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Home My WebLink About05-19-08 --.J 15056041169 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 !} } - 00 File Number INHERITANCE TAX RETURN RESIDENT DECEDENT o 33S- Date of Birth 02202008 05011928 Decedent's Last Name Suffix Decedent's First Name POYER ELLAINE (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 BOXES BELOW IX] 1. Original Retum D 4. Limited Estate [Xl D D 2. Supplemental Retum D 4a. Future Interest Compromise (date of death after 12-12-82) D 7. Decedent Maintained a Living Trust (Attach Copy of Trust) D 10. Spousal Poverty Credit (date of death D 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 D 3. Remainder Return (date of death prior to 12-13-82) D 5. Federal Estate Tax Retum Required o 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes FREDERICK M FORMAN Firm Name (If Applicable) REGISTER OF WILLS USE 81i1-Y Q g o C;~ '0 ;.g :::1: ~T~ ~ First line of address 939 CEDARS ROAD \.D Second line of address r-) .-11 -" ::?l: City or Post Office . :::6 ~~tILED ..... C) Ul State ZIP Code LEWISBERRY PA 17339 Correspondent's e-mail address: 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. Dedaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT RE OF PERSO RESPON OR FILING RETURN DATE ADDRESS 939 CEDARS ROAD LEWISBERRY PA 17339 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056041169 15056041169 MI MI --.J ~ ---I 15056042160 REV-1500 EX Decedent's Name: ELLAINE POYER 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, or transfers under Sec. 9116 (a)(1.2) x .0_ 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. 146,469.56 16. 17. 18. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056042160 Decedent's Social Security Number 107.01 1,279.25 17,389.15 139,249.00 158,024.41 8,299.85 3,255.00 11,554.85 146,469.56 146,469.56 6,591.13 6,591.13 o 15056042160 ---I REV-1500 EX Page 3 Decedent's Complete Address: File Number 2 0 0 8 - 0 0 3 3 5 DECEDENT'S NAME ELLAINE POYER STREET ADDRESS 939 CEDARS ROAD CITY I STATE I ZIP LEWISBERRY PA 17339 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 6,591.13 329.56 3. InteresUPenalty if applicable D. Interest E. Penalty Total Credits (A + B + C) (2) 329.56 0.00 TotallnteresUPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box 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) 6,261. 57 A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) 6,261. 57 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; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. D IX] b. retain the right to designate who shall use the property transferred or its income; . . . . . . . . . . . . . . . . . . .. D 129 c. retain a reversionary interest; or ................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. D 129 d. receive the promise for life of either payments, benefrts or care? ................................ D 129 2. If death occurred after December 12,1982, did decedent transfer property within one year of death w~hout receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. D IX] 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? . . . .. D [Xl 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . . .. . . . . .. .. .. .. .. . . .. .. . . . . .. . . . . .. . . . . .. .. .. . . .. .. . ... [Xj 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. 39116(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. 39116(a)(1.1 )(ii)J. 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. 39116(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. 39116(1.2) [72 P.S. 39116(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-1503 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF ELLAINE POYER FILE NUMBER 2008-00335 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUEAT DATE OF DEATH JP MORGAN CHASE & CO (JPM) 2.4964 SHARES - COMMON STOCK @ $42.865 107.01 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 107.01 REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF ELLAINE POYER FILE NUMBER 2008-00335 Include the proceeds of I~igation 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 COUNTRY MEADOWS - REFUND VALUE AT DATE OF DEATH 947.23 2 HORIZONS