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Home My WebLink About08-18-08 5056051058 REV-1500 EX (06-05j OFFIC{AL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN ~ ~ ~~ PO BOX 280601 RESIDENT DECEDENT 21 08 0006 Harrisburg. PA 17128-0601 ' ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 198-30-0041 12!22/2007 11 121 /1938 Decedent's Last Name Suffix Decedent's First Name MI SIMMERS ~~ ROBERT (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Ml SIMMERS ~-~ DOROTHY J~ I" I Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 168-26-3952 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW • 1. Original Retum o 2. Supplemental Return c~ 3. Remainder Return (date of death prior to 12-13-82) c~ 4. Limited Estate c~ 4a. Future Interest Compromise (date c~ 5. Federal Estate Tax Return Required ' of death after 12-12-82) c~ 6. Decedent Died Testate c~ 7. Decedent Maintained a Living Trust -0- g, Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) c~ 9. Litigation Proceeds Received c~ 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) c~ {Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number WILLIAM R KAUFMAN, ESQ 717-766-7702 Firm Name {If Applicable) r_> REGIStI`FR OF WILLSI~S`E ONLY First fine of address ~. ~ J 940 CENTURY DRIVE, SUITE B ~ _~` ~~~~ _, __ _ Second line of address ~ ; ~ ~ ; ~~ -, ; -~ ~-, =_~ 7 __ ~TE FILE City or Post Office State ZIP Code °t~ ~" .. MECHANICSBURG PA 17055-4376 Correspondent's a-mail address: wrkaufman.wrklaw@comcast,net 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, cor~re.,ct`and complete, Declaration of preparer other than the persona! representative is based on all information of which preparer has any knowledge. SI~~E OF~ON RE~SPON~ OR FILING RETURN DATE i 1J KID S ~r~0 /~~~~U.ST~~d'< 120 KIM ACRES DRIVE, MECHANICSBURG, PA 17055 SIG TU P P R OTH THAN REPRESENTATIVE c DAT .i ~ J ~ ~ _ ADDRESS 940 CENTURY D E, SUITE B, MECHANICSBURG, PA 17055-4376 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 I ~ 15055052059 REV-1500 EX Decedent's Name: ROBERT L. SIMMERS Decedent's Social Security Number 198-30-0041 RECAPITULATION 1. Real estate (Schedule A) 1. $ 0.00 2. Stocks and Bonds (Schedule B) 2. $5,615.40 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) 3. $ 0.00 4. Mortgages & Notes Receivable (Schedule D) 4. $ 0.00 5. Cash, Bank Deposits & Miscellaneous Personal Property {Schedule E) 5. $9,965.41 6. Jointly Owned Property (Schedule F} c~ Separate Billing Requested 6 $ 0.00 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested 7. $338,772.14 8. Total Gross Assets (total Lines 1-7) 8. $354,352.95 9. Funeral Expenses & Administrative Costs (Schedule H) 9. $9,016.65 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 10. 9~ 0.00 11. Total Deductions (total Lines 9 & 10) 11. $9,016.65 12. Net Value of Estate (Line 8 minus Line 11) 12. $345,336.30 13, Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 13. $ 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13} _ 14. $345,336.30 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. 29 16. Amount of Line 14 taxable at lineal rate X 0.045 5 17, Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 15. 16. 17. 18. 19. TAX DUE 1 g 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 $ 0.00 $2,256.11 $ 0.00 $ 0.00 $2,256.11 c~ 15056052059 _.