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HomeMy WebLinkAbout07-11-0815056041046 REV-1500 EX (05-04) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes ~ INHERITANCE TAX RETURN Dept. 280601 ~ ~ ~ ~ ~~ Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~ Q 5 Z a i 0 7~ U? z.2 20© `7 0~ z z t~ a y Decedent's Last Name Suffix Decedent's First Name MI Ha~--~-Y ~~2©THy ~ (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 tl 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ~>~ND2R ~- 121L~ ~ ~t 7 X44 7785^ Firrn Name (If Applicable) REGISTER OF WILLS USE ONLY First line of address r,a ~g mo~rv ~~ ~-~ ~ t~cJ D2 ~ c :a ~ Q `~ o ~ , ~ , , Second line of address S ~ ~ .` MT l~n _ _ - , ,~ _ - • ~ , --~ City or Post Office State ZIP Code ~-'P ILED t -~ . ' _~ -7 _ ~ ~~~ ~ ~ c _ 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. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056041046 15056041046 15056042047 REV-1500 EX Decedent's Social Security Number Decedent's Name: 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) C Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) G Separate Billing Requested........ 7. ti .~ ~ 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. ~ Q -I ~~7~i •~ L"~, 9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. S ;~ ~ ~ . 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10. ~ O 1 L'~ 11. Total Deductions (total Lines 9 ~ 10) ................................. .. 11. l ~ ~ ~_ ~ . ~` 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. _ . ~ ` 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... .. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. ~ ©~~~ .g ~~ 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 _ 15. 16. Amount of Line 14 to ble '1 Q ~ 1 1 ~ ~ ~ ~~ d '- 16 Q a 'Z-~ . /„ l • ~ T at lineal rate X .0 . 1 v.~ 17. Amount of Line 14 taxable at sibling rate X .12 • 17. • 18. Amount of Line 14 taxable at collateral rate X .15 18. • 19. TAX DUE ......................................................... 19. `"1 0~~• `~-' 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O j~~ 15056042047 Side 2 15056042047 J REV-1500 EX Page 3 File Number Decedent's Complete Address: Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit - - - _ - -_ B. Prior Payments __ _ - - -_ C. Discount - - _ - _-" - _ - Total Credits (A + B + C ) 3. InterestlPenalty if applicable D. Interest - -- __ _ _ E. Penalty (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. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. {56) 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 b. retain the right to designate who shall use the property transferred or its income : ..................................... ....... ^ c. retain a reversionary interest; or ................................................................................................................... ....... ^ 0 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 without receiving adequate consideration? ....................................................................................................... ....... ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ....... ....... ^ 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 deaths 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)J. 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)]. 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. REV-1508 EX + (1-57) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN ~CpL+o\I A 1 PpOPERTV RESIDENT DECEDENT GR~~77 ~\/'1L R I ESTATE OF FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. A{I property jointty-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH A~-T~ 50 .-v3~i -~o~~ Pnl c n,~.,~. ~ ~~5~~2.-,Z2 TOTAL (Also enter on line 5, Recapitulation) I $ 3r~~, ~ ~ ~ t0~ (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) SCNEDt~LE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t' David M Myers Funeral Home 8,400.00 t3. 