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Home My WebLink About04-18-08 .....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 Social Security Number Date of Death OFFICIAL USE ONLY County Code Year INHERITANCE TAX RETURN RESIDENT DECEDENT 2 1 0 7 File Number 01068 Decedent's Last Name Suffix Date of Birth 06141947 Decedent's First Name MI SANDRA L Spouse's First Name MI JOHN P 288404517 11062007 ADAMS (If Applicable) Enter Surviving Spouse's Information Below SpolJse's Last Name Suffix ADAMS SpolJse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 181 1. Origmal Return 0 2. Supplemental Return 0 3. Remainder Return (date of death prior to 12-13-82) 0 4. Limited Estate 0 4a. Future Interest Compromise 0 5. Federal Estate Tax Return Required (date of death after 12-12-82\ 0 6. Decedent Died Testate 0 7. Decedent Maintained a livIng Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 0 9. Litigation Proceeds Received 0 10 Spousal Poverty Credrt ~ date of death 0 11. Election to tax under Sec. 9113(A) . between 12-31-91 and -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 SHELLY J. KUNKEL 7172369301 City or Post Office HARRISBURG State PA ZIP Code 17101 (.)0 ;3t~ ~n DA ~ FJt.ED -0 3: N .. Firm Name (If Applicable) WION, ZULLI & SEIBERT 109 LOCUST STREET .::=> REGISTER<OF WILLS UsgpNL Y.; . S;o :t> ., >j;g -0 -c; .., (") :;:0 J'};. ;,,",-n -"-" :::c Cf) CI_' ?' First line of address Second line of address \D correspondent.se_mailaddress:sjkunkel.wzs@mi.ndspri.nq.com Under penalties of perjury, I declare that. I have examined this return, mcluding accompanying ..chedules 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 allmformatlon of which preparer has any knowledge /)GNA:JRE O~:~~~~ON RESPONSIBLE FOR FILING RETURN ~ATE \::..-^_~ . ( \~~>, . k t\ . )'1\ ,', Paula D. Potteiger ADDRESS O"faith Circle, Carlisle, PA 17013 TURE OF PREPARER OTHER THo,N REPRESENTATIVE " ~- ADD ES~ 109 Locust Street, Harrisburg, Pa 17101 DATE Shelly J. Kunkel Lf-'("OK L 15056041147 15056041147 --.J) 'V~ Side 1 --I 15056042148 REV-1500 EX Decedent's Name. ADAMS, SANDRA L. 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 Property (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. 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 ~ 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 15. 16. 17. 18. 19. Tax Due........................ ....J9. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 L 15056042148 Decedent's Social Security Number 288404517 15,472.70 15,472.70 14,395.06 17,257.95 31,653.01 -16,180.31 -16,180.31 0.00 D 15056042148 --I REV:1S00 EX Page 3 Decedent's Complete Address: DI= D N' AME Adams, Sandra L. _u_.___.._ _________ . _______ __._....___..__ __ _.._____.____..___ __ ____.... _ STREET ADDRESS 504 Quail Court File Number 21 - 07 - 01068 Mechanicsburg --- -------- ----iSTATE - - PA TZIP - - 17050 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 ) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits (A + B + C) (2) 0.00 Total Interest/Penalty (D + E) 4. H 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. 11' 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 + SA. This is the BALANCE DUE. (3) 0.00 (4) (5) 0.00 (5A) (58) 0.00 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;........... ......................................................... ..........1. ,x b. retain the right to designate who shall use the property transferred or its income;.................. .,.............. x c. retain a reversionary interest; or................................................... ................................... ......... .......... x d. receive the promise for life of either payments. benefits or care?............................................................. x 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?......................................,............................ ................................................ .i.- _x_, 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?.........! 