-,,,~~ cn rage 3 Decedent's Complete Adaress: 21 ~ i ~~ I I cca' DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER ROBERT L. SIMMERS 198-30-0041 STREET ADDRESS 120 KIM ACRES DRIVE CITY STATE ZIP MECHANICSBURG PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1} $2,256.11 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) $ 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total InterestlPenalty (D + E } (3) $ 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fil{ in oval on Page 2, Line 20 to request a refund. (4) $ 0.00 5. If Line 1 + Line 3 is greater than Lihe 2, enter the difference. This is the TAX DUE. (5) $2,256.11 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5g) $2,256.11 Make Check Payable to: REG/STER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" 1N THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; ^ Q b. retain the right to designate who shall use the property transferred or its income; ^ Q c. retain a reversionary interest; or ^ Q d. receive the promise for life of either payments, benefits or care? ^ Q 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death O Q without receiving adequate consideration? Q O 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? Q ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? Q ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS I5 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 exemat 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 Hated in 72 ~.S. §9116(1.2) (72 P.S. §9116(a)(1)]. 'he 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 sib{ing is defined, nder Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. - ~--__.. _ ,~-no, Q. `...~- ~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT w.~v< ~~: STOCKS & BONDS ROBERT L. SIMMERS All property jointly-owned with right of survivorship must lse disciosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRiPTlON OF DEATH 1. 60 SHS. PRUDENTIAL FINANCIAL, INC. -VALUED AT CLOSE ON 12/21/07 $5,615.40 T07AL (Also enter on Line 2, Recapitulation) ~ $5,615.40 more space is needed, insert additional sheets of the same size) .qr COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ROBERT L. SIMMERS SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY NUMBER 21 inGude the proceeds of litigation and the date the proceeds were received fi`! the estate. All property joirrtlyowned with the right of survivorship must he disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. CHECKING ACCOUNT, PNC BANK, #50-0410-0167 -SEE ATTACHED STATEMENT $3,257.46 2. MONEY MARKET ACCOUNT, PNC BANK, #50-0411-3339 -SEE ATTACHED STATEMENT 6,707.95 TOTAL r;A1so enter on line 5, Recapitulation) { $9,965.41 (If more space is needed, insert additional sheets of the same size) i~t~tt;rest l:~l~CC1Zl.~ ~.~~ . ~ ,. ~ ~$lt Sta.aw`::~~letlt 1?Iv'G I;aitk PNCBANi~ Primary account number: 50-0410-0167 Page 1 of 2 Number of enclosures: 0 For 24-hour banking, and transaction or J-=-t interest rate information, sign on to 'Q' PNC Bank Online Banking at pnc.com. For customer service call 1-866-PNC-4000 between the hours of 6 AM and Midnight ET. Para servicio en espariol, 1-866-FIOLA-PNC MovingT Please contact us at "-866-PNC-4000 We value your relationship with PNC. For questions about yotar account, please call 1-866-PNC-4000. ® Write to: Customer Service PO Box 609 Pittsburgh PA 15230-9738 Visit us at pnc.cotrt TDD terminal: 1-800-531-16413 For hearing intpairtd clients only lntereSt ~hecking Account Summary Robert ~ simmers Decd Account number: 50.0410-0167 ifor ttte period 12/12/2007 to 0111112008 ROBERT t SIMMERS DECD 120 KIM ACRES DR MECHANICSBURG PA 17055-5533 Balance Summary Beginning balance •1,777.8.1 Deposits and Checks and other Ending other additions deductions balance Average monthly Charges balance and fees `?,753.351 .Ot) Transaction Summary Checks paidl withdrawals 3 Total ATM transactions Check Card POS signed transactions r~ PNC Bank. ATM transactions Check Card/Bankcard POS PIN transactions :1 Other Bank ATM transactions U 0 0 Activity Detail Please see the Activity Detait section for additional information. Deposits and Other Additions There were 2 Depesi!s and Jti~er AdUittors Date Amount Description te!alirsg $1,851.60. 