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HomeMy WebLinkAbout01-15-0915056051058 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 ~I O (y ~ ~~ Harrisburg, PA 17128-0601 RESIDENT DECEDENT b ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 197-40-5246 10/19/2008 09/23/2049 Decedent's Last Name Suffix Decedent's First Name MI Blosser Jr Donald L (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 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date 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 tV Elizabeth E. Valle ~ ~ ::: . _ f_ a r _~ Firm Name (If Applicable) .,. ~, REGISTER OAS USE O~ _._ ' + - .,'~ t `[_ ~ ~ - i - " . First line of address - [7 C31 .,r? ~ ~ - i-_ , - .~ 152 Fieldstone Dr , - Second line of address " ~J D ~ ' City or Post Office State ZIP Code DATE FILED Carlisle Pa 17015 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 FILING RETURN DATE ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE _. _- _ _. ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 J 15056052059 REV-1500 EX Decedent's Social Security Number Donald L Blosser 197-40-5246 Decedent's Name: REC APITULATION 1. Real estate (Schedule A) . ............................................ 1. 0.00 2. ....................................... Stocks and Bonds (Schedule B) 2, 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00 4. 9 9 ( ) ............................ Mort a es & Notes Receivable Schedule D 4. 0.00 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 8,325.54 6. Jointly Owned Property (Schedule F) Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested....... . 7. 8. Total Gross Assets (total Lines 1-7) ................................... . 8. 8,325.54 9. Funeral Expenses & Administrative Costs (Schedule H) .................... . 9. 3,033.43 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............... . 10. 146.92 ' 11. Total Deductions (total Lines 9 8 10) .................................. . 11. 3,180.35 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. 5,145.19 _. _... .... . _. _ _.... _,_. _~ TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES . - ........... . . _e._~ _... ,. ..._. .. ~.... .._ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .0 45 5,145.19 15. 231.53 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Lirie 14 taxable at collateral rate X .15 18. 19. TAX DUE ........................................................ .19. 231.54 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: File Number Donald L Blosser STREET ADDRESS 152 Fieldstone Dr. - - _ _ _ __ CITY Carlisle DECEDENT'S SOCIAL SECURITY NUMBER 197-40-5246 STATE ZIP l Pa 17015 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 231.54 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 12.19 _ Total Credits (A + g + C) (2) 12.19 3. Interest/Penalty if applicable D. 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. 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) 219.35 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 219.35 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? ....... ....... ^ 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. 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)]. 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. Pennsylvania UERA HTMEiNT OP HFiVF'NUF' INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Donald L Blosser Jr. All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. If more space is needed, insert additional sheets of the same size. REV-1503 EX+ (6-98) SCFIEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Doanald L Blosser Jr. All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1504 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Donald L Blosser Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. (If more space is needed, insert additional sheets of the same size) REV-1507 EX+ (6-98) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER Donald L Blosser Jr. All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDt~LE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Donald L Blosser Jr Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY - -_ ESTATE OF FILE NUMBER Donald L Blosser 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. 0 B 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. TOTAL (Also enter on line 6, Recapitulation) 15 0.00 (If more space is needed, insert additional sheets of the same size) Pennsylvania UE'PAf?TF4 E:NT OP HFi VFiNUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER Donald L Blosser Jr. Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES 8~ ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Donald L Blosser Jr Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t' Hoffman Roth Funeral Home 2,843.43 e. 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 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 Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Zip Zip TOTAL (Also enter on line 9, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) 115.00 75.00 3,033.43 ORRSTOWNBANK A Tradition of Excellence ~ ORRS P'O' Box 250 o Shippensburg, PA 17257 Date 10/20/08 Page 1 Primary Account 143000648 Enclosures ~n~~~~n~~~~nnn~~n~~~~~~n~~~nn~~~ ~ni~~~n~~~ni~~~n~ 001429 1.0804 AV 0.449 TR00005 Donald L Blosser Jr ~ 140 Tower Cir ~ ~ Carlisle PA 17013-9627 Building? Buying? Remodeling? we can help! 1.888.ORRSTOWN - orrstown.com A C C O U N T S U M M A R Y Account Number Account Title Current Balance Enclosures 143000648 Direct Deposit Interes t Check 528 66 74-3'000277 Statement Savings . 170.83 C H E C K I N G A C C O UNT S Account Title Donald L Blosser Jr Direct Deposit Interest Check Check Safekeeping Account Number 143000648 Previous Balance Statement Dates 9/22/08 thru 10/20/08 N 861.70 3 Deposits/Credits 1,849.00 Days In The Statement Period Average Ledger 29 o, 37 Checks/Debits 2,182.08 Average Collected 75.8.94 731 35 ~ o Service Fee .00 Interest Paid Interest Earned . .04 N .04 Current Balance 528.66 Annual Percentage Yield Earned 2008 Interest Paid 0.07 0 .34 0 o Deposits and Additions -~ 0 Date Description Amount O1' 9/24 SOC SEC US TREASURY 303 1, 149.00 c v 0 0 PPD 10/03 Deposit ° ^ 10/15 Deposit 150.00 o rn 10/20 Interest Deposit 550.00 r, .04 v~ r, ~ o ~~ o .-, Electronic Debits and Withdrawals Date Description Amount 9/22 POS PUR. 09/19 DTV*DIRECTV SERVICE 166.92- ORRSTOWNBANK A Tradition of Excellence << Date 10/20/08 Page 5 Primary Account 143000648 Enclosures Donald L Blosser Jr 140 Tower Cir Carlisle PA 17013 Direct Deposit Interest Check 143000648 (Continued) - - - CHECK SII1-~ARY - - - Date Check No Amount 10/02 158 100.00 * Denotes missing check numbers Daily Balance Information Date. _____. Balance Date 9/22 554.78 10/Ol 9/23 504.78 10/02 9/24 1,603.78 10/03 9/25 1,360.29 10/06 9/26 1,310.29 10/07 9/29 1,190.29 10/08 9/30 1,150.29 10/09 Balares.... Date - Ba~~g.~.e.._ 1,090.29 10/10 505.:54 930.29 10/I4 365.54 981.30 10/15 885.54 818.05 10/16 835.54 765 5 703.54 10/20 528.66 643.54 Interest Rate Summary 9/21 0.050000 10/14 0.000000$ 10/16 0.050000 ******************************************************************************* S A V I N G S A C C O LI N T S Account Title Donald L Blosser Jr ~'~k' r~r '~. ~;~, ~r~: y .Ni, ~~E~, i~I ~~ ~i 3. ~~t, ;~ k~ ± CC? t; ? t•6. n 1:1; [(.. 1 ' ~ .~ ..~VIEfI , . r. N4 -.. ~ ~ C~O.QI? C7 FAlR ., 7 P.OOk ~ ~ p ~^' '~' ' fE~tt OP PR6W0iJSLY ly'3VEC PC'ATE ~ ~ . p TRA19 -`. PY . ~ A~k„( Tti~RU 8J ~~ ~;. k ~CF ,;~ T1RAIJSFER8Fk6NEH'~U.AFP.,N1'E ;i:` TIJ - SC~li,b.fI6.4PL~MENT ~FPLA7E OFr~' REPI'}iC~W N7,0{=t'IpG4H , V4QU'. x;1+1} ' .~ ~.~;.. 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