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HomeMy WebLinkAbout04-0408 REV-1500 EX (6-00) '~ .  COMMONWEALTH OF · PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY FILE NUMBER COUNTY CODE YEAR NUMBER Z uJ Z 0 uJ 0 DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) BOLL, MJ~BLE C. SOCIAL SECURITY NUMBER 196 - 14 - 36?5 DATE OF DEATH (MM-DD~YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE July 27, 2003 October 27, 1922 REGISTER OF WILLS (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST. AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER N/A -- -- ~-]1. Original Retum r~4. Limited Estate [-~6. Decedent Died Testate (Attach copy of WlI) r--i 9. Litigation Proceeds Received NAME Marlin R. McCaleb, Esq. FIRM NAME (IfApplicoble) Law Offices - Marlin R. McCaleb TELEPHONE NUMBER (717) 691-7770 [] 2. Supplemental Return [] 3. Remainder Reium (ate of death prior to 12.13-82) ~'~ 4a. Future interest Compromise (date of death alter 12-12-82) [~ 5. Federal Estate Tax Return Required [~7. Decedent Maintained a Living Trust (Attech copy of Trust) __ 8. Total Number of Safe Deposit Boxes [] 10. Spousal Poverty Credit (dat~ of death between 12-31-91 and 1-1-95) i'~ 11. Election to tax under Sec. 9113(A) (Attach Sch O) COMPLETEMAILINGADDRESS 219 East Main Street P.O. Box 230 / Mechanicsburg, PA 17055 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) (Schedule E) 6. Jointly Owned Propen'y (Schedule F) (6) ~"-] Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 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) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 2,541.97 7,364.96' 24,463.23 (8) 8,749.61 1,285.02 (~i) (12) (13) OFFICIAL USE ONLY 34,370.16 10,034.63 24,335.53 24,335.53 SEE INSTRUCTIONS ON REVERSE SIDE 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) 24,335.53 x .04'5 (16) 16. Amount of Line 14 taxable at lineal rate 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) 1,095.10 1,095.10 Decedent's Complete Address: STREETADDRESS Mable C. Boll 834 Lisburn Road CI~ Camp Hill ISTATE PA 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Pdor Payments C. Discount Total Credits (A + B + C ) 3. Interest/Penalty if applicable D. Interest E. Penalty Tetal 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 1 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. (1) 1,095.10 (2) O (3) o (4) 1,095.10 (5) (5A) (5B) 1,095.10 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decadent 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; ............................................ [] [] 0. retain a reversionary interest; or ...................... i ...................... ' ............................................................................. [] [] 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 cons derat on? 3. Did decedent own an "in trust for" or payable upon death bank account or secudty at his or her death? .............. [] [] 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. Under penalties of penury, I declare that I have examined this retum, including a,:z.o,,~nying 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. SI.C~ATURE OF,P..ERSON RESPON,?i,~LE r~)R FILING RETURN ADDR[=S§ ' I' ' Joint Tenant PA 17050 433 Berkshir~e,~L. ane, Mechanicsburg, ADDRESS 219 East Main Street, P.O. Box 230, Mechanicsburg, PA 17055 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 3% [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 0% [72 RS. {}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 0% [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 