12,"ZG 1,•112.GU llircct lleposit -Sur. Sec t?S'1'reasury 3U3 XtX:`XOO~I lt1 O1i0$ ~135t.0O l~ircct 1)cpr:>si1 - Pcns Pmts Finarrc Instit 1:C ECtxc~ctixti~;$`tG5 Checks and Substitute Checks ;heck Date Reference Check Date Reference lumber Amount paid number number Amount paid number 4°~[, 227.12 ]2/11 c27sss~t;u 1427 14U.U0 12/26 c13.6a32t7s 42G Z' $~i4.00 12/21 026277697 Gap in check sequence •T' Teller Cashed Check There were 3 checks fisted totaling $1.217A2. FORM953R-1005 v (~ For 24-hour information, sign on Yo PNC Bank Online Banking 1 -.. on pnacom. Account number: ~fl-f)41(i-Q 167 -continued ~~ ~~~ ~~~;~~~ 1ariz~~xa7 to altlvzaos ROBERT L SIMMERS DECD Primary account number: 50-O~F10-0167 Page 2 of 2 Banking/Check Card Withdrawals and Purchases Date Amount Description '1'2/12 31.7Si PC~S R.u•c:h:ase Toys F t?S Caatnp }sill PA 1'2;`1> 3i.fi8 PC)S Pur<hase Giant. Food Sto i\lechanicsburPa 1`2:" 13 ~~1.7~1 P<)5 Purchase Giant E'ooci Sto 141echanicshur P:1 1`?:' l l 71:20 Pt)S Purchase Giant Food Sto ~iechanicsbur P~~ 1`L:' 1.1 `25.00 0.171 Check C:arci Pm~chase. lfechanicsbur,Y, Diner 13:~ l t `21.38 017.1 Check Card Purchase Borders Books ()1004555 1`2;' 17 1 U.95 0~}i4 Check Gard Purchase Tw:t~?.UL Service 1207 I`2:' 18 10.()() 0.174 Check C:au•d Purchase Planet Fitness Dlechani l3.! 1 S I (J.00 0474 Check Card Purchase Planet Fitness D•lechani Online and Electronic Banking Deductions Date Amovnt Description 1?:'25 ].11'2.60 I~ire:et. Payment - Reeersal t?S Trc:~suty 3(J3 ~;tiX`i:Y0047A Other Deductions Dat= Amount Ol :'03 .tJO Description ()ukstanding Item Close Debit ;14cmo Re1'rrence. No 025232304 There were 4 Check CardtBank card PIN POS purchases totaling $Z2S.a0. There were 5 other Banking Machine,rCheck Card deductions totaling $77A3. There was 1 Online or Electronic Banking Deduction totaling $1,412.6x. There were 2 Other Deductions totaling $3,696.46. Daily Saiance Detail Date f3alahce I2j 12 4,746.0`_' Date 12/ 17 Balance 4,267.45 Date 12/26 Balance 4,fi70.Oti 12/13 4,fi23.5U 12/13 4,247.45 12/23 3,257.46 12j14 4,273.41 12/21 3,397.46 OI/02 3,696.46 C', U. S ~U12G~~5 ~ 225. 5~'> Date Balance 01/03 .OU a~~~ t~2~~7 3257, ~ rerrormance ~~~ ~1 _~~;~b..~: ~~. ., : ~ ~t~;~oui~t ~~~ .... =v~:._~: i'NC l;a~tk for ti+e period 1 0/7 212007 to 01/11!2008 .. _~~::~ ;i PNCBANI Primary account number: 50-0411-3339 Page 1 of 1 Number of enclosures: 0 ROBERT L SIMMERS DECD (Of For 24-hour banking, and transaction or 120 F; IM ACRE5 DR ~' interest rate information, sign on to 'a' PNC Bank Online Banking at pnc.com. MECHANICSBURG PA 17055-5533 For customer service call t-866-PNC-4000 between fire Hours of 6 A11A and Midnight ET. Para servicio en espariol, 1-866-HOLA-PNC Movingl• Please contact t+s at 1-866-PNC-4000 ® Write to: Customer Service PO Box 609 Pittsburgh PA 15230-9738 Visit us at pnc.com We value your relationship with PNC. For questions about your account, ~ TDD terminal: 1-800-531-1648 please call 1-866-PNG-4000. For hearing impaired clients only Performance Money Market Account Summary Robert L Simmers Decd Account number: 50-0411-3339 Balance Summary Beginning Deposits and balance other additions (i,(it3.1.39 23. ~fi Checks and other Ending deductions balance 1;,707.95 .00 Average monthly Charges balance and fees 4,760.•48 .ot7 Please see the Activity Detail section for additional information. Activity Detail Deposits and Other Additions Dat¢ Amount Description 1 1;'t)9 1 l.a? Interest Pa}~ment 1d:'I I 11.71 Interest P~}~nunt Other Deductions Date Amount Description 01,`U3 .f)U Uutstandi+rg Itrm CI<rse; Ulj U3 fi,707.95 llcl.