INSURANCE - REFUND 332.02 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 1,279.25 REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF ELLAINE POYER FILE NUMBER 2008-00335 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINTTENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. FREDERICK M FORMAN 939 CEDARS ROAD LEWISBERRY, PA 17339 SON B. C. JOINTLY.QWNED PROPERTY: LEDER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY.HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A 5-2-95 PNC BANK D4,778.30 50 17,389.15 SENIOR CHOICE PLAN INTEREST CHECKING ACCOUNT ACCOUNT # 81-0153-9239 TOTAL (Also enter on line 6, Recapitulation) $ 17,389.15 (If more space is needed, insert add~ional sheets of the same size) REV-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER 2008-00335 ESTATE OF ELLAINE POYER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. NONQUALIFIED ANNUITY 139,249 100 139 ,249.00 PRUDENTIAL ANNUITIES LIFE ASSURANCE CO PO BOX 13686 PHILADELPHIA, PA 19176 ANNUITY - 000344439 TOTAL (Also enter on line 7, Recapitulation) $ 139,249.00 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF ELLAINE POYER FILE NUMBER 2008-00335 ITEM NUMBER A. 1. Debts of decedent must be reported on Schedule I. DESCRIPTION 2 3 4 5 FUNERAL EXPENSES: MALPEZZI FUNERAL HOME MINISTER AT CHURCH MEMORIAL SERVICE THISILLDOUS CATERER OWENS MONUMENTAL CO COST TO OPEN GRAVE B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2. Attorney Fees Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant FREDERICK M FORMAN Street Address 939 CEDARS ROAD City LEWISBERRY State PA ZIP 17339 Relationship of Claimant to Decedent SON 3. 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 ofthe same size) AMOUNT 3,672.25 200 319.60 110 150 3,500 198 150 8,299.85 REV-1512 EX+ (12-03) SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ELLAINE POYER FILE NUMBER 2008-00335 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER 1. DESCRIPTION 2008 IRS TAX LIABILITY VALUE AT DATE OF DEATH 3,255.00 TOTAL (Also enter on line 10, Recapitulation) $ (11 more space is needed, insert additional sheets of the same size) 3,255.00 REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF ELLAINE POYER FILE NUMBER 2008-00335 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116(a)(1.2)] 1 FREDERICK M FORMAN 939 CEDARS ROAD LEWISBERRY, PA 17339 SON AMOUNT OR SHARE OF ESTATE 100% 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 (If more space is needed, insert additional sheets of the same size) TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ LAST HILL AND TESTAHENT I, Ellaine Poyer, of 577 Route 46, Columbia, NJ 07832, in the Township of White, County of Warren and state of New Jersey, do hereby make, publish and declare the following as an~ for my Last Will and Testament, hereby revoking all uills and Codicils by me heretofore made. FIRST: I direct that my Fiduciary herein named shall pay all of my just debts, provided the same are reasonable, giving to my Fiduciary full power and authority to determine the reasonableness thereof, and to compromise claims vJith any of my creditors. I hereby direct that any judicial or other accounting or financial statement made during administration of my estate or afterward shall not be made pllblic, but shall ahlays be sealed and not open to public inspection. SECOND: I hereby nominate, constitute and appoint Frederick Forman as my Fiduciary, with full power and authority to carry into effect the terms of this my Last Will and Testament, and to transfer, lease, sellar convey any and all of my property, including any business in which I may be engaged, further including the authority to execute all Bills of Sale, Deeds, Affidavits of title and any and all other documents necessary to effectuate the foreaoina powers, further directing that my Fiduciary shall n~t b~ compelled to give bond or other security, any present or future law to the contrary notwithstanding. \ ~ '\ i\~ )v""" .>, In the serve for any Fiduciary, to above. event that my Fiduciary named above ooes not reason, then I nominate Carol Forman, to be serve without bond, with the same powers as o ,)~ ~~' .