4.5%, except as noted in 72 RS. {}9116(1.2) [72 RS. {}9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 RS. §9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decadent, whether by blood or adoption. LAW OFFICES 1ARLIN R. McCALEB LAST WILL AND TESTAMENT I, MABLE C. BOLL, of the Township of Lower Allen, County of Cumberland and Commonwealth of Pennsylvania, being of sound mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void all former wills and codicils by me at any time heretofore made. FIRST. I order and direct that all my just debts and funeral expenses be paid by my Executrix or Executor, as the case may be, hereinafter named, as soon as conveniently may be done after my decease. SECOND. I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal and mixed, whatsoever and wheresoever situate, unto my daughter, TOMALYN A. PETERSON, absolutely and in fee simple, if she survives me. THIRD. If, however, my daughter, TOMALYN A. PETERSON, fails to survive me, then and in that event, I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal and mixed, whatsoever and wheresoever situate, unto my daughter's husband, THOMAS B. PETERSON, absolutely and in fee simple, if he survives me. FOURTH. If, however, my daughter, TOMALYN A. PETERSON, and her husband, THOMAS B. PETERSON, both fail to survives me, then and in that event, I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal and mixed, whatsoever and wheresoever situate, unto the REV-1508 EX+ (7-83) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCH EDU LE "E" CASH, BANK DEPOSITS AND MISCELLANEOUS PERSONAL PROPERTY FILE NUMBER Mable C. Boll D.O.D. 07-27-03 SSN: 196-14-3675 (All property Jointly-owned with the Right of Survivorship must be disclosed on Schedule "F°') ITEM NUMBEI~ DESCRIPTION Household goods, contents, furniture and furnishings. U.S. Civil Service Retirement TOTAL (Also enter on line 5, Rece~nitulation) VALUE AT DATE OF DEATH 1,110.00 1,431.97 $ 2,541.97 (If more space Is needed Insert additional sheets of ama size) SCHEDULE F- JOINTLY-OWNED PROPERTY I~B/.tSO9 EX <. (1.97) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Mable C. Boll D.0.D. 07/27/03 SSN: 196-14-3675 If an asset was 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. Tomalyn A. (Ward) Peterson Daughter 439 Berkshire Lane Mechanicsburg, PA 17050 JOINTLY-OWNED PROPERTY: ~'~'1 b~ DATE DESCRIP~ON OF ~ERi Y % OF DATE OF D~ ITEM FA ~INT MADE Imlude n~ d financi~ ins~n Md ~k ~nt numar ~ ~1~ Idm~ nu~, A~h ' DA~ OF D~ DECD'8 V~UE OF ~ER ~NANT glNT deed ~ ~inay~ real ~ta~e. V~UE OF ASS~ INTEREST DECEDE~'S INTE~Si 1. A. 11/16/!3 Regular Savings Acct. #12996-00 $ 189.45 50% 94.73 Members 1st FCU, in names of Decedent and Tomalyn A. Peterson. Principal balance as of D.O.D.: $189.28; znterest occurred to D.O.D.: $0.17. 2. A. 31/31/"2 Regular Savings Acct. #12947-00 Members 111.87 50% 55.94 1st FCU, in names of Tomal~n A. Peterson and Decedent. Principal balance as of D.O.D.: $111.77; interest accrued to D.O.D.: $0.10. 3. A. 08/07/~,1 Investment Savings Acct. #12946-05, 10,425.59 50% 5,212.80 Members 1st FCU, in names of Decedent and Tomalyn A. Peterson. Principal balance as of D.O.D.; $10,416.24; interest accrued to D.O.D.: $9.35. 4. A. 11/16/!