~it Menu Itcfcrence No 025232fi0G There were 2 Other Deductions totaling Daily Balance Detail Date Balance Date Balance Date Baiance Dat¢ Balance 10/12 6,684.39 11/09 6,696.21 12/11 6,707.95 01/03 .oo There were 2 Deposits and Other Additions totaling $23.56. FORM953R-1005 4.- = ~ ~ SCHEDr~_~: . COMMONWEALTH OF PENNSYLVANIA INTER-VIVOS TRANSFERS & tNHERITANCETAxRETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT JF ROBERT L. SIMMERS 21-08-0006 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 DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRA~ACNRA COPYEOFT HE DEED FOR REAL ESDTATE AND THE DATE OF TRANSFER. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION QF APPLICABLE) TAXABLE VALUE 1. INDIVIDUAL RETIREMENT ACCOUNT, CONTRACT NO. E0290680 $287,479.36 100% $287,479.36 BENEFICIARY -DOROTHY S. SIMMERS -SEE ATTACHED PRUDENTIAL STATEMENT 2. 2007 FEDERAL INCOME TAX REFUND RECEIVABLE -RETURN JOINTLY 2,314.00 50% 1,157.00 FILED WITH SPOUSE -DOROTHY S. SIMMERS 3. ANNUITY, METLIFE INVESTORS USA, CONTRACT NO. A2071036 50,135.78 100% 50,135.78 BENEFICIARY - IRENE SIMMERS, DECEDENT'S MOTHER -SEE ATTACHED METLIFE STATEMENT **PLEASE BILL SEPARATELY!*" enter on line 7 772.1 (If more space is needed, insert additional sheets of the same __ -..~ ~ vaua Annuity Services P.O. Box 13467 Strate is Partners Annuit One III Philadelphia, PA 19178 g y Annuity Statement October O1, 2007 through December 31, 200? >02399 3740167 002 092001 Financial Professional: ROBERT L. SIMMERS WALTER S. SHEETS 120 KIM ACRES DRIVE PRUDENTIAL - PFS MECHANICSBURG, PA 17055 150 CORPORATE CENTER DR. SUITE 105 CAMP HILL, PA 17011-1759 Annuity #: E0290680 Type: IRA Owner Name: Robert L. Simmers ^,nnwitunt: R^bert L. Simmers Page 1 of 4 Issue Date: 07115/2003 Statement Date: 01/0412008 Web site «nv.prudcntial.com Annuity Service Center at 1-888-778-2888 ` Your Financial Professional at (717) 975-81 SO Please review your statement thoroughly and contact us if you find any information you believe to be inar-curate. If we do not hear from you in 30 days, we will assume that all information is correct. Your Portfolio Your Annuity Activity Beginning Value Purchase Payments Withdrawals Contract Fccs and Chargcs* Investment Performance Current Quarter< $295,512.60 - .oa {$3;000.00) .00- $1,126.98 $293,639:88 $.287;479.36. 'r___ --- Year-to-Date $285,536,43 .00 ($12,000.00) {$816.53) $20,919.68 $293,639.58 Since Issue .00 $266,447.56 ($3,154.47) $82,346.49 Ending Value Surrender Value $293,639.58 `Contract Fees and Charges reflect certain fees and charges such as Contingent Deferred Sales Charge, transfer fees, aruiual maintenance fees, or other benefit fees or charges, if applicable or imposed during the period covered by tlus statement as of the statement date. Guaranteed Minimum income Bcneft (GMIB) Protected Value as of 12/3] j2007: $273,1:11.76 Guaranteed Minimum Income Benefit (GM[B) Maturity Date: 07/ 15/201.0 *Sce Your Benefit Values section of this statement for more details. Portfolio Detail October O1, 2007 through December 3l, 2007 VARIABLE INVESTMENTS Asset Alloc: SP Conscr\.~ativc Asset Allocation \Krnt II? a li~'fC11+ ~?lli~•r ~ l-1:\F'.?~ # of Units Unit Price Portfolio Value as of 12 J31 J2007 as of 12 /31 j2007 as of 12 j31 j2007 202,649.81249 1.44900 $293,639.58 02399 3740167 004597 006059 00001100002 A) ~ ~ ~ ~ A~ ~ ~~ a o a'. ~-~ ~ O (D -' _ ~' S ~ N ~ m ~, a o ~i 0 0 ~ ~ o °: c 'o n ~ °' o f m .~ m O ~ C .~-. N ¢'1 Al ~ O m 7 N C ~ A? O ~3 ~ p'. Q O ~~ 2 n A> ~~ N 'p ro r ~' no ~~ .