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Home My WebLink About05-12-08-~ REV-1500 15056041147 ~ (~5) OFFICIAL USE ONLY PA Department of Revenue county coda near File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po Boxzaoso~ 21 0 7 0 5 4 6 Harrisburg, PA ~~~2s-oso~ RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 195322653 05202007 11291941 Decedent's Last Name Suffix Decedent°s First Name MI DAVIS MILDRED E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 1. Original Retum ^ 2. Supplemental Retum ^ 3. Remainder Retum (date of death prior to 12-13-82) ^ 4. Limited Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required (dale of death after 12-12-82) ^ g Decedent Died Testate ^ ~ Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy o1 Trust) ^ 9. Litigation Proceeds Received ^ 1 O. Spousal Poverty Credit ((date of death 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) ^ (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number NORA F. BLAIR 7175411428 Firm Name (If Applicable) First line of address 5440 JONESTOWN ROAD Second line of address PO BOX 6216 City or Post Office State HARRISBURG PA ZIP Cod REGISTER'S Y~I ILLS US®NLY_ _ ~` - - _, . C7 .. 4-. ~ _.. --- . ~ _ n r ;-r-l -- C:~J f\? rr _ . t , '_ ~ l0~ ~ ` C ~:~ - - ~ N _ ~TE FILED ~ - , e 17112-0216 v ,~ Comespondent'se-mailaddress: NFBLAW@comcast.net Under penalties of perjury, I deGare that I have examined gris return, inducting accompanying schedules and statemer>ts, and to the best of my knowledge and belief, it is true, correct and complete. Dedaration of preparer other than the personal n>presentatrve Is based on all information of which preoarer has anv knowledge. ADDRESS ~a~-~-- Albert L. Comer Ill ~~ = S - - t~ 1240 Hi~hspire Road, Harrisburg, PA 17111 SIGNA OF PREPARER OTHER THAN REPRESENTATIVE DATE ,!~ ~~-~ ~~- Nora F. Blair ~ ~~--, t)~ 5440 Jonestown Road, Harrisburg, PA 17112-0216 Side 1 ~, 15056041147 15056041147 J .,~~1 J 15056042148 REV-1500 EX Decedent's Social Security Number oecedern~s IJane: D A V I S, M I L D R E D E. 19 5 3 2 2 6 5 3 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 Properly (Schedule F) ^ Separate Billing Requested ........... .. li. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G} ^ Separate Billing Requested ........... .. ;~. 8. Total Gross Assets (total Lines 1-7) ..................................................................... .. £;. 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... .. Si. 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ............................. ... 1C-. 11. Total Deductions (total Lines 9 8 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. 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 .00 15. 16. Amount of Line 14 taxable at lineal rate X .045 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. Tax Due ..................................................................................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 12,908.95 812.98 1,152.11 14,874.04 - --- - 18,237.45 7,194.91 25,432.36 -10,558.32 -10,558.32 0.00 Side 2 15056042148 15056042148 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 - 07 - 0546 Davis, Mildred E. STREET ADDRESS -- __- _ __ __ __ _ __ ______.__ _. ____ 514 North Front Street _ - - - - _ - -_ CITY - - _ _ _ _ STATE_ _ ,ZIP - _ _ _ i Wormleysburg PA 17043 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InterestlPenalty if applicable p, Interest E. Penaky Total Credits (A + B + C) Total Interest/Penafty (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. q, 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 W/LLS, AGENT (1) 0.00 (2) 0.00 (3) 0.00 (4) (5) 0.00 (5A) (56) ~ . Q 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 :.................................................................................. j ~_ ~xJ b. retain the right to designate who shall use the property transferred or its income :.................................... I ~ x~' c. retain a reversionary interest; or .................................................................................