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HomeMy WebLinkAbout12-30-0815056051047 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes ~ INHERITANCE TAX RETURN PO BOX 280601 Harrisburg, PA17t28-0601 RESIDENT DECEDENT ~~ ~ U ~ ~ ~~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~ P3 a?~-r~o ~ 0~-~-~'J ~~5 Decedent's Last Name Suffix Decedent's First Name MI (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 ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 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 ~ ~T N v~ ~ ~ N- o Q_ rJ ~ 7 ~ 7 .3 7 ~ 3 9 ~ ~-- Firm Name (If Applicable) ~-- First line of address ~ 7 S ~~ G- t rt. E D~ i ~ E Second line of address City oLLr,,Popst Office p / State C P` 1 1 11~~ t f~- S~ ~~ CT Correspondent's a-mail address ZIP Code REGISTER OF WILLS USE ONLY C_i ~. _~-, ,- . - - ~'~ - ~~ C7 .DATE, tvIL~D -O - ~. 't3 ~ 1 ~ "r`l 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 r has any knowledge. SIGN URE OF'F'ERSON RES ONSIBLE FOR FILING RETURN DATE ~ ~ ~ ~-~ 11 I z.Z i ~ ADDRESS yes ~~ oe C+~~~,gc~s~~z~ ~'.~ r~~.~~ i ~ ~ zZ) o~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056051047 15056051047 F _ _. _. __ 15056052048 REV-1500 EX Decedent's Socia l Security Number ~ '~'C ' ~ Decedent s Name: RECAPITULATION 1. Real estate (Schedule A) ............................................. 1. V . t / 2. Stocks and Bonds (Schedule B) ....................................... 2 - • 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. C • 4. Mortgages & Notes Receivable (Schedule D) ............................. 4. h C • 5. Cash. Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. - ~ / 7 7 "7 • 7 '~ 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. L 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property h Billi S d l G S R t d 7 U eparate ng ( c e u e eques e ........ ) O . . 8. Total Gross Assets (total Lines 1-7) .................................... 8. 1 7 `] ~ '~ . 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. ~ ~ 9 12. Net Value of Estate (Line 8 minus Line 11) ............................. . 12 7 ~ 7 '7 . '~ 13. Charitable and Governmental BequestsiSec 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. / ~_7 ~ . 7 b 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 _ 15. 16. Amount of Line 14 taxable at lineal rate X .O t~ y / ~] . S Q 16. ~ C~ 17. Amount of Line 14 taxable at sibling rate X .12 . 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. • 19. TAX DUE ........................................................ . 19. I I '7+ 7 `.' 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 15056052048 15056052048 r,EV-1500 tX Page 3 Fite Number ~ /1 O Q, v ~ ~ ~ / Decedent's Complete Address: V J DECEDENT'S NAME STREET ADDRESS I ~--~ liJ ~ Ln~ i ~-~-~`orYt ~ ~ CITY STATE ZIP _ kl t P ~t~ (~ Iti ? L ~n / 7~ ,S Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount c1) ~ l 7 Sze Total Credits (A + B + C) (2) 3. InterestlPenalty if applicable D. Interest E. Penalty Total InterestlPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 5 If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~* y ~ 7 . ~ A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) ~ /~ / '] . 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? ............................................................... ....... ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ...................................................................................................... ....... ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ....... ....... ^ ~. 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. 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)J. Asibling 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~1508 E%+ (197) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE E CASH, BANK DEPOSITS, 8~ MISC. PERSONAL PROPERTY _ ESTATE OF FILE NUMBER U ~ ~_ ~ O ~ ~ I 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. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~ d. ~-a~ 74'7, ~>.