« ON ~~ X (~Q ~m cG ~~ ~m ~~ ~ <. m ~~ Al ~ ~ N D~ ~ O Q ~ ~i Imo! 1 0 W ^~ O W ~ $m~b~ Q7 ~ ~ m 0. ~cn~No NmZ~rn ~~~ N~m~b co~r~~ Dim ~-~'ac~n3 zW ~ o~ O G ~ N O N O ~ ~ A O ~ O N m r O pm~Dc oo~~~o, • m .y to W ~ o NmZ~c°c ~~~ N~m~D ~a~~~ ~~o~w zW ~ o~ O ~ O G O N O N O ~ O A O N m r O QmpD= m~'~ma CA W Vj O N ~ Z ~ m ~~~_ N~N~D ~y~~m~5' ~~o~~WW Z ~ W O ~ ~ O O ~ O ~ O N ~ O ~ A 0 of O N m r O am~Dc m~~~~. _ m cn ~ o co [A m o°o 1 ~~~.p. N~m~~ ~~r~ yam zw ~ o~ 0 c 0 c o N O N O ~ O ~y O ~ O ~ m r O -~ ~D C~ O 7 d Q M ~• O -~ ..« co O O iQ O L. y ~? t~D {6~~ :. N ~ C ~°Oa Z~OcNo D~~ cnn~Dy ~m~ ccn-~ ~~m-'- a ~°~ p O ~ O A Qf N N ~ ~ mo0~ Z~'Oo ~'.~w ~ m D D ccn~~ Gl~~~ a ~~ O O u~i N O A O1 6II N ~ G C7 ~ 77 p, Z~O2N D.~QI c~n~Dy, W~~~ ~~m'- D ~ Oo ~ O m N ~ C ~°°~. z~Oo°o ~~~ rnn~aa ~mcn ccn-~ ~~mw ~ ~~ ~ ~ ~ G A Qf N .~ tD Q ..1 ~~ O -z ~+ 3 .w 0 tG t~ 0 C .=-h y t~D ~i ~: 1 r N -~i. r Deceased: ROBERT L SiAiMERS i2/22l07 Form 1040A Department of the Treasury -Internal Revenue Service U.S. Individual Income Tax Return IRS Use Only - Do not write or staple in this space. 2007 Label Your first name and initial Last name OMB No. 1545-0074 (See instrudions.) Your social security number ROBERT L SIMMERS 198-30-0041 Use the if a }oint return, spouse's first name and initial Last name Spouse's social security number IRS labe{. Otherwise. DOROTHY S SIMMERS 168-26-3952 please print or t e Home address (number and street). If you have a P.O. box, see instructions. Apartment no. . You must enter , yp . 120 KIM ACRES DRIVE your SSN(s) above City, town or post office. If you have a foreign address, see instructions. State ZIP code Checking a box below will PA 17055-5533 MECHANICSBURG not change your Presidential , tax or refund Election Cam ai n ~' Check here if ou, or ours ouse if filin 'ointl ,want $3 to o to this fund see instructions .. ~ You Souse Filing 1 Single 4 Head of household (with qualifying person). (See instructions.) Status 2 X Married filing jointly (even if only one had income) If the qualifying person is a child but not your dependent, 3 Married filing separately. Enter spouse's SSN above and enter this child's name here ~ full name here ~' 5 ~ Qualifying widow(er) with dependent child Check only one box. (see instructions) Exemptions 6a X^ Yourself. If someone can claim you as a dependent, do not check box 6a........... boxes checked on 6a and 6b ...... 2 fvl ~.. If more than six dependents, see instructions. - -- - ----- - - c Dependents: (1) First name Last name (2) Dependent's socia{ security number (3) Dependent's relationship to you (4) 'i if 4 nid fog child tax credit No, of children on 6c who: • lived with you...... . • did not live with you due to divorce or separation (see instructions)... . Dependents on 6c not entered above.. . d Total number of exemptions clatmed ....................... ...................... ........... Add numbers on tines above ~ 2 Income 7 Wages, salaries, tips, etc. Attach Form(s) W-2 .............. ...................... ..... 7 Attach form(s) 8a Taxable interest. Attach Schedule 1 if required .............. .......... . ........... ..... 8a 3, 770 . W-2 here. Also bTax-exempt interest. Do not include on line 8a ...................... 8b attach Form(s) 1099-R if tax 9a Ordinary dividends. Attach Schedule 1 if required ............ ...................... ..... 9a 69 . was withheld. bQualified dividends (see instructions) ...................... 9b 69. 10 Capital gain distributions (see instructions) .............. . ... ........... . .......... ..... 10 11 a IRA distributions .............. 11 a 11 b Taxable amount . ..... 11 b 12, 000 . 12a Pensions and annuities........ 12a 13, 056. 12bTaxable amount. ..... 12b 11, 894. 