HomeMy WebLinkAbout02-09-0915056051058
REV-1500 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
Po Box 2aosol INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 21 08 1194
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
11 /20/2008 04!14/1928
Decedent's Last Name Suffix Decedent's First Name MI
Calaman Marlin
V
(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
~ r 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 rv"""" „ 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
Andrew H. Shaw, Esquire (717) 243-7135
Firm Name (If Applicable) --.-- -u--.-. - .-_~...c~a.
REGISTER OF~LLS USE ON~Y'~
a
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First line of address ~~
C7
.
200 S. Spring Garden St. ,
_ ' -'~:i I
l
7 c .__:
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.
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Second line of address _~ :-~ ~
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Suite 11 '-- `°' '='
--
City or Post Office -.
State ZIP Code _. _DAj~ FILED '~ :. .
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Carlisle f~
PA 17013 _'~
Correspondent's a-mail address: andfeW~p aShaWI2W.COm
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 F_O 'FILING RETURN DATE
;~
ADDRESS
808 HucJ~leberry Ro d,~ N Bloomfield, PA 17068
SIGNATU//E OF PRE TH y#iAN REPRESENTATIVE DATE
200 S. Spring Garden St., Suite 11, Carlisle, PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056051058 15056051058
(~.
REV-1500 EX Page 3
Decedent's Complete Address:
__ _ _____ File Number
21 08 '1194
DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER
Marlin V Calaman
STREET ADDRESS
6 Westminster Court
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19) (1) 310.88
2. CreditslPayments
0.00
A. Spousal Poverty Credit
B. Prior Payments 0.00
C. Discount 15.54
Total Credits (A + g + (;) (2) 15.54
3. InteresUPenalty if applicable
0.00
D. Interest
E. Penalty 0.00
Total InteresUPenalty (D + E) (3) 295
34
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 t + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 295.34
A. Enter the interest on the tax due. (5A) 0.00
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 295.34
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 (O) 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.
REV-1508 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Marlin V. Calaman 21-08-1194
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property Jolntlyowned with right of survivorship must be disclosed on Schedule F.
(It more space is needed, insert additional sheets of the same size)
EV-1511 EX+ (12-99)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Marlin V. Calaman
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
21-08-1194
Debts of decedent must be reported on Schedule [.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' Hoffman-Roth Funeral Home & Crematory, Inc. 3,695.58
2. Additional Death Certificates 44.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s) Diane M. Shunk
Social Security Number(s)lEIN Number of Personal Representative(s)
Street Address 808 Huckleberry Road
city New Bloomfield .state PA zip 17068
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
5. Accountant's Fees
6. Tax Return Preparer's Fees
~. Legal Advertising
a. Diane M. Shunk -Miscellaneous Costs
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
700.00
0.00
98.00
217.66
325.58
5,080.82
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Funeral Services ,~~~% ~
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NEW BALANCE g
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH Receipt Date: 12/02/2008
Cumberland County - Register Of Wills FZeceipt Time: 12:55:37
One Courthouse Square Receipt No.: 1054916
Carlisle, PA 17613
