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Home My WebLink About12-01-08J 15Q56Q41147 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Vear r=ile Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box.26osot 2 1 0 8 0 8 0 2 Harrisburg, PA ~ 7128-osot RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 10 19 2007 04 27 1924 Decedent's Last Name Suffix Decedent's First Name MI ZOOK EDITH C (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name 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) n g. Decedent Died Testate ~ ~ Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes L-1 (Attach Copy of Witl) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty credit (date of death ~ 11.Election to tax under Sec. 9113(A) between 1231-91 and f-1-95) (Atlaoh SCh. O) 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;--809 ~ --, Firm Name (if Applicable] PECHT & ASSOCIATES, PC First line of address 1205 MANOR DRIVE, SUITE 200 Second line of address City or Post Office MECHANICSBURG State ZIP Code PA 17055 -_ c~ ~. - r<-a t,,r REGISTER OF WIC_L~SE OIQCX -'_ ~-; i 6 - -;-i _. -'l7 ~:; rv G..7 DATE FILED MI ,; __., i..'r -, '- , Correspondent'semailaddress: wpecht~pechtlaw.com Under penalties of perjury, 1 declare that !have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, corcect and complete. Declaration of preparer other than the personal representative is based on all information of w r has any knowledge. ~~z~- ~~ ~°"'- Robert D. Zook /!-,~2 -O,~ ADDRESS 6 Spring Creek Manor, Hershey, PA 17033 Wayne M. Pecht, Esquire 1205 Manor Drive, Suite Z00, Mechanicsburg, PA 17055 Side 1 I.,..~ 1505b041147 ~l_ DATE 15Q56041147 J 15056042148 REV-1500 EX De~edenrs name: E d it h C Z o o k Decedent's Social Security Number RECAPITULATION 1. Real Estate (Schedule A) ....................................................................................... .... 1. 2. Stocks and Bonds (Schedule 8) ............................................................................. .... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .......... .... 3. 4. Mortgages & Notes Receivable (Schedule D) ........................................................ .... 4. 14,356.82 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ............... ..... 5. 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ........... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ........... ... 7. g. Total Gross Assets (total Lines 1-7) .................................................................... .... g. 1 4, 3 5 6. 8 2 10,767.27 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... ..... 9. 1 0 4 , 4 3 4 . 5 8 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. ..... 10. 115,201.85 11. Total Deductions (total Lines 9 8 10) .................................................................. ..... 11. 12• Net Value of Estate (Line 8 minus Line 11) ......................................................... ..... 12. - 1 O O , 8 4 5 . 0 3 13. Charitable and Governmental BequestslSec 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. - 1 0 0 , 8 4 5 . 0 3 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, of transfers under Sec. 9116 0 0 0 1 s. 0. 0 0 (a>(1.2) x .o0 . 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. Side 2 15056042148 15056042148 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-08-0802 DECEDENT'S NAME Edith C Zook STREET ADDRESS West Shore Health 8~ Rehabilitation 770 Poplar Church Road CITY STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit g. Prior Payments C. Discount 0.00 (1) 0.00 Total Credits (A + B + C) (2) 0.0 0 3. Interest/Penalty 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) 0.0 0 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) Q , Q Q 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 :..................................................................................... ^ O b. retain the right to designate who shah 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? .................................................................. ^ 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? ............... ^ O 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. or 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)j. 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. SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TA% RETURN RESIDENT DECEDENT ESTATE OF rFILE NUMBER Zook, Edith C I 21-08-0802 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. (n 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-1502 EX+ (6-98} SCHEDULE H-A FUNERAL EXPENSES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Zook, Edith C 21-08-0802 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-B4 PROBATE FEES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Zook, Edith C 21-08-0802 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B4 (Rev. 6-98) Rev-1502 EX+ (6-98) SCHEDULE H-B7 OTHER ADMINISTRATIVE COSTS COMMONWEALTN OF PENNSYLVANIA continue d INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Zook, Edith C 21-08-0802 Copyright (c) 2002 form software only The Lackner Group, tnc. Form PA-1500 Schedule H-B7 (Rev. 6-98) Rev-1512 EX+ (6~8) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8~ LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Zook, Edith C 21-08-0802 Include unreimbursetl medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Pennsylvania Department of Public Welfare -Claim for restitution of medical 104,279.75 assistance per letter from DPW 2 Pharmerica -Medication 124.49 3 Sollenberger Colon and Rectal Surgery -Medical bill payable by patient 30.34 TOTAL (Also enter on Line 10, Recapitulation) ~ 104,434.58 (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-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT FILE NUMBER ESTATE OF Zook, Edith C 21-08-0 802 NUMBER NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE PERSON(S) RECEIVING PROPERTY Do Not List Trustee s (Words) ($$$) I. TAXABLE DISTRIBUTIONS (include outright spousal distributions, and transfers under Sec. 9116(a)(1.2)) 1 Denise Dahlberg Daughter NIA Insolvent 20 Raytown Road Estate Hanover, NH 03755 2 Debra Z Von Enck Daughter NIA Insolvent 2710 Knolls Lane Estate Brecksville, OH 44141 3 Robert D Zook Son NIA Insolvent 6 Spring Creek Manor Estate Hershey, PA 17033 Total Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate , on Rev 1500 cover sh eet III NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS 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, lnc. Form PA-1500 Schedule J (Rev. 6-98)