HomeMy WebLinkAbout09-02-0815056041147
REV-1500 EX (06-05) OFFICIAL USE ONL ,-
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number \
Po eox.zsosol INHERITANCE TAX RETURN 2 1 ~'`/ X5-4?
Harrisburg, PA 17128-OS01 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
07 20 2007 12 30 1946
Decedent's Last Name Suffix Decedent's First Name MI
STAGER CYNTHIA N
(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
X^ 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ qa. Future Interest Compromise ~ 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
s Decedent Died Testate ~ Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 1 p. Spousal Poverty Credit (date of death 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
DALE K. KETNER 717 692 2345
Firm Name (If Applicable)
SHAFFER & ENGLE LAW OFFICE
First line of address
129 MARKET STREET
Second line of address
City or Post Office State ZIP Code
MILLERSBURG PA 17061
REGISTER t~WILLS USE~JLY
C
~ 4- _'
n r~l
~ ~
rn t r=
',~ ~ - -'
C`? O~r~ '1d t, _
j
~~ _
DATE~ED N _
L.1 ~ J
r~
r-^,
:,-:t
Ti
Tl
~~.
Correspondent'se-mail address: dale@shafferengle.COm
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 all information of which preparer has any knowledge.
~ ~t/'p ~ ~i~r~~~'1~91 ~-~--1 Constance E. Stoneroad
mss -
129 Market et -Suite 1, Millersburg, PA 17061
SIGNATURE OF P R SENTATIVE DATE
Dale K. Ketner
ADDRESS
129 Market S reet, Millersburg, PA 17061
Side 1
15056041147 15056041147 J
--~
i
_..J 15056042148
REV-1500 EX
Decedent's Social Security Number
t)ecetlent~s Name: Cynthia N S t a g e r
RECAPITULATION
1. Real Estate (Schedule A) .......................................................................................... 1.
2. Stocks and Bonds (Schedule B) ............................................................................... 2.
3.
4.
5•
6.
7.
8. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)..........
Mortgages & Notes Receivable (Schedule D) ..........................................................
Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................
Jointly Owned Property (Schedule F) ~ Separate Billing Requested .............
Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ~ Separate Billing Requested .............
Total Gross Assets (total Lines 1-7) ....................................................................... 3.
4.
5.
6.
7,
g,
49,998.17
9, 9 9 8 1 7
3,764.40
9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9.
155,493.21
10. Debts of Decedent, Mortgage Liabilities, & Liens {Schedule I) ............................... . 10.
159,257.61
11. Total Deductions (total Lines 9 & 10) ..................................................................... . 11.
-109,259.44
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.
-109,259.44
14. Net Value Subject to Tax (Line 1 Z minus Line 13) ................................................ . 14.
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, of
transfers under Sec. 9116
0.00
15 0 0 0
(a)(1.2) X .00
.
16. Amount of Line 14 taxable 0 0 0 16. 0 . 0 0
at lineal rate X .045
17. Amount of Line 14 taxable
0 0 0
17 0 0 0
at sibling rate X .12 .
18. Amount of Line 14 taxable 0 0 0 18 0 . 0 0
at collateral rate X .15 .
19. Tax Due .................................................................................................................... . 19. 0 0 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
-f~
t~
4
..('
15056042148
Side 2
1556042148
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-07-0541
DECEDENT'S NAME
Cynthia N Stager
STREET ADDRESS
2535 Rollo Court
CITY
Mechanicsburg STATE
PA ZIP
17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) 1
O
0.00
2. Credits/Payments
A. Spousal Poverty Credit
g. Prior Payments
C. Discount 0.00
Total Credits (A + g + C) (2) 0.0 0
3. InteresUPenalty if applicable
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) 0.00
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Q . 0
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 :.................................................................................. ^
b. retain the right to designate who shall use the property transferred or its income :.................................... ^
c. retain a reversionary interest; or .................................................................................................................. ^
d. receive the promise for life of either payments, benefits or care? .............................................................. ^ ^x
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ....................................................................................................................... ^ 0
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? ...................................................................................................................... ^ ^x
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero
(0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements
for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a
natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent,
except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)].
The tax rate imposed on the net value of transfers to 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-7508 EX+ (8.98J
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF (FILE NUMBER
Stager, Cynthia N f 21-07-0541
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property Jointly-owned with the right of survivorship must be disclosed on schedule F.
(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-1151 EX+ (12-991
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Stager, Cynthia N 21-07-0541
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A, FUNERAL EXPENSES:
B.