~3 Checking Acct. #12846-11, Members 1st 4,002.98 50% 2,001.49 FCU, in names of Deceden% and Tomalyn A. Peterson. Principal balance as of D.O.D.:. $4,001.57; interest accrued to D.O.D.: $1.41. TOTAL (Also enter on line 6, Recap~lation) $ 7,364.96 (If more space is needed, insert additional sheets d the same size) MEMBERS 1 FEDERAL CREDIT UNION Primary Owner: REGULAR SAVINGS ACCOUNT: Account Numbs/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name Of loint Owner Date Joint Ownership Created n~gS~ SAV~GS Accouter: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest. Name of $oint Owner Date $oint Ownership Created c~cm~G ~ccou~r: AccoUnt Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of $oint Owner Date $oint Ownership Created IRA SAVINGS ACCOUNT: Account Number/SuffLX Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Beneficiary Mabel C. Boll Tomalyn A. Peterson 12946 -00 01/31/1972 $I89.28 $.17 $189.45 Tomalyn A. Peterson 11/16/1993 12947 -00 01/3t/1972 $111.77 $.1o $111.87 Mable C. Boll 01/31/1972 12946 -05 08/07/2001 $10,416.24 $9.35 $10,425.59 Tomalyn A. Peterson 08/07/2001 12946 -11 09/24/1984 $4,001,57 $1.41 $4,002.98 Tomalyn A. Peterson 11/16/1993 12946 -10 04/05/1984 $20,075.42 $18.02 $20,093.44 ~ Tomalyn Ward _E~Is'r lq~ERAL CRFDIT UNION Denise A. Wolfe, Immun~ St~a'vi~or August 26, 2003 Estate of: MABLE C. BOLL Date of Death: July 27, 2003 Social Security Number: 196-14-3675 $O00 Louise D~ve, P.O. Box 40, Mechanicsbm.g, PA 17055 www. membersl st. org SCHEDULE G COMMONWEALTH OF PENNSYLVANIA J INTER-VIVOS TRANSFERS & / INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Mable C. Boll D.O.D. 07/27/03 SSN: 196-14-3675 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, DESCRIPTION OF PROPERTY ................ ~' ITEM INCLUDE THE NAME OF THE TH~NSFEREE, THEIR RB-NRONSHIp TO DECEDENT AND THE DATE OF TRANSFER. % OF .NUMBER ATTACHACOPYOFTHE DEED FOR REAL ESTATE . DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE VALUE OF ASSET IN¥~I~EST (IE~'L,C~.E) 1. Allianz Annulty Policy No. 624825, payable 7,369.79 100% 7,369.79 ~to Tomalyn A. Peterson. 2. Members 1st FCU, IRA Savings Acct. 20,093.44 100% 20,093.44 #12946-10, in name of Decedent, payable upon death to TomalYn Ward (a/k/a Tomalyn A Peterson); principal balance as of D.O.D.: $20,075.42; interest accrued to D.O.D.: $18.02. TOTAL (Also enter on line 7, Recapitulation) $ 27,463.23 (If more sDa~ ets of the same size) J~N-23-2004 FRI 05:52 PI'I ALLI.AN'Z LIFE F,~2 NO, ?83 582 640! P, 02/02 Nlianz Life Ir~u~'arse ~mpr.,,m~ d Nm"~ Anmrica PO I~x $90G0 IVY, heal. lis, MN 55459-0060 D¢~mber 17, 2003 Allianz Tomalyn ^ Peterson 439 Berkshir= Lane M~chanicsbur8, PA 17050 Re: Mable C BoIL decemed Annuity. Policy Number: 624825 Dear Ms. Petetson: This leUer is ir~ retretence to a request for a d~te of death value on the above policy. Please be advised tlmt the oash value and annuItization valu~ as of July 27, 2003 was $5,180.29 and $7,305.71, r~vel~. 'l'haak you. Sincerely, Pan Strei£el C[aira Examiner MEMRERS 1 ~.DERAL CILEDIT UNION Primary Owner: REGULAR SAVINGS AccouNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name Of Joint Owner Date $oint Ownership Created ~IVESTMENT SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date $oint Ownership Created CHECKING ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date $oint Ownership Created IRA SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Beneficiary Mabel C. Boll Tomalyn A. Peterson 12946 -00 01/31/1972 $189.28 $.17 $189.45 Tomalyn A. Peterson t 1/16/1993 12947 -00 01/31/1972 $111.77 $.10 $111.87 Mable C. Boll 01/31/1972 12946 -05 08/07/2001 $10,416.24 $9.35 $10,425.59 Tomalyn A. Peterson 08/07/2001 12946 -11 09/24/1984 $4,001.57 $1.41 $4,002.98 Tomalyn A. Peterson 11/16/1993 12946 -10 04/05/1984 $20,075.42 $18.02 $20,093.44 ~ Tomalyn Ward D~~~ 1 sr FF_~I~ CREDIT UNION eni~e A. Wolfe, Inmran~ ~or August 26, 2003 Estate of: M_ABLE C. BOLL Date of Death: July 27, 2003 Social Security Number: 196-14-3675 5000 Louise Drive, P.O. Box 40, Mechanicsburg, PA 17055 www.members 1 st~org COMMOJ'gNEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mable C. Boll D.O.D. SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS 07/27/03 SSN: 196-14-3675 FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. 