CALAMAN MARLIN V
Estate File No.: 2008 -01194
Paid By Remarks: MARLIN V CALAMAN
AJW
----------------------- - Receipt Distrib ution ----- -------- ------- ----
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS ADM 45.00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 16.00 CUMBERLAND COUNTY GENERAL FUN
RENUNCIATION 10.00 CUMBERLAND COUNTY GENERAL FUN
JCP FEE 10.00 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN
Check# 103 ----------------
$86.00
Total Received......... $86.00
RECE?PT FOF. PAYMENT
~, 1`~%r'3 ~~AiZItiER STP,ASPAI,IGH
,~~;~,Pr;ara Cou::ty - RE~c~ister O{ Wills
i;:< <,~i:~t? ~GL:d::E
~'
- i'11 -. _ .'~ ~
CA'~AMAN MARL :: N
F~ e c e .i ~ t. D a t~ ~~ . .. ~ ,i ~ ~ % ~ ~'~
F~ece~pt r~.F= . ~ ; .:~
na . ~ r.. F,E'?~a~~~_s : MARLIN V CALAMADI
A~ W
------ RE?ceipt: Distribution -------- --- ----------- --
~'eE~/'~~~;t Des^~ ;ration Payment Amount i=ayee Nucne
_~: ~~~`~ ~R'y', F ;~A~,r, 1? . 00 CUMBi~RLA'~IL~ t.O'~ i'~' _.~'NER.~~: i~`'2y
.,- _! --
REV-1512 EX+ (12-03)
SCHEDULE 1
COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Marlin V. Calaman 21-08-1194
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION VALUE AT DATE
OF DEATH
~ West Shore EMS 876.61
2. Hershey Medical Center
35.00
3. Newville Community Ambulance 198.06
4. Law Office of Andrew H. Shaw 405.00
5. Cumberland Heating and Air Conditioning 64.00
6. Rental truck and gas for truck 107.65
7. October WaterlSewer
34.95
8. Final Water/Sewer 32.45
9. November Electric Bill 26.34
10. December Electric Bill 33.19
11. Final Electric Bill 15.08
12. Final Rent 255.45
13. Harland Checks 11.30
14. Mildred Walters-trash bags to clean residence
7.00
15. Lower Allen Township EMS
168.61
TOTAL (Also enter on line 10, Recapitulation) $ I 2,270.69
(If more space is needed, insert additional sheets of the same size)
~'~T;E':.hQT .IAt~n~.~. IVIHhCL11V 1..F4LH4V4l~\tV ~.LtiPi-l~.? ic,.: 714;7',1 RE.~
~:~,t.... ?~~.,~~`.Y€~E 3113()37 C'Ji`)Nr_
;f.;~ c,=-;t:~~ MEDICARE E3 Z(30225009A [ ~1~" ~:~~ °;g.. . t)9114r'20118
SENIOR f3l_iJE -- NU CON- YWW80(.)83775500 ~~ ~ a~ '''-~~ ~ _. 01 X34 F'M
3113037 }-~~~~~,~,, r~~Nf_ RU ~ c~Erv rEr<.vn_f_ERC~
._. ~_irE ~iO~
MARLIN CALAMAN
P C) B(7X 2&3 ~~:~~ TRAUMA f~ A(:;E
CARLISLE, PA 17013 ~~~~~ TRAUMA i0 !_C.~WE1'~ EXT~REfViI T~I
~:
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PARAMFDIf~ INTF_,RCF_-F-'7
A09a9
1.0 1
531 if; ~ 8:37.76
EKG ELECTRO[~ES l4f'K) A0396 1.~) x;.141 5.13
INF CONTROL GLOVES (PR) AQ382 1.C) 3.f33 3.g>:3
NSS 0.9"':, 1Cl0C)cc E3~cT A0394 1.0 2.27 ~ 2.27
~n~. ~Nf= t oc;KK Ao3~4 1 0 27.16 27.1Fi i
5~r't1 4r~Ldr Li^".'JCi"i~r?i r(; t" ii c iLii~ ;-s 741 ',ji3 it,it? ~= V ?_e i.-~,,«_
am-/ ~surrsts~,n~ c.~~ tcerrung ~~w 'y{>t,r +c; st.rr;~;1C~+ r ~,'?,~~,~7y
t~r~,,e~sed Yt)Uti' ~ia;m. e'?'•E;as~ ^,~i4 if~~rt':
MARLIN CALAMAN
6 W MINISTER CT ivoo:~zz -
PO BOX 263 "
CARLISLE PA 17013-0263 :
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.r^~!'~4=;^~ 4~9~"~f~i.'~•a'i DATE DESCRIPTION AMOUNT
_
Statement Date 11/05/08
Service Da#e(s) 09/14/08 09/14/08 AIR AMBULANCE TRANSPORT 11839.00
Type of Se^.~i~e s'?'~TPATIE±~lT 09!14/08 AIR AMBULANCE MILEAGE 4392.00
------ 10/28!08 BLUE CROSS PAY HOSP -5645.85
~"C;::l:~itl?' id l; i'i ": i<a E.;'r~ ?1t;73ui`a`,
10!28!08 BLUE (ROSS t;ONTR ADJ -10550
i 5
New Charges/Adj
$ 16
231.00 .
____A_ _ __
,
` TOTAL 35.00
New PaymentslAdj
$ -16.196.00
Account Balance '
$ 35.00
____
Amount Pending Insurance $ 0.00
:Yt(. IP t'Li(C ~2i
This new statement has been specially designed 3 c~~r hskRZtt~~ r~rt,^s'rsc7~t~, f~r~ irr~,rt•~~rtr:e ~~It<rRls~krw
with you in mind. Let us know what other Para preauntas acerca de su factura o camt~ios de seguro arntamos ron
improvements we should make. representantes disponibles Para asistir a la ronumidad hispana.
