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Home My WebLink About05-29-0815056041147 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes cou,ty code Year File Number Po Box.2soso~ INHERITANCE TAX RETURN Harrisburg, PA 17728-oso~ - RESIDENT DECEDENT 2 1 0 8 0 0 0 2 1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 189 22 9082 08 28 2007 10 05 1926 Decedent's Last Name Suffix Decedent's First Narne MI BCRGER CARL A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Names MI BURGER C~RA A Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW X 1. Original Return 2. Supplemental Return i 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise 5. Federal Estate Tax Return Required ----- (date of death after 12-12-82) -- ~ g Decedent Died Testate ~ Decedent Maintained a Living Trust O 8. Total Number of Safe Deposit Boxes (Attach Copy of Wilq (Attach Copy or Trust) 9. Litigation Proceeds Received 10. Spousal Poverty Creda (date or death between 12-31-91 and 1-1-95) 11 Election to tax under Sec. 9113(A) (Attach SCh. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL 1'AX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number MARIELLE F HAZEN 7 1 7 5 4 0 4 3 3...?~ c7 '= ~ Firm Name (If A licable) _ pp HAZEN ELDER LAW I~EGISTER ~~IUILLS U~ONL'Y' r = --~ I __ ' First line of address _ T'~ _ ... '-_ 2000 LINGLESTGWN RD. - ~ ,_,; Second line of address ~ =-j ; =-i _ , SUITE 202 i~' tv ~ City or Post Office DATE FILED O State ZIP Code HARRISBURG PA 17110 Correspondent's a-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. Declaration of preparer other than the personal representative Is based on all informati~~n of which preparer has any knowledge. SIGNATURE OF ER ON RESPONSIBLE FOR FILING RETURN DATE ~~~ ~~, ®,~ Mark C Borger ~~ /11~C~ ADDRESS ~ / / 2254 Canterbury Drive, Mechanicsburg, PA 17055 SIG E OF PREP OTHER THAN REPRESENTATIVE DATE Marielle F. Hazen , ~ /L ~ /U ~ 2000 Linglestown Road, Harrisburg, PA 17110 Side 1 15056041147 1.5056041147 V~ 15056042148 REV-1500 EX Decedent's Social Security Number oaceda~t•s Name: C a r I A B o r g e r 1 8 9 2 2 9 0 8 2 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. 4 2 8 8 5 2 6. Jointly Owned Property (Schedule F) :Separate Billing Requested ............ . 6. 4 0 , 9 0 0 5 2 nter- ivos rans ers Miscellaneous N on Probate Property I (Schedule G) j Separate Billing Requested ............ . 7, 4 2 0 7 9 4 8. Total Gross Assets (total Lines 1-7) ...................................................................... . g. 4 9 3 9 6 9 8 9. Funeral Expenses & Administrative Costs (Schedule H) ........................................ . 9. 1 4 0 6 8 2 2 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. .. 10. 4 , 3 0 3 0 7 11. Total Deductions (total Lines 9& 10) .................................................................... .. 11 • 1 8 3 7 1 2 9 12• Net Value of Estate (Line 8 minus Line 11) ........................................................... .. 12. 3 1 0 2 5 6 9 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. 3 1 0 2 5 6 9 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 .00 2 2 5 7 6 2 3 15. 0 0 0 16. Amount of Line 14 taxable at lineal rate x .045 8, 4 4 9 4 6 16. 3 8 0 2 3 17. Amount of Line 14 taxable at sibling rate X .12 0 0 0 17. 0 0 0 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 18. 0 0 0 19. Tax Due .................................................................................................................... . 19. 3 8 0 2 3 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 15056042148 :15056D42148 REV-1500 EX Page 3 Decedent's Complete Address: Fite Number 21-08-00021 Carl A Borger STREET ADDRESS Essex House 20 North 12th St. Lemoyne 'STATE - _ - i ZIP. PA I 17043 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 380.23 2. Credits/Payments --_ A. Spousal Poverty Credit - ___ _ _ B. Prior Payments C. Discount 0.00 3. Total Credits (A + g + C) Interest/Penalty if applicable (2) 0.00 __ p. 