1 2. 3. 4. 5. 6. 7. ADMINISTRAT{VE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City .State Year(s) Commission Paid: Attorney Fees Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's fees Zip Zip 94.00 75.00 TOTAL (Also enter on line 9, Recapitulation), $, 8,569.00 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA I BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER 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 dislributions, and transfers under Sec. 9116 (a) (1.2)] 1. ~~~~r~ L 2i L~ ~ ~~~ 10~ y~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 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 $ (If more space is needed, insert additional sheets of the same size) Total Banking Statement Ftx 24-hour information, sign on to PNC Bank Online Banking on pnc.com. Account number: 50-0361-808'7 -continued _ _ PNCBANK Foy eho poled o~r1 srzoo~ ~ osrl asoo~ DOROTHY E HOLLEY DECD Primary account number: 50-0361-8087 Page 3 of 3 Are yon temporarily without health insarance? An illness or injury coald set yon back financially. Short Term Medical insurance can provide health coverage with convenfent payment options. To learn more visit pnc.com/insnrance or call 1-877-284-4793. Refax and let your PNC Bank Visat~ Check Card pay the bills. Use your card to schedule one-time or recurring payments. You pay what you need without looking for stamps, writing checks, or traveling to the post office. It's that easy. Find out more at pnc.comlpaybycard. ~'I>in11un1 Plan Dorothy E Holley Decd Per~'ormanca Monoy allarkot Accoun! Summary Account number: 50-0390-4104 BAIdneA~Ifln1M1l11°y ...... :, .~. _. _ .:.~ . , . ., _ __ _ ar~ --- - __ _ __---_- 5eginiilrig - _ Gepo~its nnai ~et:KS"anu other _ ending balance -other additions deductions balance 19~822c22 45.69 12.79 19,855.12 Average monthly Charges balance and fees 19,828.35 .00 fntorest Summa Annual-Percentage Number of days Average collected Interest Paid Yield Earned (APYE) in intarast period balance for APYE this period 2.94% 29 19,828.85 45.69 ,.. __ . _ Pleaae_see the~Actlvity Detail section for additional information. ___,.. As of 08/10, a total of $418.64 in interest was paid this year. Withholding Interest earned Withholding this period year-to-date year-to-date 12.79 419.64 12.79 Acd~iriil- Detaii Deposits and Othslr Additions Date Amount Description 08/ 10 45.69 Interest Payment tittfisr Deductions Date Amount Description 08/10 12.79 Interest Withholding p BalahcP~ -~ Date Balance 07/13 19,822.22 \ 08/10 19,855.12 ~.c.~ra_ ~ t UUCP . c,~ ~lv~ o~.~.~E 18~szz.ZZ There was 1 Deposit or Other Addition totaling $48.68. There was 1 Other Deduction totaling $i Z.78. FORM953R•ion~ Total Banking Statement For 24-hour information, sign on to PNC Bank Online Banking For the period 07/13/2007 to 08/10/2007 on pnc.coln. DOROTHY E HOLLEY DECD Primary account number: 50-0361-8087 Page 2 of 3 SecoucL3ry Mrntgage Laau Licensee. PNC Mortgage, LLC uray not beyavailable in your area. Credit subject to approval. Information is accrrrete as of the date of printing and is subject to change without notice. ®2007 PNC Mortgage, LLC. Ali Rights Reserved. 49]73 6/07-9/07 Premium Plan Dorothy E Holley Decd Interest Checking Account Summary Account number: 50-0361-8087 Balance Summary Please see the Activity Detail section for Beginning Deposits and Checks and other Ending additional information. balance other additions deductions balance 13,360.87 2,554.19 4,745.02 11,170.01 Average monthly Charges balance and fees Transaction Summary __-__._~-~ T Checks paid/ Check Card POS Check Card/Bankcard withdrawals signed transactions POS PIN transactions 8 0 0 Total-ATM- PNC Bank Other Bank ransactons ATM transactions ATM transactions ....0 _ 0 0 Interest Summary _a As of 08/10, a total of $59.27 in interest vras Annual Percentage Number of days Average collected Interest Paid paid tltls year. Yield Earned (APYE) in interest period balance for APYE this period 0.381 29 11,174.13 3.35 Withholding Interest earned Withholding this period year-to-date year-to-date .93 59.27 .93 Activity° @etal= Deposits and Other Additions There were 2 Deposits and Other Additions Date Amount Description totaling $2,554.19. 