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HomeMy WebLinkAbout04-23-09 (2)15056051047 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 280801 / 1 Harrisburg, PA 17128-0601 P RESIDENT DECEDENT °~-' ~ 0 U CQ ' ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 ~3 ~-a I~ IR oao i~ooq 1~os ~~ ~-~ Decedent's Last Name Suffix Decedent's First Name MI k't- ~~ ~~' M I r ~ c~ M ~ (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 Firm Name (If Applicable) First line of address 3 S hc~c(~ L~~~ Second line of address City or Post Office State ZIP Code REGISTER OF WILLS USE ONLY N n ~~~ .r.~ ~ } ~ ~ ' C7 J Wi=t r.~ 4C:l~~ W ~`_~ ~~%C_3 "p r ) ~.~.J - ~-7 D~T~~ ED _ --i - . _._, ~ ~. _.. ~ ~,~ ,-~ -_ =j ,:';'{ Correspondent's a-mail address: M 7 ~~`t~-~'~~~ ~Mc~~~ ~ ;N ` ~ 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 c plete. Declaration of eparer of a tha a personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF; E N RE ~ :SIB~E R FILIN T r ~ / DATE/ ` n. ADDRESS ~ ~ ~ p~YIGl~V~ C$ ~k Yl~ ~ 11 / 0~© SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE II DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY L 15056051047 Side 1 15056051047 J REV-1500 EX M Decedent's Social Security Number Decedent's Namei ' 1 1 h I~G M ~ ~~~ ~~'"~~ ~ ~ ~ I a RECAPITULATION 1. Real estate (Schedule A) . .......................................... .. 1. 2. Stocks and Bonds (Schedule B) ..................................... .. 2. • 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages & Notes Receivable (Schedule D) ........................... .. 4. • 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. I 1 ~ ~ ! ~ • 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. ~ ' / / I J .~ 9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. 4 ~ S .Q O 10. Debts of Decedent, Mortgage Liabilities, ~ Liens (Schedule I) .............. .. 10. ,~~ S .~ a. 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. ~ ~ 8 p .~ 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12 ~ I ~ ~ ~p ~ • y 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... .. 13. • 14 i 13 N t V l S b t t T Li 12 Li 14 ~ ' . m nus ne ) ...................... e a ue u jec o ax ( ne .. . W TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 1 taxable //~ at lineal rate X .~ ~ ~ r0 ~ ~ ~ s ~' ~ 16. c J ~j a ~ ~ • tj 17. Amount of Line 14 taxable at sibling rate X .12 . 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. • S ~' ~ I ~ 19. TAX DUE ....................................................... .. 19. , 15056052048 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT '~ ,~ ~`~ ,'~ ~~ 15056052048 Side 2 O 15056052048 J REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'SNA~ I ~~rGll~ ~ ~k_I~~~.'Q`~~ _ STREET ADD E S CITY ~ STATE ZIP Cq ~- ~ t' S ~ ~~ ~ ~ a ~S Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit _ _ _ _ B. Prior Payments C. Discount 'a ~ ~ ~ S'~ Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E ) 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. (1) ~~' ~ ~r O!D a6 ~,s9 0 (3) (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference.'fhis is the TAX DUE. (5) ~~~~~. T A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) ~~(~, p~ 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? .................................................................................................................. ...... ^ 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 notdoes not exemot 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+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Indude the proceeds of litigation and the date the proceeds were received by the estate. All properly Jointly-owned with right of survivorsfiip must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER I DESCRIPTION 1 PSECU Account #8008102728 Regular Share ID 01 $9.06 2 PSECU Account #8008102728 Checking ID 04 $409.61 3 PSECU Account #8008102728 Money Market ID 07 $4,437.16 4 PSECU Account #8008102728 60 Month Certificate ID 53 $50,000.00 5 PSECU Acxount #8008102728 60 Month Certificate ID 55 $25,000.00 6 PSECU Account #8008102728 60 Month Certificate ID 56 $25,000.00 7 PSECU Account #8008102728 60 Month Certificate ID 57 $10,000.00 8 M&T Acxount#2588572 Classic Checking $1,921.73 9 Country Meadows Resident Refund $566.21 TOTAL (Also enter on line 5, Recapitulation) = I 117,343.77 (If more space is needed, insert additional sheets of the same size) ~, M&T Bank ST!lTEMENT PERIOD PA&E JAN.08-FIEB.Ob,2009 1 OF 3 00 0 04515M NN I17 18761 MIRIAM E $URKETT LEROY E BURKETT APT90 4905 E TRINDLE RD MECHANICSBURG PA 17050-3662 _. SCLECTED'ACCOUNT:SUMMARY.: ACCOUNT ACCOtNiT INTEREST EARNED NATURm ENDLIG TYPE NUMBER YEAR-TO-DATE DATE BALANCE CLASSIC CHECKING TOTAL DEPOSITS 000000002588572 0.00 e.» ~: C ASST C CKING 1:'.' TITLR ` LEROr~Ei suRKETT ACCOUNT NO. 2588572 LQIYALSOCK OCC[IIINT SIIMMSRY !. B1tLANCE <: D ,_ . R = ETHER. ADDITIfiNS' , _ _ _. CHECKS PAID A7 _ _.. SUBTRACTIONS _. INTEREST' PD ;' BALANCE- N0. AMOUNT NO. AMOUNT N0. AMOUNT 1,936.19 3 , 01.99 1 , 0.00 lb. 5 0.00 1,921.73 Sf_f_fl11NT A('TTVTTV DkT£> _. .. :::~. -- :.TRAtISACT `D . _ ~ _ i OTHER AFlDIT OFLS s .. <SUBTRACTIONS '-BALANCE 01-08-0 BECLNING BALANCE ;1,936.19 01-14-0 VERIZON Psy~sntREC 16.45 1,919.74 01-16-0 CNECK NUMBER 1381 1,900.00 19.74 Q2-02-0 DFAS-CLEVELAND AF ANN PAY 695.00 02-02-0 RETIREMENT PENSION 74.99 784.73 02-03-0 US TREASURY 303 SOC SEC 1,132.00 1,921.73 ENDING BALANCE •1,921.73 _.. ~MBgCS. RAxD SUl~IARY 1381 01-1b-09 1,900 AO LOOBA (6/07) PSEC~ P.O. Box 61013 pl7) 234-8484 (Harrisburg) Harrisburg, PA 11106-7013 (800) 237-7328 (Nationwide) website - http:/,/www.psecu.com 2 JOINT OWNER MIRIAM E BURKETT 4905 E TRINDLE RD STE 90 MECHANICSBURG PA 17050-3653 MEMBER NUMBER STATEMENT DATE l I 8008XXXXXX 01/31/09 i Annual Percentage Yield Earned 2.1100 from 01/01/09 through 01/31/09 ~ 01/31 Payment: Transfer From Share 53 187.27 4212.43 01/31 Payment: Transfer From Share 55 93.64 4306.07 i 01/31 Payment: Transfer From Share 56 93.64 4399.71 01/31 Payment: Transfer From Share 57 37.45 4437.16 I 01/31 Ending Balance 4437.16 Dividend YTD: Year to Date 7.28 ~ Post Eff Description ~ Amount Balance O1/O1 ID 53 60 MONTH CERTIFICATE Beginning Balance 50000.00 01/31 Payment: Dividend 4.4100 187.27 50187.27 Annual Percentage Yield Earned 4.500% from 01/01/09 through 01/31/09 i 01/31 Withdrawal Transfer To Share 07 187.27- 50000.00 ~ 01/31 Ending Balance 50000.00 60 MONTH CERTIFICATE Will Mature On 03/03/10 _____ __ _ _ Dividend YTD: Year to Date 187.27 _ Post _ _ _ Eff ____________________________________________________ Description ________ ___________ Amount _________ Balance O1/O1 ID 55 60 MONTH CERTIFICATE Beginning Balance 25000.00 01/31 Payment: Dividend 4.410°s 93.64 25093.64 Annual Percentage Yield Earned 4.500% from 01/01/09 through 01/31/09 01/31 Withdrawal Transfer To Share 07 93.64- 25000.00 01/31 Ending Balance 25000.00 ~ 60 MONTH CERTIFICATE Will Mature On 03/03/10 ~ == Dividend YTD: Year to Date _ 93.64 Post_ - Eff Description _______________________________________ ________ ____Amount- ==Balance O1/Ol ID 56 60 MONTH CERTIFICATE Beginning Balance 25000.00 01/31 Payment: Dividend 4.4100 93.64 25093.64 Annual Percentage Yield Earned 4.500% from 01/01/09 through 01/31/09 01/31 Withdrawal Transfer To Share 07 93.64- 25000.00 01/31 Ending Balance 25000.00 60 MONTH CERTIFICATE Will Mature On 03/03/10 Dividend YTD: Year to Date 93.64 --- Continued on following page --- - - -- '~, I PSEC~ P0. Box 67013 (117) 234.8484 (Harrisburg) Harrisburg, PA 17106-7013 (800) 237-7328 (Natiornuide) website - http://'www.psecu.com 3 JOINT OWNER MIRIAM E BURKETT 4905 E TRINDLE RD STE 90 MECHANICSBURG PA 17050-3653 MEMBER NUMBER STATEMENT DATE 8008XXXXXX '~ 01/31/09 Post Eff Description Amount Balance O1/O1 ID 57 60 MONTH CERTIFICATE Beginning Balance 10000.00 01/31 Payment: Dividend 4.410°s 37.45 10037.45 Annual Percentage Yield Earned 4.500% from 01/01/09 through 01/31/09 01/31 Withdrawal Transfer To Share 07 37.45- 10000.00 01/31 Ending Balance 10000.00 60 MONTH CERTIFICATE Will Mature On 04/12/10 Dividend YTD: Year to Date 37.45 ------------- --------------------------------------- Total Dividend YTD: Year to Date 419.39 Country Meadows West Shore 3 4905 East Trindle Road Mechanicsburg, PA 17050 Telephone: {717) 761-8880 Resident Statement Date: 03/01/2009 Re: Miriam Burkett Account#: 76432 Balance Due: Michael Burkett 3 Shady Lane Amount Enclosed _ Mechanicsburg, Pa 17050 .00 REV-1511 EX+ (10-06) SCHEDULE M 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. FUNERAL EXPENSES: ~. B. 1 2. 3. 4. 5. 6. 7. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: State Zip ___. __ Attorney Fees 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 Probate Fees Accountant's Fees Tax Return Preparer's Fees Zip Q `~a~a,~~ ~ 1yo.~a TOTAL (Also enter on line 9, Recapitulation) I $ ~ l Si O (If more space is needed, insert additional sheets of the same size) I REV 1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCEIEptILE 1 DEBT5 OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF ~ ~+ r ~ ~ ~ ~~ ~ ~ ~ ~ FILE NUMBER v- r ~~ . Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 ~'1 ~ ~` ~~ri'~.~ ~~~ II ~ 1S~g~ ~ g, SS ~Uf ~ /`p ~ I S p ~ ~f )t ~~. ~~~ ~ ~e~, oa ~ ~, SS ~ 3a~.~~ yG,o p TOTAL (Also enter on line 10, Recapitulation) ; I ~ O Sj ~~ (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (11-08) ~ Pennsylvania DEPARTMENT OF REVENUE INHERRANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ] BENEFICIARIES ESTATE OF L FILE NUMBER 1 r 11 G r/~ ~ ~)n r ~~1' `I NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trn~stee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 2116 (a) (1.2).] 1. ~,~ ~ ~t u ~ I vv ~kr ~~~-~ ~o rJ ~ o ~ `~ y ~t/~ ~e C ~1 c~ ~ ; ~ S ~, ~~ ~ ~ ("~ D ,S U ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 CI)VER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE 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 additional sheets of the same size. BE TT REMEMBERED, That I, MIRIAM E. BURI~3TT, of Mechanicsburg, Pennsylvania, being of sound mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, hereby rE;voking and making null and void any and all Wills and Testaments or Writings in the nature thereof, by me at any time heretofore made. ITEM 1. I order and direct the payment of all my just debts and funeral expenses as soon as conveniently may be after my decease. ITEM 2. All the rest, residue and remainder of my estate, real, personal or mixed, of whatever nature or kind and wheresoever situate, I give, deviise and bequeath unto my beloved son, MICHAEL W. BURKETT. In the event my said son should predecease me or die in a common accident with me, then I give, devise and bequeath the said rest, residue and remainder of ary estate unto the children of my said son, Mic:r~ael W. Burkett, na~-nely: DONNA S. POTTEIGER, DAVID M. BURKETT, and DIANE M. HEILAND, equally, share and share alike. In the event any of my above-named grandc:hildren should also predecease me or die in a common accident with me, then I give, devise and bequeath the share of the one so r3 ~ dying unto his or her issue; in default of issue, to my surviving grandchildre~;~ned in~iis r:? •~i ~ ~'J: -,~ D ~ ~ ,. 1 •. ('- paragraph who are living at the time of my death. , ~ T Q, ~•~~-' f '_ . . _ `~' w _. .r --.~. ITEii ~. La`t~4. l nc~~r=r~t~, constitute aAd aplZOint as Sole Execuror of this, my Last Will and Testament, my son, MICHAEL W. BtIRKETT. In the event my said son should predecease me or for any reason be unable to act or continue to act as Executor hereof, then I nominate, constitute and appoint my grandson, DAVID M. BURKETT, to act in his stead as Executor of this, my Last Wilt and Testament. My Fiduciaries shall serve without bond. IN WPTNESS WHEREOF, I, MIRIAM E. BURKETT,1he Testatrix above named, have hereunto affixed my hand and seal this ~ Nc~ day of February, 2005. ~, ~~~~~~-~.~~ ~: f~ f ~`:~~-~' (SEAL) Signed, sealed, published and declared by MIRIAM E. BURKETT, the Testatrix above named, as and for her Last Will and Testament, in the presence of us, who have, at her request, in her presence and in the presence of each other, subscribed ow- names as witnesses. ~~~'~ ~; ~~ ,~ 2 ,, C£~~L'~101~~ ~LTH ELF P~~=ti S~ I.~" ~~ ~~ SS. COUNTY QF ~ _„'~~ = L _ ~.. ~: ~ ~.~ I, biIRIAM E. BURKETT, Testatrix whose name is seed to the attached or fore~?oinQ instrument, having been duly: qualified according to'law, do hereby acknowledge that I signed and executed the instrument as my LasC Will and Testament; t11at I signed it willingly; and that I si ed it as m free and voiunt act for the ses therein ex ressed. ~ Y ~Y P~ P i Sworn or affirmed to and acknowledged before me, by NIIRIAM E. BURKETT, the Testatrix, this ~ '~ 4day of February, 2005. . --~C-'~ COMMONWEALTH OF PENNSYLVANIA bhC Ndarial Seal Mary ~, Gouflet Ndary Pubic My commission expires: d~ FMB ZL ~ ~1_~~ Silver Spring Twp., Cumberland Catrdjt My t'.omnpssion E~ires Nov.17, tart Adernbp*, Pennsylvania Association Of Notaries 4