•---...---...........----•---.... j ~; z _'' d. receive the romise for life of either a ~ ................. . P p yments, benefds or care. ............................................ `_ I ~ x I 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .................................................................................................... ' _ ~ X _ ~ :__ _ __ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... ~ 1 x 1 __, 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which _ contains a beneficiary designation? ...................................................................................................................... ' xJ 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 Jufy 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 p2 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disGosure of assets and filing a tax return are still applicable even if the surviving spouse is the only benefiaary. For dates of death on or after Juty 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger a1 death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent p2 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) p2 P.S. §9116 (a) {1)]. The tax rate imposed on the net value of transfers to os 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 carnmon with the decedent, whether by blood or adoption. ', SCHEDULE E ~~, ~ CASH, BANK DEPOSITS, & MISC. COM~IONVVEALTFI OF PENNSYWANIA % PERSONAL PROPERTY III 9JHERITANCE TAX RETURN RESIDENT DECEDENT .. FILE NUMBER ESTATE OF pavis, Mildred E. ' 21 - 07 - 0546 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 DESCRIPTION VALUE AT DATE OF NUMBER DEATH 1 Commerce Checking Account 0513138388 16.30 2 ~ Principle Bank IRA 12,892.65 TOTAL (Also enter on Line 5, Recapitulation) 12,908.95 SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT '~. - - .Davis, Mildred E. _- _. _- -- _ - - _ -I --_ _ - -- _ - ESTATE OF i FILE NUMBER 21 - 07 - 0546 If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT Albert L. Comer III 1240 Highspire Road Son A Harrisburg, PA 17111-2331 JOINTLY OWNED PROPERTY: --_ - -- _ ~~. 9CRlPTIO~C~F PRO~ER~1' Y _- _ _ _ -- _- - - -- - ITEM LETTER DATE Include name o Inanaal Ins u Ion an ban account number ~ DATE OF DEATH' % OF ~ DATE OF DEATH NUMBER !FOR JOINT MADE or similar idenf m number. Attach deed for ~ointl -held real 'VALUE OF ASSET ~ DECD'S ~ vALUE of TENANT ! JOINT estate. INTEREST DECeDENrs wTEREST 1 A .04/15/2005 Sovereign Bank Account 2331039429 1,625.95 50°to 812.98 TOTAL (Also enter on line 6, Recapitulation) 812.9$ ~~ I. COMMONWEALTH OF PENNSYLVANIA SCHEDULE G INHERITANCE TAX RETURN II INTER-VIVOS TRANSFERS & RESIDENT DECEDENT ! MISC. NON-PROBATE PROPERTY ESTATE OF Davis, Mildred E. I FILE NUMBER 21 - 07 - 0546 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. - _ _ __ __ _ _ _ _ _ _ _-r _ - - - - _ - - - _. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH % OF EXCLUSION NUMBER Include the name of the trensferee, their relationship to decedent VALUE OF ASSET DECD'S (IF APPLICABLE) TAXABLE VALUE and the date of transfer. Attach a copy of the deed for real estate. INTEREST 1 H&R Block IRA with Tina Wojciehowski as beneficiary 576.05 ! I 576.05 2 ' H8rR Block IRA with Albert Comer III as beneficiary ~' 576.06 ' 576.06 TOTAL (Also enter on line 7, Recapitulation) 1,152.11 S(~fDU.E H RJPEJ'iAl.. & ~ COMAONWEALTH OF aENNSYIVANIA i INHERRANCE TAX RETURN i ~/~ RESIDENT DECEDENT • • - ` '~. FILE NUMBER ESTATE OF Davis, Mildred E. ~ 21 - 07 - 0546 __ _ _ __ Debts of decedent must be reported on Schedule 1. ITEM NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT A. 1 'Neill Funeral Home 11,096.73 2 ' Brachendorf Memorials 1200.00+1170.00 2,370.00 3 Luncheon 496.38 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. Attorneys Fees Nora F. Blair, Esquire i 1,240.00 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 Dauphin County Register of Wills ' 100.