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. _ (4) -- _ -- -- 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. (5) 380.23 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5g) 3 8 O.2 3 Make Check Payable to: REGISTER OF WILLS, AIGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN 1'HE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................. ~ ~X ~_ "~ retain the right to designate who shall use the property transferred or its income :.................................... ~ ! x I c. retain a reversionary interest; or .................................................................................................................. _ , = ~~ d. receive the promise for life of either payments, benefits or care? ............................................................. fix, 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?......... x 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ...................................................................................................................... i x I IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE Ci 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 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-1508 EX+ (8.98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Borger, Carl A 21-08-00021 Include the proceeds of litigation antl 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 PSECU Checking Acct. #8201869347 -Share 04; Mark C. Borger, son and joint 1,484.48 owner with right of survivorship; Mark C. Borger disclaimed his entire interest in the joint bank account per attached disclaimer; account was used to satisfy surviving spouse, Cora Borger's, elective share against estate 2 PSECU Money Market Acct. #8201869347 -Share 07; Mark C. Borger, son and joint 0.00 owner with right of survivorship; portion of account that was disclaimed by Mark C. Borger per attached disclaimer, and used to satisfy surviving spouse, Cora Borger's, elective share against estate ($14,079.77 value included in vialue of PSECU Money Market listed on Schedule F.) 3 PSECU Savings Acct. #8201869347 -Share 01; Mark C. Borger, son and joint owner 2,804.04 with right of survivorship; Mark C. Borger disclaimed his entire interest in the joint bank account per attached disclaimer; account was used to satisfy suirviving spouse, Cora Borger's, elective share against estate TOTAL (Also enter on Line 5, Rec:~pitulation) I 4,288.52 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1509 EX+ (6-96) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Borger, Carl A 21-08-00021 It 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 A. Mark C Borger B C 2254 Canterbury Dr. Son Mechanicsburg, PA 17055 JOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF~ ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1 A 2/24/2003 PSECU Money Market Acct. #8201869347 81,801.03 50.000% 40,900.52 -Share 07; Mark C. Borger, son and joint owner with right of survivorship DOD value of account: $81,801.03 Taxable value of account: $40,900.52 Less amount disclaimed by son to satisfy spousal election, per attached disclaimer: $14,079.77 Less amount disclaimed by son to satisfy debts/expenses per attached disclaimer: $18,371.29 Total amount of account that passed to son, Mark C. Borger: $8,449.46 TOTAL (Also enter on Line 6, Recapitulation) (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. 40,900.52 Form PA-1500 Schedule F (Rev. 6-98) Rev-1510 EX• (6-98) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Borger, Carl A 21-08-00021 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. ITEM NUMBER DE RIPTI N F PR PERTY INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 Thrivent Annuity Contract #62257416 -Joint and 4,207.94 100.000 4,207.94 Survivor Annuity; payments under this contract now being made to Cora Borger, surviving spouse; Cora Borger taking this annuity as a charge against her elective share TOTAL (Also enter on Line 7, Recapitulation) I 4,207.94 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) REV•1151 EX+(12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES 8~ ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Borger, Carl A 21-08-00021 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A, FUNERAL EXPENSES: See continuation schedule(s) attached 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, Attorney's Fees Hazen Elder Law 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 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 12,568.22 1,500.00 TOTAL (Also enter on line 9, Recapitul<~tion) I 14,068.22 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1502 EX+(6.98) gCHEDULE H-A FUNERAL EXPENSES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Borger, Carl A 21-08-00021 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-A (Rev. F-98) Rev-1512 EX+ (6-98) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Borger, Carl A 21-08-00021 Include unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Cardiology Diagnostic LLC -medical expense 1.53 2 Cardiology Vascular Surgical Inst. -medical expense 