-:-,~ ''-''-.j In serve for Fiduciary, above. the event that my Fiduciary named above does not any reason, then I norainate Ruth Gommoll, to be to serve without bond, Hith the same powers as 'I'BIRD: I give, devise and bequeath all the rest, residue and remainder of the property of which I die seized and possessed, whether real, personal or mixed, of any kind whatever and wherever situate, to Frederick Forman, per stirpes. FOURTH: In the event no remainder beneficiary takes under paragraph Third hereinabove, then I give, devise and bequeath all the rest, resiGue and remainder of the property of which I die seized and possessed, whether real, personal or mixed, of any kind whatever and wherever situate, one half to Ruth Gommoll, per stirpes, and one half to Carol Forman, per stirpes. FIFTH: In the event there are beneficiaries under this my Last Ni11 and Testament who are under the age of 25 years, then I give, devise and bequeath the share of such minor chilJ to my Fiduciary as trustee in trust, to serve ~r~0 (~,-->:"- ._/7 .,<-z.<-<-\;:'-;/iXCN'y.- v!ithout bond, for the uses and purposes hereinafter expressed, and with full power and authority to lease, mortgag-e, assi911, grant, bargain, sell and convey any part or all of my trust estate at public or private sale, at which time and upon such terms as my trustee shall deem just and proper, to invest and reinvest the income therefrom and the principal, to borrow money, abandon property having no net value, to compromise any claim allegedly owed to or oweJ by my trust estate and at all times to have full power and authority to execute all documents necessary to effectuate the foregoing powers. A. My Trustee shall expend these trust funds for the maintenance, support and education of the minor beneficiaries, giving to my Trustee full discretion as to the amount of such expenditure of interest or principal or both for the maximum benefit of my minor beneficiaries, including the authority to make such expenditures above the level of necessity, and to base such expenditures upon any special skill or ability possessed by any of my minor beneficiaries, and to base such expenditures upon circumstances as they may appear in the future. B. On the date that each such minor beneficiary shall attain the age of 25 years, my Trustee shall distribute my trust estate pro rata to such minor beneficiary. In ~Jitness vhereof, L~ hereunto set my hand seal this 30 day of ~-=-=-=- , 19<17. and ~ i!/~ -' L L<--7 ~"/r;::. ,,'-"-'-:~ '~')::lu__~,_)__ (./ .~ ( ;;; //. . '-.)=F' -. / _"c..P'(;{~L'FC./- / c; .'-'- _ Ellaine Poyer C AFFIDAVIT I, Ellaine Poyer, the testatrix, sign my name to this instrument this .3D#loay or ;;,7u.-,-v<- , 1997 I and being duly sworn, do hereby declare to ~he undersigned authority that I sign and execute this instrument as my last will and that I sign lC willingly (or willingly direct another to sign it for me) and that I execute it as my free and voluntary act fer the purposes therein expressed, and that I am 18 years or age or older, or sound mind, and under no constraint or undue inrluence. (;) ... /:'.0 . 0 l..l:}k~4d' / C)/.'L/ Ellaine poyei/ He, Thomas R. Hampshire and Ann Harie Grunn, the witnesses, sign our names to this instrument, and, being duly sworn, do hereby declare to the undersigned authority that the testatrix signs and executes this instrument as her last will and that she signs it willingly ( or willingly directs another to sign it for her) and that each of us, in the presence and hearing of the testatrix, hereby signs this will as witness to the testatrix' signing, and that to the best of our knowledge, the testatrix is 18 years of age or older, or sound mind, and under no constraint or undue influence. ~Pi. Thomas R. ... .-:. ,-__/~~!l-i (,~~&,~.-/ ~UJ--" t'" .~:t-../U~?'----. ~nn Harie Grunn,. ". state of New Jersey :ss County of Harren Subscribed, sworn to and acknowledged before me by Ellaine Poyer, the testatrix and subscribed and sworn to before me by ThOhlas R. Hampshire and Ann !1arie Grunn, witnesses, this 3o.-+?[ day of QtL~ , 197'7 . u <:;::":,-. -'J //-/ "7 C~.a-,.",-..-= C. ,Y'"~-<-_ ELEANOR C. HAM LEN NOTARY PUBLIC OF NEW JERSEY MY COMMISSION EXPIRES JAN. 4, 2002