Loading...
HomeMy WebLinkAbout11-18-08150560712D REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code veer File Number a Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box.28oso1 2 1 0 8 I Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 206 16 7497 02 27 2008 04 11 1926 Decedent's Last Name Suffix Decedent's First Name MI SHAW DONALD (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI SHAW EDNA R Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW X ~ 1. Original Return L_' 4. Limited Estate I g Decedent Died Testate f - (Attach Copy of Will) -. - THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Return ~ J 3, Remainder Return (date of death prior to 12-13-82) 4a. Future Interest Compromise ~ S. Federal Estate Tax Return Required (date of death after 12-12-82) -- ~ Decedent Maintained a Living Trust Q B. Total Number of Safe De osit Boxes (Attach Copy of Trust) P 9. Litigation Proceeds Received 1 p. spousal Poverty Credit (dace 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 MARIELLE F HAZEN 7 1 7 5 {~(] 4 3 3~ Firm Name pf Applicable) `= © m `7 HAZEN ELDER LAW REGISTEI~ IC(F~V~1L4.S U9~bNLY -: _ •:7 First line of address _-~~j` ~ : ~ l ' y: T 2 0 0 0 L INGLESTGWN RD . . .~'~ ~ `~'~~'<-' <~-~ T ~ . Second line of address r~a~ ~ SUITE 202 ~ ..~, , City or Post Office DATE FILED Q~ ;:.f State ZIP Code HARRISBURG PA 17110 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 FfLING RETURN DATE ,~ ru~._ ~T~ ~L~,„,J Edna R Shaw ADDRESS e 711 East Winding Hill Rd, Mechanicsburg, PA 17055 SIGNAT E OF PREPARER OTHER THAN REPRESENTATIVE DATE ~~~~~~ ~ Marielle F Hazen 2000 Linglestown Rd., Harrisburg, PA 17110 Side 1 1505607120 1505607120 1505607220 REV-1500 EX Decedent's Social Security Number oeceae~rs Name: D o n a l d Shaw 2 0 6 1 6 7 4 9 7 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) 'Separate Billing Requested ............ . 6. 7. Inter-Vivos Transfers & Miscellaneous No_n-Probate Property (Schedule G) ~ Separate Billing Requested ............ . 7. 8. Total Gross Assets (total Lines 1-7) ...................................................................... . g. 9. Funeral Expenses & Administrative Costs (Schedule H) ........................................ . 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. .. 10. 11. Total Deductions (total Lines 9 & 10) .................................................................... .. 11. 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. 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 .00 8 7 4 6 2 6 9 15. 16. Amount of Line 14 taxable at lineal rate X .045 0 0 0 16. 17. Amount of Line 14 taxable at sibling rate X .12 0 0 0 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 1505607220 69,469,06 760.00 20,294,39 90,523.45 3,060.76 3,060,76 87,462.69 87,462,69 0,00 0.00 0.00 0.00 0.00 1505607220 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-08- Donald Shaw STREET ADDRESS 711 East Winding Hill Rd Mechanicsburg Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit ___._ B. Prior Payments C. Discount 3. InteresUPenalty if applicable p. Interest E. Penalty 0.00 Total Credits (A + B + C) 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. PA ~ 17055 (1> 0.00 (2) 0.00 (3) (4) (5) (5A) 0.00 (5B) ~ . 0 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 :.................................................................................. _ ~ x b. retain the right to designate who shall use the property transferred or its income :.................................... !~ ~ ~xJ c. retain a reversionary interest; or .................................................................................................................. I,-j ' X ~ d. receive the promise for life of either payments, benefits or care? .............................................................. ~ x I 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without u receiving adequate consideration? ....................................................................................................................... ~~ , rX, __. I__~ 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? ...................................................................................................................... 