13 Unemployment compensation and Alaska Permanent ~ If you did not Fund dividends ........................................... ....................... ..... 13 get a W-2, see instructions. Enclose, but 14a SOCial Security benefits ....................... 14a 27, 612. 14bTaxable amount. ..... 14b 4, 770 . do not attach, any payment. 15 Add lines 7 through 14b (far right column). This is ourtotat income ................ .. ~ 15 32, 503. Adjusted 16 Educator expenses (see instructions) ...................... 16 grOSS 17 IRA deduction (see instructions) ........................... 17 InCOme 18 Student loan interest deduction (see instructions) .......... 18 19 Tuition and fees deduction. Attach Form 8917 .............. 19 20 Add lines 16 through 19. These are your total adjustments . ....................... ..... 20 0 . 21 Subtract line 20 from line 15. This is your adjusted gross income .................... ~ 21 32, 503 . BAA For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see instructions. Form 1040A (2007) FDIA1312L 11/14/07 Form 1'040A (2007) ROBERT 1; AND DOROTHY S SI~~MEP.S 198-30-0041 Page 2 Tax, 22 Enter the amount from line 21 (adjusted gross jncome) ...................... . .......... 22 32, 503 . credits, and 23a Check X You were horn before January 2,1943, Blind Total boxes payments if~ ~ eX Spouse was born before January 2,1943, 8 Slind }checked. ~ 23a 2 b If you are married filing separately and your spouse itemizes deductions, Standard see tnstructions and check here ......................................... " 23b~ Deduction for - • People who checked any box on line 23a or 23b or who can be claimed as a dependent, see instructions. • All others: Sjngle or Married flltng separately, $5,350 Married filing jointly or Quahfytng widow(er), $10,700 Head of Household, $7,850 24 Enter your standard deduction (see left margin) ..................................... . . 24 12, 800 . _ 25 Subtract line 24 from line 22. If line 24 is more than line 22, enter -0- .................... 25 19, 703 . 26 If line 22 is $117,300 or less, multiply $3,400 by the total number of exemptions claimed on line 6d. If line 22 is over $117,300, see the instructions .............................. 26 6, 800 . 27 Subtract fine 26 from line 25. {f line 26 is more than line 25, enter -0-. This is your taxable income ................................................................... - 27 12, 903 . 28 Tax, including any alternative minimum tax (see instructions) ..................................................................... 28 1, 2 8 6 . 29 Credit for child and dependent care expenses. Attach Schedule 2 ........................................ 30 Credit for the elderly or the disabled. Attach Schedule 3 ... . 31 Educatjon credits. Attach Form 8863 ...................... . 32 Child tax credit (see instructions). Attach Form 8901 if required .............................. 33 Retirement savings Contributions credit. Attach Form 8880. . 29 30 31 32 33 34 Add {fines 29 through 33. These are your total credits ................................... 34 35 Subtract line 34 from line 28. If line 34 is more than line 28, enter -0-. .................... 35 1, 286. 36 Advance earned income credit payments from Form(s) W-2, box 9 ...................... 36 37 Add lines 35 and 36. This is your total tax .......................................... ~ 37 1, 286. 38 Federal income tax withheld from Forms W-2 and 1099..... 38 3, 600 . 39 2007 estimated tax payments and amount applied from If you have a qualifying child, attach Schedule EIC. 2006 return .............................................. 39 40a Earned income credit (EIC) ............................... 