The URL can be used to link to this page

Home My WebLink About05-22-08 (2) --I 15056041125 REV-1500 EX (06-05) PA Department of Revenue '* ~~~~:~~~~~uaITaxes INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICIAL USE ONLY County Code Year 2 1 0 8 File Number o 0 3 0 2 Date of Birth 178166165 03092 0 0 8 o 8 0 4 1 9 2 1 Decedent's Last Name Suffix Decedent's First Name Pol k Mae MI K (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 00 1. Original Return o 4. Limited Estate 00 o 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (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 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received o o o o 8. Total Number of Safe Deposit Boxes 2. Supplemental Return o o o 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required H . Ant h 0 n y Adams 717 532 327 0 Firm Name (If Applicable) S hip pen s bur g P A 17257 I-~EGISTER",O" FW IllS iJs~ LV '-',,1, C) 251 c::::.o ~ -n ::::r.: of I ' .', -~. 'I . -'(J ~ ... -.e") -< ," I.~;;s ~ I!" I . . r "'0 1 L! . ~~~; -0 '--r ";J"n :::;.: ; "-- - __ Dii~~k~~.~ ;"> - ex> II First line of address 4 9 W est Orange Street Second line of address Sui t e 3 City or Post Office State ZIP Code Correspondent's e-mail address:htadamslaw@2embarqmail.com Under penalties of pe~ury, I declare that I have examined this retum, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correcf and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGN RE OF PERSON RESPON OR Fill U Shippensrug PLEASE USE ORIGINAL FORM ONLY PA 17257 Side 1 L 15056041125 15056041125 --I \\Ji -.J 15056042126 REV-1500 EX Decedent's Name: Ma e K. Po 1 k RECAPITULATION 1. Real estate (Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 2. Stocks and Bonds (Schedule B) .................................. ~ 3. Closely Held Corporation, Partnership or SoJe-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. 16. Amount of line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X.O _ o . 0 0 15. Amount of line 14 taxable 7 6 1 o . 0 5 at lineal rate X .O~ 16. Amount of line 14 taxable o . 0 0 at sibling rate X .12 17. Amount of line 14 taxable o . 0 0 at collateral rate X .15 18. 17. 18. 19. Tax Due ................................................ 1~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056042126 Decedent's Social Security Number 178166165 17823.58 17823.58 35647.16 1 0 2 1 3.5 3 1 0 2 1 3.5 3 7610.05 7610.05 O. 0 0 342.45 O. 0 0 O. 0 0 3 42.45 o 15056042126 -.J REV-1500 EX Page 3 Decedent's Complete Address: D!:CEDENT'S' NAME M~e K. polk _~~___ .___~ ____ __ STREET ADDRESS 160 Gardner Drive SME File Number 21 08 00302 CITY Shippensburg .~ .[.. STATE -~-----~-- ~T-. I ZIP I PA 117257 -.- Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 342.45 Total Credits (A + 8 + C) (2) 3. InteresUPenalty if applicable D. Interest E. Penalty T otallnteresUPenalty ( 0 + E ) 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. 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (3) (4) (5) (5A) (58) 0.00 0.00 342.45 4. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. 342.45 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 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. ~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 orfor 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-1508 EX + (6-98) . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mae K. Polk FILE NUMBER 21 08 00302 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 VALUE AT DATE OF DEATH 17,823.58 Checking Account at Orrstown Bank TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 17,823.58 REV-1511 EX + (12-99) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mae K. Polk SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21 08 00302 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Fogelsanger-Bricker Funeral Home, Inc 4,505.00 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 H. Anthony Adams 1,000.00 3. Family Exemption: (If decedents address is not the same as claimants, attach explanation) 3,500.00 Claimant James K. Polk Street Address 160 Gardner