2. 3. 4. 5. 4. ! FUNERAL EXPENSES:' DESCRIPTION Myers Funeral Home, funeral. Gingrich Memorials, gravemarker. Bon-Ton, burial dress. Stephenson's Flowers, flowers. Deer Lodge, funeral dinner. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Sodal Security Number(s) / ElM Number of Personal Representa~ve(s) SI]'eet Address C~y State Zip Year(s) Commission Paid:. A~0meyFe~ Marlin R.. McCaleb, Esquire Family Exemplion: (If deceden.t's address is not ~he same as claimant%, attach explanation) Claimant Slmet Address C~ Stata 'Zip Rela~onship of Claimant t~ Decedent Probate Fees Accountants Fees Tax Return Preparer's Fees Register of Wills, filing Appraisement TOTAL (Also enter on line (If more space is needed, insert additional sheets of the same size) AMOUNT 7,174.00 200.00 66.71 284.96 258.94 750.00 15.00 $ 8,749.61 COMMONWEALTH Of PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Mable C. Boll D.O.D. 07/27/03 SSN: 196-14-3675 ' Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 2. 3. 4. 5. 6. 7. 8. Bonnie Miller, account payable, 2003 Personal Tax. Camp Hill Fire Co., account payable, ambulance service. Holy Spirit Hospital, account payable, medical. DBA Orthopedic Institute of PA, account payable, medical. Chart ONE, Inc., account payable, medical records. Internists of Central PA, account payable, medical. West Shore Anesthesia, account payable, medical. Silver Spring Ambulance & Rescue Assoc., account payable, ambulance service. 11.00 511.00 235.00 115.95 79.93 252.00 45.14 35.00 TOTAL (Also enter on line 10, Recapitulation $ 1,2 8 5.0 2 (If more space is needed, insert additional sheets of the same size) REV-l$13 EX + (1-67) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mable C. Boll D.O.D. 07/27/03 SCHEDULE J BENEFICIARIES SSN: 196-t4-3675 FILE NUMBER NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS (include outright spousal distributions) Tomalyn A. (Ward) Peterson 439 Berkshire Lane Mechanicsburg,.PA 17050 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Daughter AMOUNT ORSHARE OF ESTATE $24,335.53 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET 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 11'. 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) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-O601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 003868 MCCALEB MARLIN R, ESQ. 219 EAST MAIN STREET P O BOX 230 MECHANICSBURG, PA 17055 ........ fold ESTATE INFORMATION: SSN: 196-14-3675 FILE NUMBER: 21 04-0408 DECEDENT NAME: BOLL MABLE C DATE OF PAYMENT: 04/27/2004 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 07/27/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $1,095.10 REMARKS: TOTAL AMOUNT PAID: $1,095.10 SEAL CHECK#4373 INITIALS' JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS his is to certify that the information here given is correctly copied from an original certificate of death d~uly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 Local Registrar No. '~ Date oq- H~O~.;,~ ~., ~? ' COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICAIE OF DEAIH ;¥PE~PRtNT .