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Home My WebLink About03-13-09J 15056051047 REV-1500 EX (06-05) PA Depadment of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Vear File Number PO BOX 260601 INHERITANCE TAX RETURN Hanis6ur , Pq 17128-0601 - RESIDENT DECEDENT 2 1 0 8 0 O S 9 5 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 4 4 4 2 4 8 8 2 0 1 2 8 2 0 0 8 0 7 1 3 1 9 5 1 Decedent's Last Name Suffix Decedent's First Name MI C Z A J K 0 W S K I F R A N C I S E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffx 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 O 1. Original Return ~ 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 attar 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. 7o[al 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 tleath 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 8E DIRECTED TO: Name Daytime Telephone Number M A R L I N R M c C A L E B 7 1 7 6 9 1 7 7 7 p Firm Name (If Applicable) REGISTER OF WILLS USE ONLY First line of address 2 1 9 E M A I N S T R E E T r~ Second line of address C7 ~ P O B O X 2 3 0 ''-p -~ '-~~~ a r j.. i:..C7 A i 7 City or Post Office State ZIP Code --~.~ ~FdLI~_ ~ ~ J~ v~ ~ - ~. M E C H A N I C S B U R G P A 1 7 0 5 5 0 2 r~ql> -p .~u-t-~ a -~-t '._~ ~ -_ _ Correspondent's a-mail address: --I ~~ y Under penalties of perju claret al I have a fined this return, including accompanying schetlules and statements, and to the best of m kno~ ~,- -~-u it is tru omect and mplete. D ration of re ter other Than the personal representative is based on all information of which preparer has any kdnowletlge lief SI E F S F RETURN "'-'-°---- ~, DATE Administrator 03/13/2009 An 219 East Main Street P,O.BOx 230 Mechanicsbur PA 17055-0230 _ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ---- DATE ADDRESS ~___.._.-_.-_._- _. PLEASE USE ORIGINAL FORM Side 1 L 15056051047 15056051047 15056052048 REV-1500 EX Decedent's Social Security Number Decedents Name: _ Czajkowski, Francis E. 1 4 4 4 2 4 8 8 2 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 8 Notes Receivable (Schedule D) .......................... .. . 4. • 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . 5 7 8 .... ... . 2 0, 0 0 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... 6 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ... . • (Schedule G) O Separate Billing Requested..... ... 7. • 8. Total Gross Assets (total Lines 1-7) ....... .......................... ... 8. 7 8 2 0. 0 0 9. Funeral Expenses 8 Administrative Costs (Schedule H) .................. ... 9. 1 4 0 • 0 0 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ............. ... i0. • 11. Total Deductions (total Lines 9 8 10) . ............................... ... it. 1 4 0 0 0 • 12. Net Value of Estate (Line 8 minus Line 11) .... ........................ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which .. 12. ~ 6 8 0. 0 0 an election to lax has not been made (Schedule J) ...................... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES .. 14. 7 6 8 0 • 0 0 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ • 16. Amount of Line 14 taxable 15. • at lineal rate X .04:i 7 6 8 0. 0 0 16 17. Amount of Line 14 taxable . 3 4 5 . 6 0 at sibling rate X .12 • 18. Amount of Line 14 taxable 17. at collateral rate X .15 • 18. • 19. TAX DUE ........................................................ . 19. 3 4 5 6 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 15056052048 15056052048 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-08-00595 Czajkowski, Francis E. - - STREETADDRESS - -- - - _- --- - - -.533 State-. &tLeet_ -_ -_ CITY _---_- -_. -.. ___ __... -_- _.. _-. -_- ___ T -- Enola ,STATE PA _ __ --TZIP __- -- - -- ---- 17025 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments (1) 345.60 A. Spousal Poverty Credit _ - _ B. Prior Payments ~ - - - C. Discount - -- _ _- -- 3. InteresUPenalty if applicable Total Credits (A+ g + C) (2) 0.00 D. Interest E. Penalty - -- - - --_----- tal Interest/Penalty (D + E) 4. If Line 2 is greater than Line i + Line 3, enter the difference. This is the OVERPAYMENT (3) . 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) 345.60 A. Enter the interest on the tax due. (SA) 7.65 B. Enter the total of Line 5 + SA. This is the BALANCE DUE . (5B) 353.25 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 : .......................... ^ o c. retain a reversionary interest; or ....................... .............................................. .............................................. ....... ^ X d. receive the promise for life of either payments, benefts 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? .................................................................................................................. ...... IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. .&';~"?'k&~~.k;k~~~?o£;"s.t;~r"o${~~;~ h~T ae$~'n7~z~+a<~*~i,o x~~;'tro~.~s`a',„„ai~°n"t~~„ks~'s1~'?*"v~;"~°t «''~'~~`$ ~x"~ For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on he net value of~transfers to or far 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 exert 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. nEVn50B Ex•ItAn SCHEDULE E COMMONWEAkTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. ,INHERITANCE TAX RETURN ___ _ _ Francis E. Czajkowski SS#144-42-4882 FILE NUMBER _ 01/28/2008 21-08-0595 Indude the proceeds of litigation and the date the proceeds were received by the estate All properly Jointtyovmed vAth the right of survivorship moat lw disclosed on Schedule F. ITEM NUMBER DESCRIPTION i. PA Department of Treasury, Bureau of Unclaimed Property At the time of his death, Decedent held Certificate. No. CRR062192, issued 10/01/87, for 34 shs, of Consolidated Rail Corporation, and Certificate No. CRR138247, issued 09/15/92, for 34 shs. of Consolidated Rail Corporation. Conrail merged with CSX Corporation on 06/02/97, and an exchange of certificates was required. For some unknown reason, Decedent never exchangedhis shares, with.ahea..result that they escheated to PA Department of Treasury, Bureau of Unclaimed Property. Upon discovery of this information, Decedent's Administrator submitted a claim for unclaimed property on 10/08/08. When the REV-1500 for Decedent was filed on 10/24/08, the Bureau had not confirmed the validity of this claim or its value, so that it could not be included in the REV-1500. The claim and its value were not confirmed by the Bureau until it issued its check on 03/09/09 in the amount of $7,820.00. (It more space is needed, OF DEATH 7,820.00 TOTAL (Also enter on line 5, Recapitulation) I ; 7.820.00 REV-1511 EX+(12-eg) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT VF E. A. I FUNERAL EXPENSES: 1. SCNEDIILE H FUNERAL EXPENSES 8 ADMINISTRATIVE COSTS SS#144-42-4882 01/28/2008 Debts of decedent must be reported on Schedule I. NUMBER e. ADMINISTRATIVE COSTS: t~ Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State _ Zp 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 Additional Probate Fee 5. Accountant's Fees 8. Tax Return Preparer's Fees ~~ Register of Wills, Filing Supplemental Inheritance Tax Return 125.00 15.00 (If more space is needed, insert additional sheets of the same size) TOTAL (Also enter on line 9, Recapitulation) I $ 140.00 REV-1513 EX+ (9-00) COMMONWEALTH OP PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES Francis E. Czajkowski SS#144-42-4882 01/28/2008 " 'V,^uLn 21-08-0595 IUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE I TAXABLE DISTRIBUTIONS [include outdght spousal distdbutions, and transfers under Do Nat List Trustee(s) OF ESTATE Sec. 9716 (a) (1.2)] t~ Frank J. Czajkowski 90 Union Valley Road Father Entire Estate Monroe Township, NJ 08831 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, 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 1. B. CHARRABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET (If more space is needed, insert addmonal sheets of the same size) S