07/2G 2,550.84 Direct Deposit - Annuitypay Ta Life Ins Co Pia00457841 08/10. 3-.35 Interest Payment _, Checks and Substitute Checks Check Date Reference Check Date Reference number Amount paid number number Amount paid number 655 240.00 07/ 16 085469224 659 96.00 07/24 o24s55o39 656 3,323.29 07/17 085779665 660 25.80 07/31 029761655 657 48.00 07/23 oss543o5s 661 624.00 07/31 024693132 658 96.00 07/20 049380503 662 T 288.00 OS/O1 027466212 " Gap in.checksequence- "T" Tesler Cashed Check There were 8 checks listed totaling $4,744.09. Other Deductions There was 1 Other Deduction totaling Date Amount Description $.83. 08/10 .93 Interest Withholding Daily-Balance Detail Date Balance Date Balance Date Balance Date Balance 07/13 13,360:87 07/20 9,701.58 07/26 12,108.42 U8/10 11,170.04 07/16 13,120.87 07/23 9,653.58 07%31 11,455.62 07/17 9,797.58 07/24 9,557.58 03/U1 11,167.62 ESTABLISHED IN 1695 DAVID M. MYERS BY SAMUEL D. MYERS JOHN M. MYERS SALLY A. MYERS DAVID M. MYERS FUNERAL HOME SECOND AND WALNUT STREET5 NEWPORT, PENNSYLVANIA 17074 PHONE (717) 567-3138 Dorothy E. Holley Traditional funeral with Reynoldsville 18 gauge casket, protective, with crepe interior Wilbert Monarch Burial Vult Grave opening- Newport Cemetery (M-F) Clergy honorarium Spray of flowers Obituary Notice in Harrisburg newspaper Date marker- Rice Memorials Burial dress Luncheon $ 5,945.00 995.00 500.00 200.00 150.00 200.00 120.00 140.00 150.00 $ 8,400.00 ~~ WEST SHORE EMS -MALS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011 ~ Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ~~~~ ~Q~ f 4};RGI~\'Cl' h[ED[CAL SF•.RVICES PATIENT NAME: DOROTHY HOLLEY PATIENT NUMBER: 533 REJ CALL NUMBER: 3085297A NONE INSURANCE: PALMETTO GBA WA160163515 DATE OF CALL: 05/22/2007 ~ ,~ CAPITAL BLUE CROSS YWR195281072 TIME OF CALL: ~ \~"~__ CAPITAL BLUE CROSS YWM80033155300 CALLER: ~ n 3085297A FROM: C/O SANDRA RILEY (. ~11 ~1(~C`. x~ ~ TO: .HARRISBURG HOSPITAL ~~ .x n DOROTHY HOLLEY ~` t C/O SANDRA RILEY REASONS} ALTERED LEVEL OF CONSCIOU ~ a~1~ 18 MOUNTAIN VIEW DR FOR Head Injury CARLISLE, PA 17013-3680 TRANSPORT INVOICE DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT GLUCOSE BLOOD A0394 1.0 6.42 6.42 PERIPHERAL IV A0394 1.0 35.00 35.00 ALS EMERGENCY LEVEL 1 A0427 1.0 1015.98 1015.98 ALS MILEAGE A0425 4.0 11.32 45.28 Oxygen Administration A0422 1.0 56.15 56.15 Total Charges 1158.83 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Total Credits 0.00 PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~- RcTS~Rn~Fn (_NF(_K FFF _ ~~~ nn $1158.83 DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT 1158.83 AMOUNT DUE PATIENT NAME: HOLLEY, DOROTHY E CALL NUMBER 3085297A AMOUNT $ :PATIENT NUMBER: 533 BILLING DATE: 07/19/2007 ENCLOSED A claim for this invoice amount was denied by your insurance ~ VISA carrier. Balance is your responsibility -please remit. -~~~ - AND MASTER CARD ACCEPTED WEST SHORE EMS -MALS 205 GRANDVIEW AVE CAMP HILL, PA 17011 IN YOUR HOME CARE DONT STAY HOME WITHOUT US 19 S. Hanover St., Suite 108 Carlisle, PA. 17013 Phone (717) 243-5080 DATE: July 23, 2007 INVOICE # 102 BILL TO: ~ Sandy Riley 18 Mountain View Dr. ' Carlisle, PA. 17013 ~ ~ . , 3a FOR: Personal Care _ _- -_ __~ESGRtPTIOi~I _ _ _- _-- _ _HOllR$ RATI< _ _ AMOUNT Personal Care for Dorothy Holley week of 7/16!2007 41.00 16.00 $ 656.00 l~ ~~ ~~ d ~~ 0