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Home My WebLink About04-02-08 --.J 15056041125 REV -1500 EX (06-05) PA Department of Revenue '* ~~~~xo~~~~~1uaITaxes INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW SClcial Security Number Date of Death OFFICIAL USE ONLY County Code Year 2 0 8 Date of Birth 177420390 o 1 0 4 2 0 0 8 0517196 Deicedent's Last Name Suffix Decedent's First Name BURKHOLDER BET H (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW [XJ 1. Original Return o 4. Limited Estate o o 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received o o o o 2. Supplemental Return o o 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust 0 (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death 0 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 8. Total Number of Safe Deposit Boxes HUBERT Firm Name (If Applicable) x. GI LROY, File Number 000 8 2 MI A MI E S Q 7 1 7 2 4 3 33 4 REGISTER OF WILLS USE ONLY MARTSON LAW OFFICES First line of address (") c'g -?' :;...... cp~. ri'l ("') ~ hi :~u5~ o o E A S T H I G H STREET Second line of address City or Post Office State ZIP Code P:D jJ.-i CARLI SLE P A 1 7 0 1 3 Corre,spondent's e-mail address: ,.." (~ <:::> ex> > -0 ::::0 I N ..,., ~.I ;~ ~:_~~ f~.~~ t :~ ;~.=::~ r f~ rr. ;.'C:;) .'i;:;;(71 ~e:;.:. ::? -'~." C) F: f'n </>~ N .. c...> ~ CARLISLE ER THAN REPRESENTATIVE CARLISLE PLEASE USE ORIGINAL FORM ONLY PA 17013 Side 1 L 15056041125 15056041125 ...J --I 15056042126 REV-1500 EX Decedent's Name: BETH A. BURKHOLDER 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) 0 Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properly (Schedule G) 0 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. 2479340 TAl( 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.O _ 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 15. 16. 17. 18. 19. Tax Due . . . . . . . . . . .., . . . . .,. . . . . . . . . . . . . .... . .. . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056042126 Decedent's Social Security Number 177420390 o . 0 0 118 9 2 8 8 9 2 8 6566.00 7038. 23604. 2479340 2 2 o 15056042126 -.J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 08 00082 DECEDENT'S NAME BETH A. BURKHOLDER STREET ADDRESS 304 SOUTH FILBERT STREET CITY I STATE I ZIP MECHANICSBURG PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2, Credits/Payments A, Spousal Poverty Credit 8, Prior Payments C, Discount (1 ) Total Credits (A + 8 + C) (2) 3, Interest/P,enalty if applicable D. Interest E, Penalty Total Interest/Penalty ( D + E ) (3) 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. (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, 8, Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (58) 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; ...................................................................... 0 00 b. retain the right to designate who shall use the property transferred or its income; ............................... 0 00 c. retain a reversionary interest; or ................................................................................................ 0 00 d. receive the promise for life of either payments, benefits or care? ....................................................... 0 00 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 00 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. ~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 zero (0) percent [72 P.S. ~9116 (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 P.S. ~9116(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. ~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 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. REV-1504 EX + (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF BETH A. BURKHOLDER FILE NUMBER 21 08 00082 Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH B A BURKHOLDER CONSULTING (no funds are available to determine valuation; there are incomplete income tax records for years 2007 and previous years; bank accounts were all overdrawn; no evidence of accounts receivable; no real or personal property was owned by proprietorship) 0.00 TOTAL (Also enter on line 3, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 REV-1508 EX + (6-98) '* SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BETH A. BURKHOLDER FILE NUMBER 21 08 00082 Include 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. ITEM NUMBER 1. DESCRIPTION Commerce Bank, Account No. 537477317, (overdrawn account) VALUE AT DATE OF DEATH -31.16 2. Orrstown Bank., Account No. 111000722, (overdrawn account) -5.00 3. Orrstown Bank., Account No. 111900219 (overdrawn account) -851. 