~.U*.~NT ~"".~,"',.~ [ o~,. July ....... 27, 2003 .L,c,.,~ · Mable C. Boll Female · 196 -- 14 -- 3675 80 v.. ; t Oct27, 1922 Carlisle PA. ~.,.I-I · East Pennsboro Twp. West Shore Health & Rehabilitation .oE) ~El,,..,,.,~c,~.. ~s~} White Secretar Federal Government ~ [] "0 g] ~"'"'"~""~ ~ Widowed ,~. IA~l~(~lle~l'C~dl°~'~tt~PC~d~ 1~. S,,, penp~ylvani~ ~ ,~ ~ ~. Ham~eR 439 Berkshire Lane' Mechanicsburg, Pennsylvania ,~.~ Cumberland ,.. Har~ Criswell t,.- Emily Sweeney Toma n Peterson d ~ Y 1~. 42 SUS~X Rea Camp Hill, Pa. 17011 ~ ~ ~0 ~.~ I~ · I ~ ~~-~ ~/ Jul 31 ~003 I Mt Zion Cemete~ I Carlisle Pa. 17013 ~ ~ ~ · ~ ~ ~~ I~. F~-0~43~8-[ ~ ~ ~un~ml~. ~ne. a7 fia~t ~ain Stm~t ~chanic~bur¢, Pa 17055 , , I~. ~.~o~..1~. 7-~/ ~ '-'-I, ~ I~~ I I(~ ~ ~ I I I ~ ~ I ~ ~ I. ~ ~ ~. I~ u. I~, I~, , " I~ I~* I~. ~ I~- Ig, l,~,~,~ ~. ~o, ~oo ~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRTSDURG, PA 17128-0601 CONNONWEALTH OF PENNSYLVANIA DEPARTNENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLO#ANCE OR DZSALLOHANCE OF DEDUCTIONS AND ASSESSNENT OF TAX RE¥-1~47 EX AFP (Gl-DS) HARLIN R HCCALEB ESQ H R HCCALEB LAW OFCS PO BOX 250 HECHANZCSBURG PA 17055 DATE ESTATE OF DATE OF DEATH FILE NUNBER COUNTY ACH 06-1~-2004 BOLL 07-27-2003 21 04-0~08 CUHBERLAND 101 Amount HABEL C HAKE CHECK PAYABLE AND REHZT PAYHENT TO: REGTSTER OF WTLLS CUHBERLAND CO COURT HOUSE CARLTSLE, PA 17013 CUT ALONG THIS LINE ~.- RETA/N LOWER PORTION FOR YOUR RECORDS ~ REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX ESTATE OF BOLL HABEL CFZLE NO. 21 04-0R08 ACN 101 DATE 06-14-2004 TAX RETURN HAS: (X} ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate [Schedule A) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Stock/Partnersh/p Interest (Schedule C) ($) ~. Nortgages/Notes Rece/veble (Schedule D) (~) 5. Cash/Bank Deposits/H/sc. Personal Proper~y (Schedule E) (E) 6. Jo/ntly Owned Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. Tote1Assa~s APPROVED DEDUCTIONS AND EXEHPTZONS: 9. Funeral Expensas/Adm. Costs/H/sc. Expenses (Schedule H) (9) 10. Debts/Nortgege Liabilities/Liens (Schedule I) (10) 11. Total Deductions 12. Net Value of Tax Return 2~5~1.97 7~364.96 Zq~63.Z3 8,749.61 1,285.02 (11) (12) 15. 1~. NOTE: .00 NOTE: To /nsure proper .00 cred/t to your account, .00 subm/t the upper portion .00 of this form with your tax payment. Charitable/Governmental Bequests; Non-elected 9115 Trusts (Schedule J) (15) Nat Value of Estate Subject to Tax (1~) Zf an assessment ~as issued previously, llnes 14, 15 and/or 16, 17, reflect figures that include the total of ALL returns assessed to date. ASSESSHENT OF TAX: 16. Amount of Line 1~ at Spousal rate 16. Amount of L/ne 1~ ~exablm at L/neal/Class A ra~e 17. Amount of L/ne 1~ at S/bl/ng rate 18. Amoun~ of L/ne 1~ taxable at Collateral/Class B rata 19. Principal Tax Due TAX CREDITS: PAYHENT RECEIPT DATE NUNBER I INTEREST/PEN PAID (-) .... 00 0~-27-2004 ¢~ CD003868~.. . ~. · 34,370.16 24,335.53 IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .00 24,335.53 18 and 19 w111 (1.6) .00 X O0 = .00 (16) 24,335.53 X 0~5= 1,095.10 (17) . O0 X 12 = . O0 (18) .00 x 15 = .00 (19)= 1,095.10 ANOUNT PAID 1,095.10 TOTAL TAX CREDIT BALANCE OF TAX DUEI INTEREST AND PEN. TOTAL DUE 1,095.10 .00 .00 .00 ( IF TOTAL DUE ZS LESS THAN $1, NO PAYNENT TS REK)UIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU NAY BE D~E/~ A REFUND. SEE REVERSE SIDE OF THIS FOR. FOR INSTRUCTIONS.) ~/--~" RESERVATION: PURPOSE OF NOTICE: PAYHENT: REFUND (CR): OBJECTIONS: ADNIN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: Estates of decedents dying on or before December 1Z, 198Z -- if any future interest in the estate is transfarred in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Coaeanaealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class B (collateral) rata on any such futura interest. To fulfill the requirements of Section Zi~O of fha Inheritance and Estate Tax Act, Act Z5 of ZO00o (?Z P.S. Section 91~0). Detach the top portion of this Notica and submit with your payment to the Register of Hills printed on the reverse side. --Hake check or money order payable to: REGISTER OF NILES, AGENT A refund of a tax credit, ~hich was nat requested on tho Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inharitanca and Estate Tax" (REV-1515). Applications ara availabla et the Office of the Register of Hills, any of the Z5 Revenue District Offices, or by calling the special Z4-hour ansaaring service for forms ordering: 1-aoo-56Z-ZOSO; services for taxpayers aith special hearing and / or speaking needs: 1-BOO-qqT-5OZO (TT only). Any party in interest not satisfied aith the appraisement, allo~anca, or disalloaance of deductions, or assessment of tax (including discount or interest) as sheen on this Notice must object within sixty [60) days of receipt of this Notice by: --~rittan protest to the PA Department of Revenue, Board of Appeals, Dept. Z810Z1, Harrisburg, PA 171ZB-10Z1, OR --election to have tha matter determined at audit of the account of the personal representative, OR --appaa! to the Orphans' Court. Factual errors discovered on this assessment should ba addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. ZEOS01, Harrisburg, PA 171ZB-0601 Phone (717) 787-6505. Sam page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-IS01) for an explanation of administratively correctable errors. If any tax due is paid aithin three (5) colander months after tha dacadant's death, a fiva percent (SI) discount of the tax paid is allowed° The 1SI tax amnesty non-participation penalty is computad on the total of tha tax and interest assessed, and not paid before January 18, 1996, the first day after the and of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same tiaa period as you would appeal the tax and interest that has bean assessed as indicated on this notice. Interest is charged beginning aith first day of delinquency, or nine (93 months and one (1) day free the date of death, to the date of payment. Taxes ahich became delinquent bafora January 1, 19aZ bear interest at the rate of six (6X) percent par annum calculated at a daily rate of .00016~. All taxes ahich became dalinquant on and after January 1, 198Z mill bear interest at a rate which will vary from colander year to calendar year aith that rate announced by the PA Department of Revenue. The applicable interest rates for 198Z through ZOO4 are: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor 198Z ZOZ .O00Sq8 ~1Y~'8-1991 llX .000501 ~ 9Z .000z47 1985 16Z .000458 X99Z 9Z .OOOZ~7 200Z 6Z .OOO164 198~ I1Z .OO03Ol 1993-1994 7Z .00019Z 2005 52 .000137 1985 152 .000556 1995-1998 9Z .000247 ZOOq qZ .000110 1986 lOX .O00Z7q 1999 7Z .OO019Z 1987 102 .O0027~ ZOO0 7Z .OOO19Z --Interest is calculatad as follows: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DALLY INTEREST FACTOR --Any Notice issued altar the tax becomes delinquent ~ill reflect an interest calculation to fiftaen (lS) days beyond the date of the assassaent. If payment is made after the interest computation date sheen an the Notice, additional interest must ba calculated.