'i_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. ' a 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 exemot 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)]. I-STATE 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-1603 EX+ (6.9g) COAM40NWEALTH OF PENNSYLVANIA INHERITANCE TA% RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER Shaw, Donald 21-08- All property Jointly-owned with right of survivorship must 6e dlaclosed on Schedule F. ~„ ~.,..,~ ~Na~~ is nccucu, au~nwnal pages or the same slze) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-7500 Schedule B (Rev. 6-98) Rev-1608 EX+ (8.98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSVIVANfA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Shaw, Donald FILE NUMBER 21-08- InGude the proceeds of litigation and the date the proceeds were received by the estate. All property jolntlyowned with the right of survivorship must be disclosed on schedule F. ITEM NUMBER DESCRIPTION 1 Bureau of Unclaimed Property -Receipt of Claim #100142256 Prudential Financial Inc Demutualization Cash 2 Bureau of Unclaimed Property -Receipt of Claim #100142257 -Penn Treaty American Corporation/Underlying funds VALUE AT DATE OF DEATH 599.24 160.76 TOTAL (Also enter on Line 5, Recapitulation) I 760 00 (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-1510 EX+ (g•98) COMMONWEALTH OF PENNSYLVANIA MHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER . Shaw, Donald 21-08- 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 O R INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 DWS Scudder - DWWS GNMA Fund-S -Edna R. 20,294.39 20,294.39 Shaw, surviving spouse, was designated beneficiary. TOTAL (Also enter on Line 7, Recapitulation) I 20,294.39 (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 G (Rev. 6-98) REV-1161 Ex+ (12.991 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Shaw, Donald 21-08- Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION NUMBER AMOUNT A. FUNERAL EXPENSES: B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Edna R Shaw Social Security Number(s) / EIN Number of Personal Representative(s): street Address 711 East Winding Hill Rd city Mechanicsburg state PA Z;p 17055 Year(s) Commission paid 2. Attorney's Fees Hazen Elder Law 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 2,268.00 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 792.76 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 3 060.76 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Shaw, Donald 21-08- ITEM NUMBER DESCRIPTION AMOUNT Other Administrative Costs 1 Mellon Investor Services -Surety Bond in Lieu of Probate to transfer Manulife 792.76 Financial Corp. shares of stock to spouse. H-87 Subtotal 792.76 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Pennsylvania Treasury -Bureau of Unclaimed Property hops://www.patreasury.org:442/unclaimed/ClaimForm.asl Commonwealth of Pennsylvania Treasury Department Bureau of Unclaimed Property Property ID's: 5702385 PROPERTY DESCRIPTION Property /Holder Informations) - (A) Original Owner's Name Property Id: 5702385 SHAW, DONALD L (Joint Tenants) '(B) Original Owner's Address as Reported Joint Owners: 711 E Winding Hill Rd Edna, R Shaw (Joint Tenants) Mechanicsburg, PA 17055 (C) Holder Reporting Funds ~(D) Last Transaction Date Penn Treaty American Corporation_ 12/31/1998 __ (F) Type of Funds Reported ` ~ - Underlying (G) Certificate, Policy or Check Number Cusip: 707874103 _._. CLAIMANT INFORMATION NAME OF CLAIMANT(S): Edna R Shaw SOCIAL SECURITY NUMBER: l7~_~a_~~7q DATE OF BIRTH: 4/29/1928 CURRENT MAILING ADDRESS: 711 E. Winding Hill/Road CITY: Mechanicsburg PHONE NUMBER: (717) -76 - 6-45 90 STATE: PA ZIP: 17055 EMAIL ADDRESS: Iisa.ccpaCa~gmail com I certify that I am legally entitled to try to claim the property, as stated below, that has been reported and delivered to the Treasury Department, Bureau of Unclaimed Property. I further hereby certify that the information provided, herein, is true and correct subject to the penalties of 18 C.S.§4904, relating to unsworn falsification to authorities. SIGNATURE OF CLAIMANT (IN INK): ~~_ Date: d 8' SIGNATURE OF ADDITIONAL CLAIMANT (IN INK): Date: State law limits the fee a third party can charge an owner for the recovery of unclaimed property to 15 percent of the property value. Please contact the Bureau of Unclaimed Property at 1-800-222-2046 with any additional questions. "'" If You Paid A Fee To Claim Your Property, Please Complete The Following** The Pennsylvania Treasury Department does not charge a fee to claim or recover unclaimed property. Third parties who assist with the recovery of unclaimed property are subject to requirements set forth under section 1301.11 of Pennsylvania's Unclaimed Property Act. They must disclose the nature and value of the property as well as where it is being held. (Pennsylvania Treasury Department). The fee a third part can charge to assist with the recovery of property cannot exceed 15% of the total value of the property. Was/Is a third party involved in providing this claim form to you/the claimant or assisting with the claim in any way? .,Yes No ones number of third ~~ ~ ~ Did the third party charge or inform you/the claimant of a fee, or receive payment, for any service or assistance in connection with the claim? If so, please state the amount of such fee/payment. Yes ~_No $ Please specify amount of fee/payment. Please note that the above information concerning third parties must be submitted in all cases where a third party is involved in the claim, including claims submitted by the third parties as representatives or agents of the claimant.