72 4. Orrstown Bank., Account No. 106110 140 (overdrawn account) -301.40 5. Decedent resided in home of another individual and owned no personal property or furnishings TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) -1 189.28 REV-1511 EX+(12-99) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BETH A. BURKHOLDER SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21 08 00082 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Myers Funeral Home, Mechanicsburg, P A 4,500.00 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 Martson Law Offices 2,000.00 3. Family Exemption: (If decedent's address is not the same as claimants, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees Register of Wills of Cumberland County 51.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Register of Wills, filing fee, inheritance tax return 15.00 TOTAL (Also enter on line 9, Recapitulation) $ 6,566.00 (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 INHERIT ANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BETH A. BURKHOLDER FILE NUMBER 21 08 00082 RepClrt debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH See Attachment Page(s) TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 17.038.12 Continuation of REV-1500 Inheritance Tax Return Resident Decedent BETH A. BURKHOLDER Decedent's Name Page 1 21 08 00082 File Number Schedule I - Debts of Decedent, Mortgage Liabilities, & Liens ITEM NUMBER 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. DESCRIPTION Carlisle HMA Physician Management, account payable, #607104 AMOUNT 1,632.00 Carlisle Regional Medical Center, account payable, #9389719 5,972.86 Carlisle Regional Medical Center, account payable, #7461603858179066 33.33 Carlisle Regional Medical Center, account payable, #7462450858179063 1,218.87 Carlisle Regional Medical Center, account payable, #8226864858179061 929.13 Central Penna Rehabilitation, now Morganstein Defa1cis Rehab Institute, account payable, #7757 60.50 Kinetic Imaging, Inc., account payable, #9389719 80.00 Hamilton Law Group, attorneys for Lehigh Anesthesia Assoc PC, account payable, #670746-1 718.20 Medical Arts Allergy, PC, account payable, #10028 194.00 Pinnacle Credit Services, account payable, #5440450060232778 857.36 Quest Diagnostics, account payable, #3819408903 26.47 Midland Credit Management, Inc., for Aspen Mastercard, account payable, #8521804203 891.78 Sam Brinley, account payable, #2007-14 180.00 Law Offices of Mitchell N. Kay PC, for Capital One Bank, account payable, reference #66054018- 10 938.46 Collect America, account payable, #4447962110065228 562.86 SUBTOTAL SCHEDULE I 14,295.82 Continuation of REV-1500 Inheritance Tax Return Resident Decedent BETH A. BURKHOLDER Decedent's Name Page 2 21 08 00082 File Number Schedule I - Debts of Decedent, Mortgage Liabilities, & Liens ITEM NUMBER DESCRIPTION AMOUNT 16. SKO Brenner American, Inc., for Dianon Systems, account payable, #EE6051098 590.00 17. First Premier Bank, account payable, #4301718110092330 732.33 18. Powell Rogers & Speaks, Inc., for Giant Stores, account #106 110140, for nonsufficient funds 135.65 19. The Hartford, account payable, #44PH193440 718.00 20. Verizon Pennsylvania, account payable, #X1634994-VN-ST51O-999 67.12 21. AOL, account payable, #0362241952 179.85 22. Emergency Preplan Services, account payable 319.35 SUBTOTAL SCHEDULE I 2,742.30 GRAND TOTAL SCHEDULE I $ 17,038.12 ~ ORRSTOWN BANK A Tradition of Excellence March 28, 2008 To: Martson Law Offices 10 East High Street Carlisle Pa 17013 From: Traci Y ohe Orrstown Bank Customer Service Center PO BOX 250 Shippensburg, Pa 17257 Re: Estate of Beth Ann Burkholder Date of death January 4, 2008 IT IS HERERBY CERTIFIED THAT THE ABOVE NA10ED DECEDENT. ON THE ABOVE DATE, HAD THE FOLLOWING ACCOUNTS WITH ORRSTOWN BANK. CHECKING ACCOUNT Account # Title of Account Date opened 111000722 Beth Ann Burkholder 09/11/03 Principle -$5.00 Accrued Interest 0.00 106110140 B A Burkholder Consulting 2/15/00 -$301.40 0.00 1119000219 B A Burkholder Consulting 4/12/04 -$851.72 0.00 SA VINGS ACCOUNT Account # Title of Account Date opened Principle Accrued Interest CERTIFICA TE OF DEPOSIT Account # Title of Account Date Opened Principle Accrued Interest P.O. Box 250. Shippensburg, PA 17257. 717.530.3530. 717.532.4143 fax -- ~ -~/'""' COlTllTlerce .Bank January 25, 2008 Beth Ann Burkholder DBA: B A Burkholder Consulting 304 South Filbert Street Mechanicsburg P A 17055 Re: Account Number: 537477317 Dear Beth According to our records, the checking account noted above has been overdrawn in the amount of $31.16 since January 4, 2008 as a result of insufficient funds. A cash deposit must be made to cover the overdraft within ten days of the date of this letter. If a deposit is not received, the account will be closed and further collection action will be taken. The Balance due after February 4,2008 will be $43.38 which includes additional fees and taxes. If you have any questions, please contact your branch representative. Sincerely, Commerce Bank Harrisburg, N.A. Deposit Services Department 1-888-937-0004 Commerce Bank! Harrisburg. N.A. PO Box 4999 3801 Paxton Street Harrisburg, PA 17111-0999 commercepc.com