1 x 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation?................................................,....... .................................... ............ ......:.. x I IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETUR 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. 39116 (a) (1.1) (i)). For datl~s 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 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 datEls 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 81S 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. *' SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Adams, Sandra L. Include thEl proceeds of litigation and the date the proceeds were received by the estatEAII property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM NUMBER 1 DESCRIPTION VALUE AT DATE OF DEATH 25.00 Member's 1st Federal Credit Union 5000 Louise Drive Mechanicsburg, PA 17055 Regular Savings Account # 283160-00 Valuation at Date of Death See Member's 1 st FCU correspondence attached hereto as Exhibit E. No accrued interest 2 Member's 1st Federal Credit Union 5000 LOUIse Drive Mechanicsburg, PA 17055 Investment Savings Account # 283160-05 Valuation at Date of Death See Member's 1st FCU correspondence attached hereto as Exhibit E. 3 Member's 1 st Federal Credit Union !5000 Louise Drive Mechanicsburg, PA 17055 Investment Savings Account # 283160-05 Accrued interest through date of death. TOTAL (Also enter on Line 5, Recapitulation) 15,443.51 4.19 15,472.70 *' SCHEDULE H FlJNERALEXPENSES & ADNINISlRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT I -- ------- - - -- ---- ----------- ---l-- --- -----------_____ I FILE NUMBER I 21-07-01068 ESTATE OF Adams, Sandra L. Debts of decedent must be reported on Schedule I. --- -- -~- ---- -- - - -- ITEM NUMBER FUNERAL EXPENSES: -- - -------.----------,,--- ----------------- A. 1 Malpezzi Funeral Home - Funeral bill DESCRIPTION AMOUNT 2 Funeral Plot - Longsdorff Cemetery B. : ADMINISTRATIVE COSTS: 1. ,Personal Representative's Commissions . Paula D. Potteiger Social Security Number(s) / ErN Number of Personal Representative(s): Street Address 30 Faith Circle 2. 3. City Carlisle State PA Zip 17013 Year(s) Commission paid Attorney's Fees Wion, Zulli & Seibert -- Shelly J Kunkel Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant John P. Adams Street Address 504 Quail Court City Mechanicsburg State PA Zip 17050 Relationship of Claimant to Decedent Spouse Probate Fees Cumberland County Register of Wills 4. 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1 The Cumberland Law Journal - Estate Advertisement TOTAL (Also enter on line 9, Recapitulation) 5,452.48 575.00 1,000.00 3,500.00 3,500.00 88.00 75.00 14,395.06 . SchedUeH fu1eraI Expel ases & AdniristraINe Q)sts conIin.Ied COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ____~_ ___ ESTATE OF Adams, Sandra L. I FILE NUMBER \21-07-01068 2 The Sentinel - Estate Advertisement 174.58 3 Cumberland County Register of Wills - Filing Fee for PA 1500 15.00 4 Cumberland County Register of Wills - Filing Fee for Inventory 15.00 Page 2 of Schedule H *' SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ~ -" -- ---"-"--c"="'"~~"c_c"~ ESTATE OF Adams, Sandra L. FILE NUMBER 21 - 07 - 01068 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1 Quantum Imaging and Theraputic Associates - Medical bill(s) 1,192.82 2 Spirit Physician Services - Medical bill 92.29 3 Pathology Associates of Central PA - Medical bill(s) 78.53 4 MSHMC Physicians - Medical bill 243.22 5 Central Medical Equipment Co. - Medical bill 126.00 6 Camp Hill Emergency Physicians - Medical bill 27.34 7 Susquehanna Surgeons - Medical bill 33.12 8 MS Hershey Medical Center - Hospital Bill(s) 440.40 9 Pinnacle Health Hospitals - Hospital Bill(s) 2,688.12 10 Holy Spirit Health System - Hospital Bill(s) 1,295.13 11 West Shore EMS - ALS - Ambulance Bill 954.10 12 Rehab Medicine Associates, P.C. - Medical Bill 45.36 13 Sanford and Roumm Rheumatology - Medical Bill 11.34 14 Women's Cancer Center of Central Pennsylvania - Medical Bill 44.37 15 Capital One - Credit Card bill (Account ending -8769) 4,234.18 TOTAL (Also enter on Line 10, Recapitulation) 17,257.95 *' SCHEDULE I DEBTS OF DECEDENT, MORTGAGE i LIABILITIES, & LIENS continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Adams, Sandra L. Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION 16 Capital One - Credit Card Bill (Account ending -0678) 17 L VNV Funding LLC - Sears Credit Card Bill (Account ending -4190) FILE NUMBER 21 - 07 - 01068 18 i Commonwealth Financial Systems - Collection Agency for Providian - Credit Card Bill 19 Exxon/Mobil - Credit Card Bill AMOUNT 380.17 3,054.86 2,271.65 44.95 Page 2 of Schedule I ...J 15056042148 REV-1500 EX Decedent's Name: ADAMS, SANDRA L. 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 Property (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. 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 ~ 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 15. 16. 17. 18. 19. Tax Due......... .............. ........... ............................'-9. :20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 L 15056042148 Decedent's Social Security Number 288404517 15,472.70 15,472.70 14,365.06 17,257.95 31,623.01 -16,150.31 -16,150.31 0.00 D 15056042148 ...J REV-1513 EX+ (9-00) . SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF NUMBEH NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY -r --R-ELATIO~isHIP TO DECEDENT Do Not List Trusteels) FILE NUMBER 21 - 07 - 01068 -- -.- --- --- --- SHARE OF ESTATE! AMOUNT OF ESTATE (Words) ($$$) Adams, Sandra L. ') <- Paula D. Potteiger 30 Faith Circle Carlisle, PA 17013 Daughter 1/2 Residue I. 'TAXABLE DISTRIBUTIONS{include outright spousal ! C1istributions, and transfers , under Sec. 9116 (a) (1.2)] 1 i John P. Adams 504 Quail Court Mechanicsburg, PA 17050 Spouse 1/2 Residue ,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 I TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEEF 0.00 REGULAR SAVINGS ACCOUNT: Account Number/ Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established CHECKING ACCOUNT: Account Number/Suffix Date Account Established rincipal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established INVESTMENT SAVINGS ACCOUNT: Account Number/ Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Estate of: SANDRA ADAMS Date of Death: November 6,2007 S,ocial Security Number: 288-40-4517 ~1~ MEMBERS 1st FEDERAL CREDIT UNION 283160-00 04/12/2006 $25.00 $.00 $25.00 None 172527 -00 12/08/1997 $3,319.70 $.44 $3,320.14 John P. Adams 12/08/1997 172527 -11 12/08/1997 $.00 $.00 $.00 John P. Adams 12/08/1997 283160-05 04/12/2006 $15,443.51 $4.19 $15,447.70 None ,CSERS 1S~ FEDErL C~I]O(T UNION \YCt~ f\j- ~\~ Danielle A. Kline Insurance Services Specialist November 29, 2007 5000 Louise Drive . Po. Box 40 . Mechanicsburg, Pennsylvania 17055 . (800) 283-2328 . www.members1st.org DAVID A. WION FRANCIS A. ZULLI JEAN D. SEIBERT SHELLY J. KUNKEL Register of Wills Office Cumberland County Courthouse 1 Courthouse Square Carlisle, P A 17013 Dear Register of Wills: LAw OFFICES ~ rg'~ ((@ ~e/k,t P.O. BOx \12\ HARRISBURG, PA \7108-1121 113 E. MAIN STREET HUMMELSTOWN,PA 17036 (717) 566-250 I 109 locUST STREET HARRISBURG,PA 17\0\ (717) 236-9301 (717) 232-1488 FAX (717) 236-6100 EMAIL: WZS@MINDSPRlNG.COM April 16, 2008 ("') r;;O . c:~ :::0 ~:Ju ,-rC) ~C!>r; ~~~ (")0 " C.., ,~_~""'Tl -~~ 'O~ )> ~ .;:::) = = )> -0 ::0 co -0 :x ~ .. \.0 Enclosed please find an original and four copies of the Inventory along with an original and four copies of the P A Inheritance Tax Return for the above-referenced estate. Also enclosed is a check in the amount of $30.00 to cover the cost of filing these documents. RE: Estate of Sandra L. Adams No. 21-07-01068 Kindly date stamp the three whole sets marked "copy" and return same to me in the envelope I have provided. Thank you. SJKlkd Enclosures ~e trul,yYOUrs, '. ~ Shelly . Kunkel (l.-(l~ e; (lsJ& ...... .... .... 0 ..... Yl Yl ~ ..... ~ srg.g.~ "'do~a. >~p.~ .- (1) (l.... -.lC/lot=: ~.g g Yl VJe;~g (1) (l ~ o (1) ~ o ~ (1) it \il -tB. ~~~ -~ ~ lo:lC ~ 0 ;,:~~ :;\ ~_'" ~ n ~ ~~ ~ m 3-~ ~ ~ I