40a bNontaxable combat pay election, 40b 41 Additional child tax credit. Attach Form 8812 ............... 41 _ 42 Add lines 38, 39, AOa, and 41. These are your total payments .................................. . . - 42 3, 600 . Refund 43 If line 42 is more than line 37, subtract line 37 from line 42. This is the amount you overpaid ...................................................... 43 2 , 314 . 44a Amount of line 43 you want refunded to ou. If Form 8888 is attached, check here. ~ ~ 44a 2, 314 . Direct deposit? - bRouting See instructlons number.......... XXXXXXXXXXXXXXXXX - c T e: Checking ~ Savings and fill in 44b, 44c, and 44d or '' dAccount Form 8888. number .......... XXX 45 Amount of line 43 you want applied to your 2008 estimated tax ............................................ 45 Amount 46 Amount you owe. Subtract line 42 from line 37. For details on how to pay, you owe see instructlons ................................................................... - 46 47 Estimated tax enalt see instructions . .................. 47 Third party Do you want to allow another person to discuss this return with the IRS (see instructions)? .......... X Yes. Complete the following. No designee Designee's ` name Phone ~ no. Personal identification ` number (PIN) Si n Under penalties of perjury, I decl I examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they g ly i t all and sources of income I received during t are true, correct, and accJ he tax year. Declaration of preparer (other than the taxpayer) is based on all here k wledge. information of which th ~ ~~ Your signature Date Your occupation Daytime phone number Joint return? l. J See instructions. , RETIRED 717 766-4808 p Spouse's signature. If a joint return, both must sign. Date Spouse's occupation ~ I ' x 1, .x ~ ~ ; y r '~ cords. for your ~e Filin as Survivin Souse RETIRED { }.. ~ `~,''~ y .. Date Check if Preparer's SSN or PTIN Paid Preparer's signature ~ William R. Kaufman CPA JD employed X 208-38-7696 preparer's Firm's name DeMuth Management Consultants_ _ --------- _ _ _ _ _ --"- -"- useonly (orppyoursdself• ~ 940 Century Dr ad s da EIN 23-2871292 __ nd dre s, ZlPcode Mechanicsbur PA 17055-4376 noone (717) 790-9001 FDIA1312L ~tna~o~ Form 1040A (2007) MetLife Investors USA P.O. Box 14593 ~ Des Moines fA 54306-3593 ~~~ ~~ ~~ February 21, 2008 MR. JAMES SIMMERS POA Copy to: MR. CHARLES LITTLE IRENE SIMMERS PNC {NVESTMENTS 670 BENTZEL RD 2 EAST MAIN ST LEWISBERRY PA 17339 MECHANICSBURG PA 17055 RE: riE~'I'~{~ E If+l`JESTO~t.~s USA 9NStlR.'~tdCr v~rr~r~~"-~iv`i CCi~ i ~v+Ci'_;As^.C7. i~;6 OWNER Robert Simmers Dear Mr. Simmers: Thank you for your recent inquiry regarding .the contract referenced above. Our records indicate that the date of death and the account value on that date are: Date of Death: December 22, 2007 Account Value; $50,135.78 If you have any questions, please contact our Customer Service Center at (800) 284-4.536 Monday through Friday between 8:30 a.m. and 6:30 p.m., ET. Sincerely, Ashlee Reed Sr. Annuity Representative -Post issue Processing MetLife Annuity Operations and Services REV-1541 EX ~ (1406) • 4: , '~~ COMMONWEALTH OF PENNSYLVANIA SCHEDULE H INHERITANCE TAX RETURN FUNERAL EXPENSES & RESIDENT DECEDENT ADMINISTRATIVE COSTS ESTATE OF ROBERT L. SIMMERS FfLE NUMBER 21-08- 0006 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. MYERS FUNERAL HOME, MECHANICSBURG, PA -FUNERAL EXPENSES $3,108.50 2. COLONY HOUSE FAMILY RESTAURANT, MECHANICSBURG, PA -POST-FUNERAL LUNCHEON 500.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Street Address State Zip City Year(s) Commission Paid: 2. Attorney Fees 1,200.