HomeMy WebLinkAbout07-01-0815056041125
REV-1500 EX (06-05)
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number
Po Box 28oso1 2 1 0 8 0 0 0 0 2
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
1 9 2 1 4 7 2 0 7 1 2 3 1 2 0 0 7 0 7 1 0 1 9 2 0
Decedent's Last Name Suffix Decedent's First Name MI
E l l i o t t R a y W
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
0 1. Original Return
4. Limited Estate
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
2. Supplemental Return
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
between 12-31-91 and 1-1-95)
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
Firm Name (1f Applicable)
First line of address
Second line of address
City or Post Office
r~~
State ZIP Code
~ ~ t ~.
REGISTE WILLS U ~E= ONLY_
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DATE FILED~.,t
SIGNA RE OF MfcM1tRER$~EN~9~fE----~ DATE, f,
ADDRE,S$c ~ 6~J` // ~~~
1 ~- CK~ ~ ~~-- ,~ w c ~ 7
PLEASE E ORIGINAL FORM Y TT
Side 1
15056041125 15056041125
J ~~~
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 information of which preparer has any knowledge.
15056042126
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: Ray W. Elliott 1 9 2 1 4 7 2 0 7
RECAPITULATION
1 2 4 2 3 2 3 4
1. Real estate (Schedule A) ....... ...... , ...
...................... . 1. ,
2. Stocks and Bonds (Schedule 8) ................................. . 2. •
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .... . 3.
4. Mortgages & Notes Receivable (Schedule D) ....................... . 4.
6 7 5 8 , 4 3
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... . 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ...... . 6.
7. Inter-Vivos'Transfers & Miscellaneous Non-Probate Property
arate Billing Requested
^ Se
h
l
G
7
......
p
edu
e
)
(Sc .
.
8. Total Gross Assets (total Lines 1-7) ........ . ................. . 8. 1 3 0 9 9 0 , 7 7
s 1 3 4 1 2 , 8 3
9. ...............
Funeral Expenses & Administrative Costs (Schedule H) .
.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ........... . 10.
11. Total Deductions (total Lines 9 & 10) .......................... . 11. 1 3 4 1 2 , 8 3
12. Net Value of Estate (Line 8 minus Line 11) ........................ . 12• 1 1 7 5 7 7 , 9 4
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ................. . 13.
1 1 7 5 7 7 • 9 4
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
0 0
0
15
(a)(1.2) X.0 , .
16. Amount of Line 14 taxable 1 1 7 6 8 9 5 4
at lineal rate X .045 16.
17. Amount of Line 14 taxable 0 0 0 17
at sibling rate X .12 .
18. Amount of Line 14 taxable 0 0 0
at collateral rate X .15 18.
19. Tax Due ............ ............................. ..... ..19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
15056042126
Side 2
0. 0 0
5 2 9 6. 0 3
0. 0 0
0. 0 0
5 2 9 6. 0 3
15056042126
REVs1500 EX P`3ge 3
Decedent's Complete Address:
File Number
21 08 00002
DECEDENTS NAME
Ra W. Elliott
i
STREET ADDRESS
'
CfTY STATE ZIP
Tax Payments and Credits:
7 • Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. Interest/Penalty if applicable
D. {nterest
E. Penalty
Total Credits (A + B + C) (2)
Total Interest/Penalty (D + E) (3)
4. 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.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
(1) 5,296.03
0.00
0.00
0.00
(5) 5,296.03
(5A)
B. Enter the total of Line 5 +5A. This is the BALANCE DUE. (56) 5,296.03
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 : ................................................................
i ...... ~ O
ncome; ........................
b. retain the right to designate who shalt use the property transferred or its ......
^
c. retain a reversionary interest; or .......................................................................................... ......
^
d. receive the promise for life of either payments, benefits or care? ................................................. ......
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
^
0
without receiving adequate consideration? .................................................................................
'
" ......
^
or payable upon death bank account or security at his or her death? ...
in trust for
3. Did decedent own an ......
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ............................................................................................ ...... ^
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(x)(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(x)(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(x)(1.3)]. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
(4)
REV'1502 EX+~6-98)
SCHEDULE A
COMMONWEALTH OF PENNSYLVANIA REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
NUMBER
Ray W. Elliott 21 08 00002
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be
exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Lot of land together with residence constructed thereon at 109 Newville Road, 124,232.34
Shipensburg, Cumberland County, Pennsylvania
HUD-1 attached
TOTAL (Also enter on line 1
(If more space is needed, insert additional sheets of the same size)
REb'-1508 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Ray W. E{liott 21 08 00002
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 VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Net sale of household goods sold at public auction 6,431.75
2. Refund from Adams Electric Company 54.28
3. Refund from Homowners Inc. 136.00
4. Refund from Blue Cross 136.40
TOTAL (Also enter on line 5, Recapitulation) ~ $ 6, 758.43
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX ~ (12-99)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES 8~
ADMiNiSTRATIVE COSTS
ESTATE OF FILE NUMBER
Ray W. Elliott 21 08 00002
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Fogelsanger-Bricker Funeral Home 9,265.57
2. Mongul Church (meal at Funeral) 200.00
3. Spring Hill Cemetary-Grave Opening 700.00
B.