3.43 3 Conforti Physical Therapy -medical expense 40.92 4 Essex House -final housing expense 2,325.00 5 Hazen Elder Law -legal services rendered for decedent before death; paid after 323.00 death 6 HealthSouth Reg. Specialty Hospital -medical expense 28.00 7 Hershey Kidney Specialists -medical expense 31.45 8 Holy Spirit Hospital -medical expense 1,158.44 9 Internists of Central PA -medical expense 85.15 10 Kantor and Tkatch -medical expense 24.53 11 Kunkel Surgical Group -medical expense 27.79 12 Orthopedic Surgeons of Central PA -medical expense 3.56 13 Physicians of Rehabilitation -medical expense 30.11 14 Pinnacle Health Emergency -medical expense 8.10 15 Pinnacle Health Hospitals -medical expense 199.93 16 Pulmonary 8~ Critical Care Medical Assoc. -medical expense 6.07 Total of Continuation Schedule See attached page TOTAL (Also enter on Line 10, Recapitulation) 4,303.07 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) Rev-1512 EX+ (6-98) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA continued INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Borger, Carl A 21-08-00021 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) REV-1579 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Borger, Carl A 21-08-00 021 NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHAF2E OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) (Words) ($$$) I~ TAXABLE DISTRIBUTIONS (include outright spousal and transfers distributions , under Sec. 9116(a)(1.2)] 1 Cora Alice Borger Spouse 22,576.23 Essex House 20 N. 12th Street Lemoyne, PA 17043 2 Mark C. Borger Son 8,449.46 2254 Canterbury Dr. Mechanicsburg, PA 17055 Total 31,025.69 Enter dollar amounts for distributions shown above on lines 1 5 through 18, as appropr iate, on Rev 1500 cove r sheet II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO Ti~X IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I U.UU Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98) Attachment to REV-1500 filed in the Estate of Carl A. Borger, deceased Decedent died owning the following assets: • Joint savings account valued at $2,804.04 held jointly with sc-n, Mark C. Borger, who disclaimed his entire interest in this account to satisfy surviving spouse's elective share (as seen on Schedule E of REV-1500). • Joint checking account valued at $1,484.48 held jointly with son, Mark C. Borger, who disclaimed his entire interest in this account to satisfy surviving spouse's elective share (as seen on Schedule E of REV-1500). • Joint money market account valued at $81,801.03 held jointly with son, Mark C. Borger (as seen on Schedule F of REV-1500). Mark C. Borger disclaimed a portion of this account in the amount of $14,079.77 to satisfy surviving spouse's elective share (as seen on Schedule E of REV-1500). Mark C. Borger also disclaimed a portion of this account in the amount of $18,371.29 to satisfy the estate debts and expenses. The total amount of this joint account that actually passed to Mark C. Borger was $8.,449.46 (as seen on side 2 of the cover page ofREV-1500). • Annuity contract valued at $4,207.94, which named surviving; spouse, Cora Borger, as beneficiary. Cora Borger retained her beneficial interest in the annuity, which was taken as a charge against her elective share (as seen on Schedule G of REV-1500). • 2001 Toyota Echo, which was jointly held with surviving spouse, Cora Borger. The vehicle was sold to a third party for $8,395.00 (its fair market value). Cora Borger retained her beneficial interest in the vehicle, which was taken as a charge against her elective share. This asset was not reported on the REV-1500 since it was property jointly held by husband and wife. Below are the spousal election and disclaimer calculations: Total assets subject to election Less expenses Net Estate $98,692.49 ($18,371.29) $80,321.20 One-third net estate (elective share) $26,773.73 Less annuity that spouse took as charge against her elective share ($4,207.94) Less '/z vehicle that spouse took as charge against her elective share ($4,197.50) Spouse's remaining elective share $18,368.29 Spouse's remaining elective share $18,368.29 Less joint savings account disclaimed by son ($2,804.04) Less joint checking account disclaimed by son ($1,484.48) Amount son needs to disclaim from money market account to $14,079.77 fully satisfy spouse's elective share (as seen on Sch. E of REV-1500) IN RE: ESTATE OF CARL A. BORGER, Deceased. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. ELECTION OF SPOUSE TO TAKE AGAINST CONVEYANCES TO: MARK C. BORGER, Personal Representative of the Estate of Carl A. Borger. TO: The Register of Wills of Cumberland County and the Clerk of the' Orphans' Court Division of the above Court. PLEASE TAKE NOTICE that the undersigned, MARK C. BORGER, Agent under a Durable Power of Attorney dated November 13, 2003, for CORA A. BORGER, surviving spouse of CARL A. BORGER, deceased, does hereby elect to take against all inter vivos conveyances or transfers made by the said decedent which may be treated as testamentary dispositions so far as the undersigned is concerned under and pursuant to Chapter 22 of the Probate, Estates and Fiduciaries Code, 22 Pa. C.S.A. Section 2201 et seq., as amended, and to take said elective share under and pursuant to this election as provided for in said Code. This notice shall be filed of record as provided by law or rule of court. sue; ~~ / ~ [, rtl 1/GJ 9 Date: Z ~ I (~ ~ ~~~`,~ 1u~,y'r,~- .r ` ~,~ ~ ~~ MARK C. BORGER, gent for CORA A. ~ ~~~ BORGER, surviving spouse of CARL A. ~~ BORGER r~ ;~ - ~-~ =,~ COMMONWEALTH OF PENNSYLVANIA COUNT" OF ~ o~•~-~--- "- `'~ ~.,~. -w ON THIS, the ~ ISM day of ~ ~, 2007, before me a Na><ar~j Publi.~for the , Commonwealth of Pennsylvania, personally appeared MARK C. BORGER Agent fo~COIt A. BORGER, known to me to be the person whose name is subscribed to the within ELECTION OF SPOUSE TO TAKE AGAINST CONVEYANCES and acknowlf~dge that he executed the same for the purposes therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. (i ~ ~C» d~Clw~y~ Notary Public COMMONWEALTH OF PENNSYLVANW NotarW Seal Ca1me Elders Waofiame, Ndary PubNc N ~C E~iF-t g.1~20 1 IN RE: ESTATE OF CARL A. BORGER, Deceased. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT D:[VISION NO. 2008-00021 DISCLAIMER IN ACCORDANCE WITH 20 Pa. C.S.A. X6201 1. Carl A. Borger (Decedent) died on August 28, 2007, without a Will, survived by his spouse, Cora A. Borger, and his two (2) children, Mark C. Borger and Susan Mann. Decedent's estate consists of three (3) accounts he held jointly with Mark C. Borger valued at $86,089.55, a vehicle valued at $8,395.00, and a joint and survivor annuity contract valued at $4,207.94. 2. Decedent's estate is subject to the payment of funeral expenses, administration expenses, debts and taxes totaling approximately $18,371.29 to be paid from the joint accounts, leaving a net distributable estate of $80,321.20. 3. Pursuant to 20 Pa. C.S.A. §6304, any sum of the joint accounts remaining on deposit at Decedent's death belongs to the surviving joint owner of the accounts, Mark C. Borger. 4. Cora A. Borger has elected to take against Decedent's conveyances in accordance with 22 Pa. C.S.A. §2201 et seq. 5. Mark C. Borger desires to disclaim his interest in the joint accounts to the extent the funds are needed to satisfy debts and expenses of the esl:ate and Cora A. Borger's election against the conveyances. Therefore, intending to be legally bound, I, Mark C. Borger, do hereby disclaim my interest in the joint accounts to the extent the funds are needed to satisfy the Spousal Election Against Conveyances filed with the Orphans' Court of Cumberl;~nd County on January 7, 2008. r~ have hereunto set my hand and seal this _ ~ ~ day of ,1 , 2008. Witness: `-~ ~~~1 ~~r~~ [SEAL] Mark C. Borger COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN SS: ON THIS, the ~~~day of W ~ a , 2008, before :me a Notary Public for the Commonwealth of Pennsylvania, personally ppeared MARK C. BO]2GER, known to me to be the person whose name is subscribed to the within Disclaimer in Accordance with 20 Pa. C.S.A. §6201 and acknowledge that he executed the same for the purposes therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. ~U~-ur~t~~ ~J~r~~1c'v`~.. Notary Public COMMONWEALTH pF PENNSYLVANIA Notarial Seal Corinne Eggers Wopd~ouse. Notary Public City of Hanisbung, Dauptrn County MY t~T~sion E~ires Aug. 14, 2011 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1543 E% AFP (09-00) INFORMATION NOTICE A N D TAX PAYE R RESPONSE. FILE N0. 21 ACN 07147698 DATE 11-05-2007 TYPE OF ACCOUNT EST. OF CARL A BORGER ® SAVINGS S.S. N0. 189-22-9082 ^ CHECKING DATE OF DEATH 08-28-2007 ^ TRUST COUNTY CUMBERLAND ^ CERTIF. 12EMIT PAYMEN T AND FORMS T0: MARK C BORGER REGISTER OF WI LLS 2254 CANTERBURY DR CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055-5770 CARLISLE, PA 17013 PSECU has provided the Department with the information listed b~zlow which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a point owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questions may be answered by calling (717) 787-8327. COMPLETE PART I BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Under penalties of perjury, I declare that the facts I have reported ab~~ve a e true, correct and complete to the best of my knowledge and belief. .