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 3,500.00 Claimant DOROTHY S. SIMMERS Street Address 120 KIM ACRES DRIVE City MECHANICSBURG State PA Zip 17055 Relationship of Claimant to Decedent SPOUSE 4. Probate Fees CUMBERLAND COUNTY REGISTER OF WILLS '121.00 5. Accountant's Fees 6. Tax Return Preparer's Fees DeMUTH MANAGEMENT CONSULTANTS, FINAL INCOME TAX RETURN 275.00 7. ESTATE ADVERTISEMENT -CUMBERLAND LAW JOURNAL '75.00 8. ESTATE ADVERTISEMENT -HARRISBURG PATRIOT NEWS 222.15 9. INHERITANCE TAX FILING FEE -CUMBERLAND COUNTY REGISTER OF WILLS 15.00 TOTAL (Also enter on line 9, Recapitulation) ~ $9,016.65 more space is needed, insert additional sheets of the same size) DONALD L. DEMUTH PROFESSIONAL MANAGEMENT CONSULTANNTS 940 CENTURY DRIVE MECHANICSBURG, PA 17055 (717) 790-9001 FAX: (717) 790-9031 DONALD L. DEMUTH, C.H.B.C., M.B.A., C.P.AJP.F.SJA.B.V. WILLIAM R. KAUFMAN, C.P.A., J.D. March 20, 2008 Dorothy S. Simmers 120 Kim Acres Drive Mechanicsburg, PA 17055 Fee for Preparation of 2007 Personal Income Tax Returns: ~.7~ PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW 30URNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, alegal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland I.aw Journal on the following dates, viz: ,March 28 April 4, and April 11, 2008 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law 3ournal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. Simmers, Robert L., deed. Late of Cumberland County. Administratrix: Dorothy S. Sim- mers c/o William R. Kaufman, Esquire, 940 Century Drive, Me- chanicsburg, PA 17055-4376. Attorney: William R. Kaufman, Esquire, 944 Century Drive, Me- chanicsburg, PA 17055-4376. ` ~' Lisa Marie C~ylle, Editor (.. '~ SWORN TO AND SUBSCRIBED before me this 11 day of April, 2008 ~ GEC Notary NOTA.R(AL SEAL OEBCRAH A COLLfNS Notary Public CARLISLE BCRO, CUMBERLAND COUNTY My Commission Expires Apr 28, 2010 The Patriot-f~e~s Co. 812 Market ~.~ =. Harrisburg, PA 17101 Inquiries - 717-255-8292 WILLIAM R. itAUFMAN ATTORNEY AT LAW 940 CENTURY DRIVE MECHANICSBURG ~,~~~, ~triot-dews Now you know PA 17055 ~~O ~ ~ ~ ALL CHARGES ARE NEl ACCT # NAME AD ORDER # DATE EDITION ADDTL. INFO. TYPE OF CHARGE AMOUNT 93620 WILLIAM R. KAUFMAN 93620 WILLIAM R. KAUFMAN 93620 WILLIAM R. KAUFMAN 93620 WILLIAM R. KAUFMAN 0001826547 03/19/08 REGULAR BOLD TEXT CHARGE $4.00 0001826547 03!19108 REGULAR 0001826547 03/26!08 REGULAR 0001826547 04/02/08 REGULAR TOTAL: REMITTANCE ADDRESS The Patriot-News Co. 23794 Network PL Chicago, IL 60673-1237 BASIC AD CHARGE $71.05 BASIC AD CHARGE $71.05 BASIC AD CHARGE $71.05 AFFIDAVIT CHARGE $5.00 $222.15 Please include the Account # or Ad Order # (above) with your remittance--Thank You NOTE: This invoice replaces the Order Confirmation which we previously sent with Proofs of Publication i REV-1513 EX + (9-00)) . Q., `~ 'fir COMMONWEALTH OF PENNSYLVANIA SCHEDULE J INHERITANCE TAX RETURN BENEFIC{ARIES RESIDENT DECEDENT ESTATE OF ROBERT L. SIMMERS FILE NUMBER 21-08-0006 RELATIONSHIP TO DECEDENT r~ourrroR NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) sH~ OF ESTATE TAXABLE DISTRIBUTIONS [include outright spousal distributions, and t transfers under Sec. 9116 (a) (1.2)] 1. DOROTHY S. SIMMERS SPOUSE 100% 120 KIM ACRES DRIVE MECHANICSBURG, PA 17055 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 [I -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ 0.00 (If more space is needed, insert additional sheets of the same size) W ~ ~; ~ ~ a r--~o oomin• •z ~ ~~.(linino (~Vo ac,~r~--o ~o .dam - E O ~ ~ _~ ~ 2 Q U W f r~~~~ M_ o r w "" ~~~ N U Ma o N M O W "i O 1- Fa "ao ~ c ..._~ 1. ,' 7 _ C~ ~_ i~ V~ ~~'~ Q~ N O ~ M (,~ ~ c~ y ~ ~ ~ ~ V O ~ ~ ~ ~ 3 ^v ~ L f %.~ "~ J ~ ~ ^~ •~ ti r~ v r, 'J