment amount Net payment amount 269.37 269.37 0199917 118 0 ~ g g g ~ 7 118 I: 0 ~ b 0 7 b ~ 5 0 I: b 2 0 5 1.. 5 2 5 a ~ 118