-~ HOME C ~(7 ) l/ S~d ~~~ l~ld' WORK ( 7~7 ) 94( ~~ E! ~ f! ~ ~7 TAXPAYER SIGNAT RE TELEPHONE NUMBER DATE TOTAL (Enter on Line 5 of Tax Computation) 8 GENERAL INFORMATION FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. Inheritance tax becomes delinquent nine months after the decedent's date of death. A joint account is taxable even though the decedent's name was added as a matter of convenience. Accounts (including those held between husband and wife) which the decedent put in joint names within one year prior to death are fully taxable as transfers. Accounts established jointly between husband and wife more than one year prior to death are not taxable. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with your check for the amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept 280601, Harrisburg, PA 17128-0601 in the envelope provided. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent dying after 12/12/82: Accounts which the decedent put in joint names within one (1) year of death are taxable fully as transfers. However, there is an exclusion not to exceed 53,000 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk (~^) appears before your first name in the address portion of this notice, the 53,000 exclusion already has been deducted from the account balance as reported by the financial institution. Enter the total balance of the account including interest accrued to the date of death. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons. 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.71 (TAXABLE FOR EACH SURVIVOR) B. The percent taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT X 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50i (TAXABLE FOR EACH SURVIVOR) The amount subject to tax (line 4) is determined by multiplying the account balance (line 2) by the percent taxable (line 3). Enter the total of the debts and deductions listed in Part 3. The amount taxable (line 6) is determined by subtracting the debts and deductions (line 5) from the amount subject to tax Cline 4). Enter the appropriate tax rate (line 7) as determined below. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3% 6% 15% 15% 01/01/95 to 06/30/00 0% 6% 15% 15% 07/01/00 to present 0% 4.5%~ 12% 15% *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 0%. The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The "Collateral" class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. Vou legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paper 8 1/2" x 11". Proof of payment may be requested by the PA Department of Revenue. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1543 E% AFP (09-00) INFORMATION NOTICE AN D TAXP AY E R RESPONSE: FILE N0. 21 ACN 07147697 DATE 11-05-2007 TYPE OF ACCOUNT EST. OF CARL A BORGER ^ savlNGs S.S. N0. 189-22-9082 ® CHECKING DATE OF DEATH 08-28-2007 ^ TRUST COUNTY CUMBERLAND ^ CERTIF. f2EMIT PAYMENT AND FORMS T0: MARK C BORGER REGISTER OF WILLS 2254 CANTERBURY DR CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055-5770 CARLISLE, PA 17013 PSECU has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a point owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questions may be answered by calling C717) 787-8327. COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable Account No. 820 1 869347-B Date 02-24-2003 To insure groper credit to your account, two Established (2) copies of this notice must accompany your Account Balance 1 , 484.48 Payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax 742.24 (3) months of the decedent's date of death, Tax Rate X . 045 you may deduct a 5% discount of the tax due. Any inheritance tax due will become delinquent Potential TaX Due 33.40 nine (9) months after the date of death. PART TAXPAYER RESPONSE ~FA~IIrI1R~'fll~R3#?'I11~1~~l~l~i€I~E~€I~t~fi~~IH~AH~D~FI: _;::: ; ::;~;;;; ;::::~:.. ; :. , . ~ ~~I E,...T ..A~~.E~~H:EH'Y':s;;~A~ED °#INfiNISNO•fi~ CiE~iif A. ^ The above information and tax due is correct. 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or you may check box "A" and return this notice to the Register of C 0 N E ~ / Wills and an official assessment will be issued by the PA Depar+tment of Revenue. B L 0 C K B' he above asset has been or will be reported and tax paid with the f'ennsvlvania Inheritance Tax return 0 N L Y to be filed by the decedent's representative. C. ^ The above information is incorrect and/or debts and deductions were paid by you. You must complete PART 2^ and/or PART 3^ below. I f o u i n d i c a e ~ ;:~ ~ :;:;;::;;;:~ s:;::;;:;:~ is ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ~:::;:;:;:~ ;:::::::::;:::::;:::;:::;:.....;.,.,.,.,.,...,.,.,., PART v t a different tax rate, please state your relationship to decedent: .................._._..._ _ _ _ ____ ,. 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 X 4 5 6 7 X 8 PART DEBTS AND DEDUCTIONS CLAIMED ^3 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported~7above are true, correct and complete to the bes~ my knowledge and belief. HOME C >~~ / ) /;~~ ~ 7~ [gam /~~ ~"fi~-L~ W O R K C//~ ) ~ 7~ .Z b/ i C( b 7 TAX AVER SIGNATURE TELEPHONE NUMBER D T TOTAL (Enter on Line 5 of Tax Computation) S GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even though the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) which the decedent put in joint names within one year prior to death are fully taxable as transfers. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with your check for the amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept 280601, Harrisburg, PA 17128-0601 in the envelope provided. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent dying after 12/12/82: Accounts which the decedent put in joint names within one (1) year of death are taxable fully as transfers. However, there is an exclusion not to exceed 53,OD0 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk (~~) appears before your first name in the address portion of this notice, the 53,000 exclusion already has been deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for ]oint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons. 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7% (TAXABLE FOR EACH SURVIVOR) B. The percent taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT X 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50% (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (line 4) is determined by multiplying the account balance (line 2) by the percent taxable (line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (line 6) is determined by subtracting the debts and deductions Cline 5) from the amount subject to tax (line 4). 7. Enter the appropriate tax rate (line 7) as determined below. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3% 6% 15% 15% 01/01/95 to 06/30/00 0% 6% 15% 15% 07/01/00 to present 0% 4.5%* 12% 15% ^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 0%. The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The "Collateral" class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paper 8 1/2" x 11". Proof of payment may be requested by the PA Department of Revenue. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 28D601 HARRISBURG, PA 17128-0601 REV-1543 E% AFP (09-007 INFORMATION NOTICE AND TAX P AY E R RESPONSE. ILE N0. 21 ACN 07147696 DATE 11-05-2007 TYPE OF ACCOUNT EST. OF CARL A BORGER ® SAVINGS S.S. N0. 189-22-9082 ^ CHECKING DATE OF DEATH D8-28-2007 ^ TRUST COUNTY CUMBERLAND ^ CERTIF. REMIT PAYMENT AND FORMS T0: MARK C BORGER REGISTER OF WI LLS 2254 CANTERBURY DR CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055-5770 CARLISLE, PA 17013 PSECU has provided the Department with the information listed b~alow which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questions may be answered by calling (717) 787-8327. COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 8201869347-C Date 02-24-2003 To insure proper credit to your account, two Established (2) copies of this notice must accompany your $ D 1 . D 3 payment to the Register of Wills. Make check Account Balance 81, payable to: "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If i:ax payments are made within three Amount Subject to Tax 4D,9DD.52 (3) months of the decedent's date of death, TaX Rate X .045 You may deduct a 5% discount of the tax due. Any inherii:ance tax due will become delinquent Potential Tax Due 1,84D.52 nine C9) months after the date of death. PART TAXPAYER RESPONSE r: ~"' I4.:Ef •~[l'I!~"_.._T.i'1.:.:,1'!!~'~~#1~1'ESi,.,.,Li'F'F { ,ss:~f ~" RK [lL~;'M' 't'~1...:{!7L~...; ~1~E,,;l~,r,F;lm'~,.i4~E::.:'!"Jl~':: i~C!'i`X~ ~4'~''i'X~~` ~L'ijjs~;:}::'.4'il~Ca'~L•'llf:~ ~'i.'~ii~ :':'FL!''!`~iCi 7:`31:1Y~'1!~'!:'C%ill.:`Pi A. ^ The above information and tax due is correct. 