2
3
4.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s)lEtN Number of Personal Representative(s) _
Street Address
City State _
Year(s) Commission Paid:
Attorney Fees H.Anthony Adams
Family Exemption: (If decedents address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State
Relationship of Claimant to Decedent
Zip
Probate Fees ~ 317.00
5 Acxountant's Fees
6. Tax Return Preparers Fees
7.
8.
9.
10
11
Return from estate assets of pension overpayment 114.09
Swain Healthcare Center 44.29
Continuing Coer RX medication 144.03
JRS final tax payment made by this Estate 574.49
Expenses of Estate 53.36
TOTAL (Also enter on line 9, Recapitulation) I $ 13.412.83
Zip
2,000.00
(If more space is needed, insert additional sheets of the same size)
REV-:513 EX + (9a~0)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Rav W. Elliott 21 08 00002
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
j TAXABLE DISTRIBUTIONS [nclude outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. Larry Elliott Lineal
179 Chamberlin Road 25%
Shippensburg, PA 17257
2. Ronald Elliott Lineal
1548 Orrstowm Road 25%
Shippensburg, PA 17257
3. Gloria Wrights Lineal
2 Willow Drive 25%
Shippensburg, PA 17257
4. Susie Elliott Collateral
20 Fish Hatchery Road 5%
Shippensburg, PA 17257
5. Thomas Elliott Lineal
10751 Spring Ridge Road 5°I°
Shippensburg, PA 17257
6. Carol Elliott Lineal
111 Whiskey Run Road 5%
Newville, PA 17241
7. Mary Box Lineal
106 Lincoln Street 5%
Enola, PA 17025
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
jj. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
Ray W. Elliott
Decedent's Name
Page 1
21 08 00002
File Number
Schedule J -Beneficiaries -1
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT
Do Not List Trustee(s) AMOUNT OR SHARE
OF ESTATE
I TAXABLE DISTRIBUTIONS (include outright spousal distributions)
8. Jennifer Lantz Lineal
616 Park Avenue 5%
Belton, MO 64012
B. Type of Loan -
1.[ ] FHF. 2:j ] FmHA 3.[) Conv. Unins. 6. File Number: 7. Loan Number: 8. Mortgage Insurence Case Number
4.[ J VA 5.[ ]Conv. Ins. 883736-01
C. NOTE: This form furnishes a statement of settlement costs. Amounts paid to and by the settlement agent are shown. Items marked
"
"
(p.o.c.)
were paid outside the closing; they are shown for informational purposes and are not induded in the totals.
D. Name & Address of Borrower: E. Name, Address & TIN of Seller: F. Name & Address of Lender:
Mervin M. Burkholder Estate of Ray W. Elliott AgChoice Fann Credit, ACA
109 Farm CredR Drive
Chambersburg PA 17201
G. Property Location: TIN of Seller. H. Settlement Agent:
109 Newville Road Place of Settlement H. Anthony Adams, Esquire
Shippensburg, PA 17257 49 West Orange Street, Suite 3
Shippensburg, PA 17257 I. Settlement Date: January 14, 2008
J. Summary of Borrower's Transaction K Summary of Seller's Transaction
1 D0. Gross Amount Due from Borrower: 400. Gross Amount Due to Seller.
101. Contrad sales price 125,000.00 401. Contred sales price 125,000.00
102. Personal Property 402. Personal Property
103. Borrower's settlement charges (line 1400) $3,155.00 403.
1 Ct4. 404
105. 405.
Adjustments for items paid by seller in advance Adjustments for items paid by seller in advance
106. CityAown taxes to 406. Cityftown taxes to
107. County taxes to 407. County taxes to
1 D8. Assessments to 408. Assessments to '
1 D9. School taxes to 489.90 409.School taxes to 489.90
110. 41 D.
111. 411.
112. 412.
113. 413.
120. Gross Amount Due from Borrower $128,644.90 420. Gross Amount Due to Seller $125,489.90
200. Amounts Paid by or in Behalf of Borrower. 500. Reductions in Amount Due to Seller.
201. Deposits or earnest money 501. Excess deposit (see instrudions)
202. Pdndpal amount of new loan(s) 110,000.00 502. Settlement charges to seller (line 1400) $1,250.00
203. Existing loan(s) taken subjed to 503. Existing loan(s) taken subjed to
204. 504. Payoff of first mortgage
205. 505. Payoff of second mortgage
206. 506.
207. 507.
208. S08.~
209. 509.
Adjustments for items unpaid by seller Adjustments for items unpaid by seller
21 D. CityAown taxes to 7.56 510. Cityftown taxes to 7.56
211. County taxes to ~ 511. County taxes to
212. Assessments to 512. Assessments to
213. School taxes to 513.Schooltaxes to
214. 514.