~I=mow, ,~~ /S<~-~D '(R e.~ ~ ~0 1 '1.~ ~.-~ I I U - 1= ~ t"~ ~ ~l i/~IC_~, :J C:s TOTAL (Also enter on line 5, Recapitulation) I $ ~ 7~ '~ r] ~-{ ~]'-f (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) ` ~~ SCNEDIJLE H ~~ , COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. 1 FUNERAL EXPENSES: y l ~~ W K. I r v ~~{t~'T PP ~~ ~ ~s~ P~ ~ ~,zj ~ B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City _ State Zip Year(s) Commission Paid: 2. Attorney Fees 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. Probate Fees ~ ~ g' LJL9 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ n ~ ~~ 5~ (If more space is needed, insert additional sheets of the same size) REV~1512 EX+ (12-03) COMMONWEALTH Of= PENNSYLVANIA INHERITANCE T4X RETURN RESIDENT DECEDENT SCFIEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIEN5 ESTATE OF FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ~o (If more space is needed, insert additional sheets of the same size) ` RE 1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN ESTATE OF FILE NUMBER ~ ~ ~~ ~t 1- }-~ ~~ a ~ o ~ D 0 3 ~ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] ~.2.~~'N-cam- ~ ,ti ~~ ~.~ a~..1 ~ ~ ~ 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 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) 1 _~_ _. -._-__~.-_._. __.._-.___. _. _ .. _.._____ ~~ c~ ~~ t-~~-~~ ~~~v~c~ ~ - ~-~ ~~1~ c~ oL . ~ c C~ c~..1 J ~-C l~ c- ~ ~ ~ 'y0 ~~ (~ ~1 Cam. lr~i ~ ~..1 ~ ~ rLC~ I ~ ~- J ~ ~~f~~T L~an~c ACCOUNT Nq. - ACCOUNT TYPE --- -- STATEMENT PERIOD PAGE ]75?~H110 FREE CHECKING --- - FEB.06-IMAR.05,2008 1 OF 1 00 0 06825M NM 017 16660 JANICE L HORNE C/0 ELMCROFT OF SHIPPENSBURG 475 EUGENE DR CHAMBERSBURG PA 17202 waLNUr BorroM BEGINNING. ACCOUNT SUMMARY f)EPOSTTS & OTHER CURRENT ENDING BALANCE OTHER ADDITIONS CHECKS PAID CVO. AMOUNT NO, SUBTRACTIONS INTEREST PD BALANCE 17,,122 99 3 AMOUNT N0. AMOUNT 1,954.34 1 142.59 1 1,460.00 0.00 17,774.74 PosrlNC - ACCOUNT ACTIVITY DATE '!DEPOSxTS,INTEREST CHECKS 8 OTHER DAILY TRANSACTION DESCRIPTION & -0THER ADDITIONS SUBTRACTIONS BALANCE 02-06-08 BEGINNING f'~ALANCE 02-07-08 SENIOR CARE INC SCOH MASTE $17,422.99 02-13-08 CHECK NUMBER 1053 • ~ ~ C l._ 1,4~60.00 15,962.99 02-29-OS U:5 TREASURY 220 VA BENEFIT ~` ~,~ \ ~ ~ _ ~~~~ ~ x/142.59 15,820.40 03-03-08 U:5 TREASURY 312 CIVIL SERV 921.00 16,741.40 03-03-08 U:i TREASURY 303 SOC SEC 629.34 404.00 17,774.74 ENDING BALANCE _ 517,774.74 ~- CHECKS PAID SUMMARY 1053 112-:L 3- 08 142.59 WOW DOESN'T IT FEEL GOOD TO HAVE A PLAN? PLAPMIING YOUR FUTURE CAN SOMETIMES PRESENT DIFFICULT QUESTIONS AND CHOICES. AT TIMES, IT MAY SEEM A BIT OVERWHELMING. WELL, CLOSE YOUR EYES, TAKE A BREATH, AND COUNT TO THREE. YOU'RE IN THE COMFORT ZONE. LET'S TALK ABOUT YOUR CHALLENGES AND GOALS TODAY. CONTACT AN M8T BRANCH REPRESENTATIVE SO WE CAN BEGIN THE CONVERSATION OR TO LEARN MORE VISIT WWW.MTB.COM/COMFORTZONE. - ~ / ~ ~ Y ~ t~~5~ h15 i7 mc3 u~.A n1C~ 7 ~o2S. 7 8 - ~~`~G iPEG~_5r.~e a~ wi~5 LOOBA (8/07) .~° ~~w \~~ WSEMS - Chambersburq ALS/BLS ~' 1 L~ nV ~ Z~ o~_ `' ~'~° 205 GRANDVIEW AVE /V~~~ SUITE 211 1~ CAMP HILL, PA 17011 ~~~ Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ~~ST ~~0~ PATIENT NAME: JANICE HORNE INSURANCE: MEDICARE B 201181335A FEP 802127684 0001426 ~~'~~'^~ ANICE HORNE HIPPENSBURG HEALTHCARE CTR 121 WALNUT BOTTOM RD SHIPPENSBURG, PA 17257 PATIENT NUMBER: 7098 WCS 0001426 NONE CALL NUMBER: DATE OF CALL: 02/05%2008 TIME OF CALL: 12:35 PM CHAMBERSBURG HOSPITAL CALLER: CHAMBERSBURG HOSPITAL FROM: SHIPPENSBURG HEALTH CARE CEN' TO: REASON(S) FOR TRANSPORT INVOICE FRACTURE -HIP ROUTINE TRANSPORT DISCHARGE DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT INVALID COACH NON-MEMBER A0999 1.0 72.93 72.93 MILEAGE INVALID COACH A0999 14.9 5.34 79.57 Oxygen Administration A0422 1.0 58.96 58.96 Total Charges 211.46 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT y.~ .~ 0 ~ ~~ ~< I~ T©ta! Credits 0.00 PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT --~ $211.46 RETURNED CHECK FEE - X31.00