Drive SME City ShippensburQ State P A Zip 17257 Relationship of Claimant to Decedent so 4. Probate Fees 5. Accountants Fees 6. Tax Return Preparer's Fees 7. Chambersburg Hospital 1,012.81 8. Shippensburg Area EMS 195.72 TOTAL (Also enter on line 9, Recapitulation) $ 10213.53 .. (If more space is needed, Insert additional sheets of the same size) ,"'-"" '" <'* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mae K Polk SCHEDULE J BENEFICIARIES RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. James K. Polk Lineal 160 Gardener Drive SME 100 Shippensburg, PA 17257 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 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ .. FILE NUMBER 21 08 00302 (If more space IS needed, Insert additional sheets of the same size) LAST WILL AND TESTAMENT KNOW ALL MEN BY THESE PRESENTS, that I, MAE K. POLK, of Shippensburg, Franklin County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking all prior wills and codicils by me at any time heretofore made. FIRST: I direct the payment of all my legal debts, funeral expenses including my grave marker and all expenses of my last illness, state, federal estate and inheritance taxes and administration costs shall be paid as soon as may be conveniently done following my decease leaving all specific bequests free of tax to the legatee. I further direct that the burial of my son, James K. Polk, be in my cemetery lot at the Middle Spring Presbyterian Church cemetery. SECOND: I give, devise and bequeath all my property be it real, personal and mixed to my son, James K. Polk. If James K. Polk should predecease me or if we should die in a common disaster, I give and bequeath all of my property be it real, mixed or personal to my son, Joseph W. Polk. THIRD: I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as part of the expenses of the administration of my estate FOURTH: I nominate and appoint, James K. Polk, as Executor of this my Last Will and Testament. If he should fail to serve or be unable to serve, then in either of those said events, I nominate and appoint, Joseph W. Polk, as Executor of this my Last Will and Testament. IN WITNESS WHEREOF, I, MAE K. POLK, to this my Last Will and Testament set my hand and official seal, this /t,,- day of ~ 2004. 9ft~ MAE K. POLK lr: Q4 (SEAL) Sworn to and subscribed, declared and Published by MAE K. POLK, as Her Last Will and Testament, and so Done in the presence of we the Witnesses, who sign at her request, And in her presence, and in the presence Of each other. O~P- /JJ Ji~ ,dL C/V~ /'" COMMONWEALTH OF PENNSYLVANIA: :SS COUNTY OF CUMBERLAND I, MAE K. POLK, whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed it willingly; and that I signed it as my free and voluntary act for the purpose therein expressed. i!t~ ;r 9~ ME. POLK Sworn to and acknowledged, before me, By MAE K. POLK, the~esta~, This 1<..5- day of ~ 2004. Notarial Seal H. Anthony Adams, Notary Public Shippensburg Boro, Cumberland County My Commission Expires May 15, 2006 L19I"ber. PennsYIV<im3AsSOCialion ot Notaries COMMONWEALTH OF PENNSYLVANIA: ' :SS Notary Public COUN1Y OF CUMBERLAND WE, Darlene M. Bigler and Sharon Coleman Adams, the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we saw the Testatrix sign and execute the instrument as her Last Will and Testament; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses, and that to the best of our knowledge and belief the Testatrix was at the time at least eighteen (18) or more years of age and of sound mind and under no constraint or undue influence. f~ fJ1 &jIw d2 ~ (1 /) : / ~" / / ~/ .~J2.<&>- / Sworn to and subscribed before me by, Darlene M. Bigler and Sharon co~ The witnesses, this I SfY'day o. 2004. ~~ G Notarial Seal I H. Anthony Adams, Notary Public ' Shippensburg Bore, Cumberland County My Commission Expires May 15, 2006 r," ,); .jsr. Pennsylvania Association ot Notaries - j ~ :. . ~\ ~ ~o p tr. ~ ~.~ ~ ~ \l ,,~~ ~ ~~ ;i 1.rI Ul } .. l. -- --.. ~ .~. ;,....-. ;.::::: - --:;.. .;:... - -' ~: ~ -' .;:... ~ - ~ -:::- -. ~. .;:-. ..::-. ~ -. -. =:-* -. :::;... --::.: