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Home My WebLink About09-04-08J 15056041147 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN 2 1 0 7 110 9 PO BOX.280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 168 34 2100 09 13 2007 10 05 1943 Decedent's Last Name Suffix Decedent's First Name MI PETERSON MINNIE K (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS F;ETURN 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 ~ 4a. Future Interest Compromise ~ 5. Federal Estate Tax Return Required (date of death after 12-12-82) X^ 6 Decedent Died Testate ~ ~ Decedent Maintained a Living Trust 0 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. 0) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number WAYNE M PECHT 717 691 9809 Firm Name (If Applicable) PECHT & ASSOCIATES, PC First line of address 1205 MANOR DRIVE, SUITE 200 Second line of address City or Post Office State ZIP Code MECHANICSI3URG PA 17055 ~.s REGISTER~ILLS US~NLY `~- _• ~+. ~.".'.t -~Q ~ _ ( 1 ~ t V ~ te ~ r; r " > Z rT t _ J ' ~. r~ . ~ +-~ ~''l ~ ~ -r'1 ~ _~~ -i7 -~-~ 40 F- - `~C'f -' v Correspondent'se-mail address: wpecht@pechtlaw.com Under penalties of perjury, I declare that I have examined this return, inGuding 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. ADDRESS Linda L Klinger ~5--c~ 8 561 Old Orchard Lade, Camp Hill, PA 17011 IGr{ATURE,dFIPREPARER OT R THApf REPRESENTATIVE Wayne M Pecht 1205 Manor Drive, Suite 200, Mechanicsburg, PA 17055 DATE '' -~(. r Side 1 15056041147 15056041147 J ~,J J 15056042148 REV-1500 EX Decedent's Social Security Number Decedents name: M i n n i e K P e t e r s o n 1 6 8 3 4 2 1 0 0 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. 18,307.56 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ 5. 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ............. 6. 324.61 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ............. 7. 8, Total Gross Assets (total Lines 1-7) ....................................................................... g, 1 8 , 6 3 2.17 5,712.88 9. • Funeral Expenses & Administrative Costs (Schedule H) ............................... .......... 9. 27,967.27 10. • Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ...................... .......... 10. 11. Total Deductions (total Lines 9 & 10) ............................................................ .......... 11. 33,680.15 12• Net Value of Estate (Line 8 minus Line 11) ................................................... .......... 12. -15,047.98 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ....................................... .......... 13. - 1 5 , 0 4 7 9 8 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, of transfers under Sec. 9116 (a)(1.2) X .00 0 . 0 0 15. 16. Amount of Line 14 taxable 0 . 0 0 16 at lineal rate X .045 . 17. Amount of Line 14 taxable 0 0 0 at sibling rate X .12 . 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 18. 19. Tax Due .............................................................. ...................................................... . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 15056042148 1505642148 0.00 0.00 0.00 0.00 0.00 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-07-1109 DECEDENT'S NAME Minnie K Peterson STREET ADDRESS 391 Sherwood Drive CITY Carlisle STATE PA ZIP 17015 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments q. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty if applicable p. Interest E. Penalty 0.00 Total Credits (A + B + C) (1) 0.00 (2) 0.00 Total Interest/Penalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. 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. A, Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT (3) (4) (5) 0.00 (5A) (5B) Q . Q Q ,, , -- 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 :.................................................................................. ^ ^x b. retain the right to designate who shall use the property transferred or its income :.................................... ^ ^x c. retain a reversionary interest; or .................................................................................................................. ^ ^x 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. t :. ., = ;. ~ 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-1b08 EX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Peterson, Minnie K 21-07-1109 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Members 1st Federal Credit Union Holiday Club Account #34999-02 -Per valuation 33.43 letter from Members 1st 2 2006 Ford Escape -per proceeds checks for purchase of vehicle 12,000.00 3 American Health and Life Insurance Company death benefit from CitiFinancial loan 2,525.40 insurance per letter dated 09/13/2007 4 State Farm Mutual Automobile Insurance Company -Hospital and Intensive Care 3,700.00 hospital income benefit per check #1134253176 dated 10/30/2007 5 State Farm Mutual Automobile Insurance Company refund of Hospital Income 48.73 Policy -Per letter from Insurance Agent and copy of insurance check TOTAL (Also enter on Line 5, Recapitulation) 18,307.56 (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+ (6.98) . SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Peterson, Minnie K 21-07-1109 If an asset waa 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. Linda L Klinger 561 Old Orchard Lane Daughter Camp Hill, PA 17011 B. Lisa A Hauenstein 391 Sherwood Drive Daughter Carlisle, PA 17015 C. 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 B 1/31/1992 Members 1st Federal Credit Union 940.50 33.330% 313.47 Checking Account #34999-11 -Per valuation letter from Members 1st 2 A B 10/3/1983 Members 1st Federal Credit Union 33.43 33.333% 11.14 Regular Savings Account # 34999-00 Established jointly with Linda Peterson Klinger and Lisa Peterson Hauenstein - Pervaluation Letter from Members 1st TOTAL (Also enter on Line 6, Recapitulation) I 324.61 (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 F (Rev. 6-98) Rev-1502 EX+(6-98) SCHEDULE H-A FUNERAL EXPENSES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Peterson, Minnie K 21-07-1109 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-A (Rev. 6-98) Rev-1502 EX+ (6-98) SCHEDULE H-B1 PERSONAL REPRESENTATIVE'S COMMISSIONS COMMONWEALTH OF PENNSYLVANIA continued INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Peterson, Minnie K 21-07-1109 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B1 (Rev. 6-98) Rev-1602 EX+ (6.98) SCHEDULE H-B2 ATTORNEY'S FEES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Peterson, Minnie K 21-07-1109 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B2 (Rev. 6-98) Rev-1502 EX+(6-98) SCHEDULE H-B4 PROBATE FEES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Peterson, Minnie K 21-07-1109 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-64 (Rev. 6-98) Rev-1502 EX+ (6.96) SCHEDULE H-B7 OTHER ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN continue RESIDENT DECEDENT ESTATE OF FILE NUMBER Peterson, Minnie K 21-07-1109 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-67 (Rev. 6-98) 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 Peterson, Minnie K 21-07-1109 Include unreimbursed medical expenses. ITEM DESCRIPTION VAOF DEATHTE NUMBER 1 Burick Azizhkhan Internal Medicine -patient balance after insurance payment -Per 53.78 provider invoice 2 Cardiovascular Surgical Institute -patient balance after insurance payments for 177.45 outpatient consult and cannula -Per provider invoice 3 Holy Spirit Hospital -charges related to inpatient services from 8/13/07 to 9113/07 - 1,776.75 Per provider invoice 4 Holy Spirit Hospital -patient charges for service provided 5/23/06 -Per Notice from 45.00 Bureau of Account Management 5 Holy Spirit Hospital -patient co-pay for admission 8/16/07 -Per provider invoice 100.00 6 Holy Spirit Hospital -Patient co-pay for admission 8/23107 -Per provider invoice 500.00 7 IRS -Federal Income Taxes & Penalties for tax year 2004 -Per Notice of Intent to 5,680.67 Levy 8 IRS -Federal Income Taxes 8< Penalties for tax year 2005 -Per Notice of Intent to 10,372.82 Levy 9 IRS -Federal Income Taxes 8~ Penalties for tax year 2006 -Per IRS Account 3,737.54 Summary 10 Members 1st VISA credit card balance -Per valuation letter from Members 1st 1,811.27 11 Moffitt Heart 8~ Vascular Group -for patient's responsibility for payment of 8/13107 43.16 Office visit after insurance 12 PA Income Tax Lien -unpaid income taxes 2005 -Per Bureau of Individual Taxes 1,104.97 Detailed Account Statement Total of Continuation Schedule See attached page TOTAL (Also enter on Line 10, Recapitulation) 27,967.27 (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) COMMONWEALTH OF PENNSYIVANiA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS continued ESTATE OF FILE NUMBER Peterson, Minnie K 21-07-1109 ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 13 Quantum Imaging & Therapeutic Associates -patient charges after insurance 36.00 payment -Per provider invoice 14 ~ Wells Fargo -loan balance 15 ~ West Shore Tax Bureau -unpaid taxes for 2006 -per Notice dated February 28, 2008 TOTAL (Also enter on Line 10, Recapitulation) 2,235.00 292.86 27,967.27 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 COMMNHERITANCE TAX RN TURNANIA BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Peterson, Minnie K 21-07-1109 NUMBER NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE PERSONS} RECEIVING PROPERTY (Words) ($$$) Do Not List Trustees I~ TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec, 9116(a)(1.2)j 1 Lisa A Hauenstein Daughter fifty percent of 391 Sherwood Drive residual Carlisle, PA 17015 2 Linda L Klinger Daughter fifty percent of 561 Old Orchard Lane residual Camp Hill, PA 17011 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 1S 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 0.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98)