1
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Constance E. Stoneroad
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address 129 Market Street -Suite 1
~;ty Millersburg state PA zip 17061
Year(s) Commission paid 2008
2, Attorney's Fees Shaffer & Engle Law Office
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. I Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
1,500.00
250.00
93.00
7. Other Administrative Costs 1,921.40
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 3,764.40
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
Rev-7502 EX+ (6.98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H-B7
OTHER
ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Stager, Cynthia N 21-07-0541
ITEM
NUMBER
DESCRIPTION
AMOUNT
1 Auers Memorial Home -Death Certificates for John Shickley 17.00
2 Cumberland County Journal -Legal Advertise 75.00
3 Cumberland County Sentinel -Legal Advertise 174.58
4 Halifax National Bank -Check fees 8.12
5 Keystone Guardianship Services -Fees and costs related to the filings and 1,130.06
notifications re: termination of guardianship and establishing estate
6 Keystone Guardianship Services -Reimbursement for Administrator Costs - 274.64
Postage, Copies, Faxes, Long Distance Phone calls, etc.
7 Register of Wills -Short Certificates 12.00
8 Register of Wills -Filing of Releases 195.00
9 Vital Chek -Death Certificates for Cynthia 35.00
Subtotal I 1,921.40
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B7 (Rev. 6-98)
Rev1512 EX+ t6-98)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Stager, Cynthia N 21-07-0541
Include unrelmbursed medical expenses.
ITEM DESCRIPTION vAOF EATHTE
NUMBER
1 Apex Asset Management (Carlisle HMA Physcian Management) -Medical Expenses 3,955.00
prior to DOD.
2 Bureau of Account Management (Holy Spirit) -Medical Expenses prior to DOD. 41,686.97
3 Carlisle Digestive Disease -Medical Expenses prior to DOD. 400.00
4 Carlisle Ear Nose 8~ throat Associates -Medical Expenses prior to DOD. 413.05
5 Center for Kidney Disease & Hypertension -Medical Expenses prior to DOD. 536.78
6 Cumberland Goodwill Fire Rescue -Medical Expenses prior to DOD. 426.30
7 Guistwhite Family Practice -Medical Expenses prior to DOD. 1,368.00
8 Health Network -Medical Expenses prior to DOD. 109.99
9 Healthsouth of Mechanicsburg -Medical Expenses prior to DOD. 4,656.26
10 Heartland -Medical Expenses prior to DOD. 2,905.76
11 Hollinger Funeral Home 8~ Crematory, Inc -Prepaid burial arrangements, Check 1,750.00
written prior to DOD
12 Holy Spirit Hospital -Medical Expenses prior to DOD. 31,082.05
13 Internists of Central PA -Medical Expenses prior to DOD. 5,025.00
14 Kantor 8- Tkatch Assoc -Medical Expenses prior to DOD. 1,500.00
15 Keystone Guardianship Services -Filing Cost and Guardianship Set up Fee, Check 520.00
written prior to DOD
Total of Continuation Schedules See attached
pages
TOTAL (Also enter on Line 10, Recapitulation) 155,493.21
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-7500 Schedule I (Rev. 6-98)
Rev-1b12 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
continued
ESTATE OF (FILE NUMBER
Stager, Cynthia N 21-07-0541
ITEM
NUMBER
DESCRIPTION VALUE AT DATE
OF DEATH
16 Kinetic Imaging -Medical Expenses prior to DOD. 410.00
17 Manor Care Nursing Home -Invoice presented to Keystone at time of appointment, 10,607.18
Check written prior to DOD
18 Masland Associates -Medical Expenses prior to DOD. 38.00
19 Moffiee Heart 8- Vascular -Medical Expenses prior to DOD. 1,560.00
20 NCO Financial Systems (Camp Hill Emergency Physcians) -Medical Expenses prior 806.00
to DOD.
21 I NCO Financial Systems (Carlisle Regional Medical Center) -Medical Expenses prior
to DOD.