Phone: (717) X31-SU69 or (8f)0) 25~-2619
Please a-mail your ideas to: Available Hours: Monday, Tuesda} ~. \b'ednesda} '3:DO am to 5:30 pm
_ t, i.hursda
. t~ Friday 8:0() am to -1:31) pm
or wrfte to us at _
Written Correspondence
Penn State Milton S. Hershey Medical Center Penn tircte Milton.:. llershc~ Medic:r.l Center
Statement Ideas,. PO Box 854, MG A410 Patient Financial ti:; reices i)cpanmcnt
Hershey, PA 17033 PO E3o~ A_i~k, MC F~~310
Iler~hc~, F'A 171)33-ORid
t,~.p<,~, ~:a,?; ~s~~tt'/t~r1~Bc'!£t4t' ~t'1~~a'~F7~~~'a rj°~1"#'d~a'~f'y,SPY"~°'~lc°r"F'ra°rr~°`ildif9S,f't'g.>'e'"~w _
NERSNEwST-; •;
MARLIN CALAMAN
PO 80X 263
CARLISLE, PA 17413
1,
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Page: 1
Printed: 11 106/08 15:35
ID: Newv-2519
DOB: 04/14/1928
-. •. •
Patient: MARGIN CALAMAN _ __. .... _ ..-ii~r..M,-.,~t~' [3ClB C14J't471928
Claim Number. 47$04765)ia
gnos~s i~ X59.8
~
~
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1
A 500.00 i 500.00
01 09!14-09/14108 010 A0429SI 156.85 146.73 196.42 156.42
Procedure: BLS EMERGENCY TRANSPORT
Date first b4{led: 1 Q(15108
02 09114-09/14108 010 A0425S1 1 A 12.00 1 12.00 4.91 5.45 1.64 1.64
Procedure: MILEAGE
Date first billed: 10/15/08
10-15-08 MEDICARE DENIED. CLAIM NOT COVERED BY THIS PAYER.
PLEASE CALL )N WITH YOUR CORRECT PRIMARY )NSURANCE INFORMATION OR PAYMENT l5 NC)W DUE FROM YOU
Fatlent Totals: 512.00 512.00 0.0{l 161.76 152.18 198.06 198.06
Total Amount Due By Guarantor: 198.06
vvvvvv DETACH HERE vvvvvv
Diane Shunk
808 Huckleberry Road
New Bloomfield PA 17068
~L:4.rd^nc!~i~ ~« R!!~rlir~. ~M~~mMn
Previous Balance
Fees
Page: 1
12/01 /2008
;Account No: 209-OOM
Statement No: 1696
Rate Hours
11/03/2008 Prepare for hearing.. 150.00 0.60
11/04!2008 Prepare for and attend hearing. 150.00 1.50
11/06!2008 Telephone conference with client. 150.00 0.10
11/19/2008 Meet with client. 150.00 0.50
For Current Services Rendered 2.70
Total Current Work
Payments
11.07.`2008 Payment
Balance Due
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Please direct all questions regarding this statement to this office within ten days.
- _ __ Thank you for your payment.
_ __
885.00
90.00
225.00
15.00
75.00
405.00
405.00
-85.00
$405.00
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STAMP
~~ea4e i~clucle
all corresp-cjndence.
CI~MBERLANCI
HEATING & AiR Ct7NDtl'tC?NiNG
1 p7 Lirrtekiin Ro~cl
Cark~isle, €'A 1?~)~ ~~
NE~~E~
Customer Name: Cust Ph -Email:
:: d. ^.~i~~ 717 85A-9b9"?
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Rental Date/Tints: S~ h~S a ~ , a~^
Return Date/Time: :2!o!2C)0~ i .;h yr-,
Chargeable Rental Periods: i -
_ ..
_ ., ,., .
E~yuipment 'Fl2 t7ut MY In MI Rate MI Coverage Missing or Damage Rental Rental Actual
Charge Charge: Rate Charge Charges
.. gi~}'1.~'
P. ~'
ri-..
Environmental Fee: : _.
Tax: , .,
~~~ '~~~ -r.. ~~,d'~ ~..: ~ Motor Vehicle lax:
~ ~ I ~ (' ~ ~ t ~ E ~ ~ ~ ~ Rental Charges: ,~,
Previous Paid: ;,I,:.-
Cash Retund:
Net Refunded T'aday:
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• 'REV-1513 EX+(g-00)
SCFIEDIJLE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Marlin V. Calaman 21-08-1194
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
t TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1 Vernon R. Calaman, 931 W. Locust St., York, PA 17401 son 3,306.55
2~ Nancy L. Calaman, 625 N. Pitt St., Carlisle, PA 17013 daughter 3,306.56
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 NUT 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
(If more space is needed, insert additional sheets of the same size)