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1 PP&L 77.84 ___ TOTAL (Also enter on line 9, Recapitulation) 18,237.45 Sched~~ie H Funeral E~er»s ~ j COMMONWEALTH OF PENNSYLVANIA ^~,,~w~,,~,~ INHERITANCE TAX RETURN ~ ~~~ ~+~.J~ {+1J11~ 1{JC~IJ I' RESIDENT DECEDENT __ -- - --- ~ FILE NUMBER ESTATE OF Davis, Mildred E. 121 - 07 - 0546 2 Shipping Expenses 49.50 3 2007 Federal Estate Income Tax 2, 807.00 Page 2 of Schedule H j SCHEDULE DEBTS OF DECEDENT, MORTGAGE °°' ~" ~E°~~~,~"~Iw ! LIABILITIES, 8~ LIENS RESIDENT DECEDENT ~. _ __ _-_--. _-__ - -- _r-_ FILE NUMBER ESTATE OF DaV1S, Mildred E. 21 - 07 - 0546 Include unreimbursed medical expenses. - -_ - ____ ITEM NUMBER DESCRIPTION ._ __ __ 1 PPBL 2 Camp Hill Emergency Physicia 27.34+11.77 3 Family Home Medical 4 Holy Spirit Hospital 248.32+996.83+103.93 + 354.00 5 Mobile X-Ray Imaging, Inc. 6 Quantum lmaging & Therapeutic Associates 136.56+23.20+29.69 7 Physicians of Rehab 8 Urology of Central PA 9 Hershey Kidney Specialists INC 10 Moffitt Heart 8~ Vascular Group 11 West Shore Emergency Med 12 Susquehanna internal Medicine 36.64+504.96 13 Sears 1029.72 14 Comcast 15 Phillip & Cohen for Portfolio Recovery Assocaites 16 Capital One AMOUNT _- __ --- 92.43 39.11 24.05 1,703.08 10.91 189.45 152.05 i 55.00 621.57 122.56 70.12 541.60 1, 029.72 36.00 1,509.11 998.15 TOTAL (Also enter on Line 10, Recapitulation) 7,194.91 REV-1513 E7(+ (8-00) j SCHEDULE J COMM HEN R TANCE TAX ETURNANIA ' BENEFICIARIES ' RESIDENT DECEDENT - __ ESTATE OF FILE NUMBER Davis, Mildred E. 21 - 07 - 0546 RELATIONSHIP TO SHARE OF ESTATE 'AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT , (Words} ~ ($$$) RECEIVING PROPERTY oo Na uu Tnntoe(s) - - _. - -- - _ _ - _ i- - - _ ._ ---- - - - -- - - _ - __- ---~ --- __ - _. ---- I~ '.TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1 Albert L. Comer III ~ Son !One half of net 1240 Highspire Road 'estate. Harrisburg, PA 17111 2 Tinamarie M. Wojciechowski Daughter One half of net 1013 Main Street i 'estate. Oberlin, PA 17113 .Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet III '.NON-TAXABLE DISTRIBUTIONS: !A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TU TAX IS SNOT BEING MADE , B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 y k ~.i I^ 1 . ~^ s., rInST-CLASS ~'ER '~ 1 ,, ~y ISA FIRST-C1A55 'CRErFR L n .~ r USA FIRST-GLASS ~ ~T$ ll5A FIRST-CLASS FOAEVEA (/,A~, `-. C t d r r =r .t. ~ 1 3 !' 4~ • 6 s- ~ ~ n '~ i a a ~ t~ oc ~ ~~ rl I ~ ,~ a~,~ ~ ~~~~~ ~ ~~ ~ '~ a ~ + ~ °' ~~>~ ~; o ,~; O ~ ~w ~ G~ ^~ .~ _~ .~ LL~ ., •~ ~ f. 1 fl i~~' ~ ~~ ~ _; ~ F• ~ y c~ .: -~ -~ ~ _ .~ ~~ fF. '. ;j <~ ~= -, ~: .. ~, ~; ~; ~1 NORA F. BT ,ATR, Post Office Box 6216 Attorney at Law FAX (717} 541-1429 Harrisburg, Pa 17112-0218 5440 Jonestown Road (717) 541-1428 NFBLAW@paonline.com TO: ~~ti~~ l(~~1 U UrYI ~ r ~ I ~'+~ CF,1= ~ ~S DATE: S~ ` ~ - ~~` CLIENT: Cc~ ~ r~,Yl~r~ ,~ll~-~~.5 ENCLOSED PLEASE FIlVD THE FOLLOWING DOCUMENT (S) _ Deed _ Quit Claim Deed _ Mortgage Satisfaction Piece Petition Other: ALSO ENCLOSED: Inventory Inheritance Tax Return Status Report - Answer _ Motion Matrix Chapter 7 Petition _ Chapter 13 Petition - Bankruptcy Schedules _ Filing Fee Application and Order Objection to Plan Self-addressed Stamped Envelope for Return of Order/decree Self-addressed Stamped Envelope for Return of Copies and Order/decree Self-addressed Stamped Envelope for Return of Copies Self-addressed Stamped Envelope Stamped Envelope Addressed to Grantee(s) Stamped Envelope Addressed to Debtor(s) _ Check for additional probate fees Amount $ Check for inheritance tax Amount $ Check for filing fees Amount $ Other: PLEASE TIlVIE STAMP AND RETURN THE COPIES TO MY OFFICE. PLEASE RETURN SIGNED ORDER/DECREE TO MY OFFICE. YOUR ASSISTANCE IS GREATLY APPRECIATED. IF T'HFR.F. IS A PROBLEM, PI~~SE CALL ME AT 541-1428 OR 1-877-233-9540.