22 Neurological Surgery, LTD -Medical Expenses prior to DOD.
23 Neurology Center, P.C. -Medical Expenses prior to DOD.
24 NRA Group, LLC (Associated Cardiologists) -Medical Expenses prior to DOD.
25 NRA Group, LLC (Physicians of Rehab) -Medical Expenses prior to DOD.
26 NRA Group, LLC (Pinnacle Heatlh Systems) -Medical Expenses prior to DOD.
27 NRA Group, LLC (Quantum Imaging) -Medical Expenses prior to DOD.
28 NRA Group, LLC (WSO Imaging Center) -Medical Expenses prior to DOD.
29 NRA Group, LLC (WSO Imaging Center) -Medical Expenses prior to DOD.
30 Pennsylvania Gastroenterology Consultant -Medical Expenses prior to DOD.
19,695.30
250.00
240.00
50.00
1,416.00
9,641.30
1,117.00
958.00
136.00
2,955.00
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98)
Rev-1512 EX+ (6.98)
SCHEDULE f
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TA% RETURN continued
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Stager, Cynthia N 21-07-0541
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
31 Philip D. Carey, MD -Medical Expenses prior to DOD. 130.00
32 Quantum Imaging 8~ Therapeutic Assoc -Medical Expenses prior to DOD. 3,804.00
33 Spirit Physcian Services -Medical Expenses prior to DOD. 1,342.00
34 West Shore Anesthesia Assoc -Medical Expenses prior to DOD. 568.00
35 West Shore EMS -Medical Expenses prior to DOD. 2,714.42
36 West Shore Pathology -Medical Expenses prior to DOD. 300.00
37 Yellow Breeches EMS, Inc -Medical Expenses prior to DOD. 419.85
TOTAL {Also enter on Line 10, Recapitulation) ~ 155,493.21
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98)
REV-1513 EX+ (9-00)
SCHEDULE J
ANIA
COM BENEFICIARIES
MHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Stager, Cynthia N 21-07-05 41
NAME AND ADDRESS OF RELATIONSHIP TO
DECEDENT SHARE 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)]
Elsie Nalis Mother
CIO Rosemary Arend, POA
1558 Dellsway Road
Baltimore, MD 21286
Total
Enter dollar amounts for distributions shown above on lines 1 5 through 18, as appropri ate, on Rev 1500 cove r sheet
II. NON-TAXABLE DISTRIBUTIONS:
A, SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBU I TUNS UN uNt ~ s vr- rcty- louu wvtrc ar~e~ I I v.vv
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98)
KEYSTONE 717.9 23455• FAXT717.692.35541• TOLL FREE 1,88&1236-9519
GUARDIANS HL-~L1guS~I~E~S 27,9~1~ORTH FRONT STREET SUITE 112 HARRISBURG, PA 17110
j~ y {(~~1(~~ 6.95ll FAX 717.692.3554 • TOLL FREE 1-888-236-9519
Glenda Farner Strasbaugh
Register of Wills r
i Courthouse Square N
Carlisle, Pa 1~oi3 ~ f` : ~}
N `~. `S ~
~~ ,
In re: Cynthia Stager, deceased ~
2io~-o54i ~ ~?
.~ ~
Dear Ms. Strasbaugh:
Please find enclosed the following items regarding the above-mentioned
estate:
1) The original Inheritance Tax Return and Inventory to be stamped
and filed
2) Check No. 1254 for $15.0o for the filing of the same
3) Check No. i32 for 30.0o for additional probate fees
4) A copy of the Inheritance Tax Return for the Pa Department of
Revenue
5) A copy of the first page of the Inheritance Tax and a copy of the
Inventory to be stamped and returned to us in the provided
envelope for our file.
If you have any questions regarding this request, please do not hesitate to
contact us.
Thank you in advance for your assistance.
Sin~erely,
.,~i~~
Constance E. Stoneroad
CESJsld
CONSTANCESTONEROAD
CONNIE@KEYSTONEGUARDIAN.COM
JEFFREY B. ENGLE, ESQUIRE
JEFP@KEYSTONEGUARDIAN.COM
MICHELLE DREIBELBIS
SHELLEY@KEYSTONEGUARDIAN.COM
Enclosure(s)
O
O
r y
°,a`c0 m
~m°'°m3
b ~
w ~,
Q ~ M
~~3°
~ ay
4
N
non
~~
e ~ ~
~• ~ O
N
~.
Q O
O
W
X 3
~ _
Ki~
N ~j r
O
~y O
7 ~
~ aL
ao
~ ° ~ 3.
~~3~y~
rn~c~ o
o ~ Qix~~~
Sm$$o
~C3NV~
~°'°0~
~-
~m~~
a~o$
~~_~~~
x,m
N Q C
~ O
w ~
3 ~'
N ~
r~~~
`~
~
~o
~ ~ ~,
C
~ ~
9
~ ~ b
~
~ z
'
^ ^
- CNri
C
v ~
~ ~ ~ ~
~
~ 0 ~
„'j
~
~
~
~
W V ~
~
'!
~
~ W ~
r~'1
? ~'! ~j
dq
~'
~.~ ~~3~ c
i
y
v
~ ~ :~ ~d ~- ~3S 8~~t 3
(~
x r
t 1•. -
3