215. 515.
216. 516.
217. 517.
218. 518.
219. 519.
220. Total Paid By/for Borrower $110,007.56 520. Total Reduction Amount Due Seller $1,257.56
300. Cash at Settlement Fromtto Borrowor 600. Cash at Settlement ToHrom Seller
301. Gross amount due from borrower (line 120)
302. Less amounts paid by/for borrower (line 220) $128,644.90
'$110,007.56 601. Gross amount due to seller (line 420)
602. Less reductions in amount due seller (line 520) $125,489.90
$1,257.56
303. Cash X from to Borrower $18,637.34 603. Cash X to from Seller $124,232.34
Substitute Forth 7099 Setter Statement
The information in Blocks E, G, H, I & line 401 (or, if line 401 is asterisked, line 403 and 404) is important tax information and is being
furnished to the Internal Revenue Service. If you are required to file a return, a sandion will be imposed on you if this item is required to be
reported and the IRS determines that it has not been reported. If this real estate is your pdndpal residence, file Forth 2119, Sale or
Exchange of Principal Residence, for any gain, with your income tax return; for other transactions, complete the applicable parts of Form
4797, Form 6252 andlor Schedule D (Form 1040). You are required to provide the Settlement Agent (named above) with your coned
taxpayer identificetion number. If you do not provide the Settlement Agent wfth your taxpayer identifiption number, you may be subjed to
civil or criminal penalties imposed by law. Under penalties of perjury, I certify that the number shown on this statement is my cortect
taxpayer identification number.
(Seller) (Seller)
L Sett~gnrent Charges
7DO. ~ oral ~alesfBrokers Commission: based on rice $125,000.00 % Paid from Paid from
Divisidn of Commission line 700 as follows: Borrowefs Seller's
701. Funds at Funds at
702. Settlement Settlement
703. Commission aid at Settlement _
$ 0.00
704. -
600. Items Pa able in Connection with Loan -
801. Loan On nation Fee to A Choice Farm Credit, ACA 1,ODO.OD
802. Loan Discount -
803. A sisal Fee -
804. Credit Re ort -
805. Lender's Ins Fee -
806. Mort a e Insurance A lication Fee -
807. A ication Fee to A Choice Farm Credit, ACA 350.00
806. Flood Determination fee to A Choice Farts Credit, ACA 18 Dp '
809. -
810. '
811. -
812. -
813.
814.
9D0. Items Re uired b Lender to ee Paid in Advance -
901. Interest from to $ er da
902. Mort a e Insurance Premium for
903. Hazard Insurance Premium for
904.
905.
1000. Reserves De osited with Lender
10D1. Hazard insurance months $ er month $ 0.00
1 D02. Mort a e insurance months $ er month $ D.00
1003. C' ro taxes months $ er month $ 0.00
1004. Coun ro taxes months $ er month $ 0.00
1005. Annual assessments months $ r month $ 0.00
1006.School taxes months $ er rtronth $ 0.00
1007.
1008.
1009. A r ate AccouMin Ad'ustment
1100. Title Cha
1101. SetDementldosin fee
1102. AbstradRide search
1103. Title examination
1104, Tdle insurance binder
1105. Document re oration
1106. Nora fees
1107. Attome s fees to H. Anthon Adams. Es wire 450.00
indudes above item numbers
1108. Title insurance
indudes above item numbers
1109. Lender's covers e
1110. Owner's covers e
1111.
1112.
1113.
1200. Government Recordin and Transfer Cha es
1201. Recordi fees: Deed 38.50 Mort a e 48.50 Release $ 87.00
1202. C~ /coum tax/stam s: Deed 1,250.00 Mort a e $1,250.00
1203. Statetax/stam s: Deed 1,250.00 Mort a e $1,250.00
1204.
1205.
1206.
1300. Additional Settlement Cha es
1301. Surv
1302. Pest Ins 'on
1303.
1304.
1305.
1306.
1307.
1308.
1d0o. Total Settlement Charges (This Number Trensfere to Lines 103 & 502 Above
$3,155.00
$1,250.00
- CERTIFICA710N
I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, d is a true and accurate statement of all receipts end
disburse eats made on my axount or by me in this transaction. I further certify that I have received a copy of the HUD-1 Settlement Statement
Seller Borrower
~ Seller ~~jr--c~ Bonower
7o the besl of y knowfed a the HU Settlement Statement which 1 have prepared s true and accurate accoun of the funds which were received and
have been o wi ~ u sgae as part of the settlement d this transaction. ~ r,
Settlemenl Agem S/ Date
WMNIN(i. M u ~ miro b bne+M~Y mske lelee Mtemar,is ro tl~e UnbE Steles on Nis Or enY otlier emJSr ~°^^- penalUe6 upon oami nn uwiuGe a fine aM iniprieonmmt. For Oebtlc eee: TIDe 1a ll.S.
LoOe Section 10D1 eM Setlvi 1D10.