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or you may check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. C ONE B L 0 C K B. The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the decedent's representative. C. ^ The above information is incorrect and/or debts and deductions were paid by you. You must complete PART 2^ and/or PART 3^ below. TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due PART If you indicate a different tax rate, please state your relationship to decedent: OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 X 4 5 6 7 X 8 PART DEBTS AND DEDUCTIONS CLAIMED a DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true`,, co~trrect and compl te~ th best ,of my knowledge and belief. HOME C~[~ ) - ~ 2S ~(J ' ' ~; ,. /G1% WORK C / ) yl// ~~ / ~/ J 7 TAXPAYER SIGNATURE TELEPHONE NUMBER DA E TOTAL (Enter on Line 5 of Tax Computation) 5 GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even though the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) which the decedent put in joint names within one year prior to death are fully taxable as transfers. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with your check for the amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept 280601, Harrisburg, PA 17128-0601 in the envelope provided. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent dying after 12/12/82: Accounts which the decedent put in joint names within one C1) year of death are taxable fully as transfers. However, there is an exclusion not to exceed 53,000 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk (~^) appears before your first name in the address portion of this notice, the 53,000 exclusion already has been deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons. 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7% (TAXABLE FOR EACH SURVIVOR) B. The percent taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT X lOD = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50% (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (line 4) is determined by multiplying the account balance (line 2) by the percent taxable (line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (line 6) is determined by subtracting the debts and deductions (line 5) from the amount subject to tax (line 4). 7. Enter the appropriate tax rate (line 7) as determined below. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3% 6% 15% 15% 01/01/95 to 06/30/00 0% 6% 15% 15% 07/01/00 to present 0% 4.5%* 12% 15% 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 steDParent of the child is 0%. The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The "Collateral" class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paper B 1/2" x 11". Proof of payment may be requested by the PA Department of Revenue. HAZF.IV EinF.R LAW An Estate Planning and Elder Law Firm 2000 Linglestown Road, Suite 202 Harrisburg, PA 17110 ~rrr.: (71'~ 540-4332 Fnx: (717) 5401313 VIA CERTIFIED MAIL www. HazenElderLaw.com Marielle F. Hazen, CELA* Marci S. Miller, Associate May 27, 2008 Register of Wills ~-~ Cumberland County Courthouse =~ ~ ~ -~ _~ r.~ ~_ One Courthouse Square ;:, ;_~ ~ , Carlisle, PA 17013 ~ ~,~ r,, ' -- ~, - - Re: Estate of Carl A. Borger =" =; ?~ File No.: 21-08-00021 1_ Inheritance Tax Return }`' ^' N 0 To: The Register of Wills: Enclosed for filing please find the original and one (1) copy of the above- referenced Inheritance Tax Return, along with a copy of the first page of the Inheritance Tax Return. Please date stamp the first page of the Return and send it to our office in the enclosed self-addressed envelope. Please note that this is anon-probate estate. Also enclosed are two checks, one in the amount of $380.13 for the inheritance tax owed and the other in the amount of $15.00 for payment of the ta.x return filing fee. If you have any questions or require any additional inforniation, please do not hesitate to contact me. Sincerely, ~, C . ~~ Marci S. Miller Enclosures cc: Mark Borger ~Cer[ified Elder Law Attorney by the National Elder Lain Foundation as authorized by the P~nnsyluania Supreme Court ~.-. _ ~~w ~~r o 0 ~I~. N F ~P ~ ff ~ k ~ ~ J ~ LL. y ~ Q r6 , ~~ w ~n J ;'!Nfl ~~~I 2 i -k r ru .~- ~~ m '~ ru ~~ ~ ~~ ~ ~~ o ~~- a ~~ ---- o ~~ o ~~ ~ ~~ o ~~ ~~ m ~~ ~`- ~. O ~~ O f~ - r-r,,. ~ )",law i ~,Iji~ `1' ~ ~~~~Y 29 F . ; ~ 2 i /~ ~~'\ ~~ ~f~ f f .1. N t~ _.,i ~- N a~ . ^., O V a~.., ~- r ~ O ~ ~ a ,~ ~ bA . ~ V~ ~ .~ ~ ~ O O fV RS N a 0 ~ ~ o ~ ~ U ~ 4., ~' o ~ o ~ ~ 0 0 0 ~ a~ ~ U ~ ~ o ~U °'U '~ O a-. a~ U