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Home My WebLink About06-17-09~ REV-1500 1505607120 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO 60X.280601 Harrisburg, PA 17128-0601 ~~ RESIDENT DECEDENT 2 1 0 9 0 3 1 1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 041188462 03202009 07101916 Decedent's Last Name Suffix Decedent's First Name MI CAMPISI JOHN (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 ^ qa. Future Interest Compromise ^ 5. Federal Estate Tax Return Required (date of death after 12-12-92) ^ g Decedent Died Testate (Attach Copy of Will) ^ 9. Litigation Proceeds Received ^ ~ Decedent Maintained a Living Trust (Attach Copy of Trust) ^ 1 D Spousal Poverty Credit (dale of death between 1231-91 and 1-1-95) 8. Total Number of Safe Deposit Boxes ^ 11. Election to tax under Sec. 9113(A) (Attach Sch. O) -CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: ame Daytime Telephone Number FRANCIS A ZULLI 7172321488 Firm Name (If Applicable) WION, ZULLI AND SEIBERT First line of address 109 LOCUST STREET Second line of address City or Post Office State ZIP Code REGISTER OF WILLS USE ONLY C '•0 b w . - ,:z~ ~ s Cr n' ~,j =L C-7 ~ ~: D`1ET ~D r ~^ T~ .~ ~J t: 7 ?3 HARRISBURG PA 17101 ~aC~`i -~ `-~ Ti ~ ~ !V j-- r'r~1 Correspondent'se-mail address: WzS@mindspring.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. SIGN T RE OF PERSON RESPONSIBLE FOR FILING RETURN DATE C ~~~_ Lauren C. Fulton ~l.x[cu_~~ ~ --/5~-d g ADDRESS 1 No 25th Stre mp Hill, PA 17011 SI NATUR F PREPARER OTHER AN R PRESEN TIVE D TE ,(,, ~ ,~ Francis A Zulli ~ - / S - d 9 1 ocust Street, Harri b rg, PA 17101 Side 1 1505607120 1505607120 REV-1500 EX 1505607220 oecedernsName CAMPISI, JOHN 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. 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. 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) ...................................................................... 11. 12• Net Value of Estate (Line 8 minus Line 11) ............................................................. 12. 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) ................................................. 13. Decedent's Social Security Number 041188462 __ _ _ __ 107,748.01 107,748.01 __ 3,800.50 1,234.85 5,035.35 102,712.66 102,712.66 14. Net Value Subject to Tax (Line 12 minus Line 13) ................................................ . 14. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .00 15. 16. Amount of Line 14 taxable 10 2 , 7 12.6 6 4 , 6 2 2 . 0 7 16 at lineal rate X .045 . 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. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 4,622.07 Side 2 1505607220 1505607220 REV-1500 EX Page 3 File Number 21 - 09 - 0311 Decedent's Complete Address: Campisi, John _ _ _ _ __ STREET ADDRESS ~ 20 North 12th Street -_ CITY ~ STATE ZIP Lemoyne PA 17043 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 4,622.07 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 231.10 __ _ __._ _ Total Credits (A + g + C) (2) 2 31.1 3. InteresUPenalty if applicable p, Interest E. Penalty Total InteresUPenalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2 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. (5) 4, 390.97 A. Enter the interest on the tax due. (5A) g. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) t4, 3 9 0.9 7 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 b. retain the right to des gnatetwho hall use the property transferred or its income :.................................... 'f _l~ x~ c. retain a reversionary interest; or .................................................................................................................. :. d. receive the promise for life of either payments, benefits or care? .............................................................. ~_ _ ; r x I 2. If deaths ccurgred after December~12, 1982, did decedent transfer property within one year of death without I II recewin ade uate consideration ................ x 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... _ !, ' x_ 4. Did decedent own an Individual Retirement Account, annuity, or other non' probate property which ___ x contains a beneficiary designation? .......................... ~ I ~-_~ 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 )J. 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)J. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. SCHEDULE E CASH, BANK DEPOSITS, & MISC. '~ COMMONWEALTH OF PENNSYLVANIA ~, PERSONAL PROPERTY INHERITANCE TAX RETURN j RESIDENT DECEDENT ~' - J._ __-_..__ _~_--_ -_____- __.---_ _-_ -:- ___ _ _ __ _ -- __ FILE NUMBER ESTATE OF Cam ISI, John 21 - 09 - 0311 P I Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM DESCRIPTION NUMBER 1 Wachovia Bank Certificate of Deposit No. 4237 Accrued Interest 2 Wachovia Bank Certificate of Deposit No. 2563 Accrued Interest 3 Wachovia Bank Certificate of Deposit No. 2636 Accrued Interest 4 Wachovia Bank Certificate of Deposit No. 2456 5 Accrued Interest 6 Wachovia Bank Checking Accouunt No. 4200 Accrued Interest 7 1998 Dodge Stratas _ __ . VALUE AT DATE OF DEATH __ __ 51,291.32 142.40 5,440.54 13.97 10,485.34 26.93 26,000.00 33.01 13,814.03 0.47 500.00 __ _ _ __ TOTAL (Also enter on Line 5, Recapitulation) 107,748.01 ' SCHEDULE H j FI~RAL EXPENSES & j COMMONWEALTH Of PENNSYLVANIA ~~ T ~ i INHERITANCE TAX RETURN "V C ESTATE OF Campisi, John Debts of decedent must be reported on Schedule I. ITEM ' DESCRIPTION NUMBER I FUNERAL EXPENSES: A. 1 Myers - Harner Funeral Home -Funeral FILE NUMIitK 21 -09-0311 AMOUNT _. _ ,. 2,390.00 g. ~ ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s): Street Address City State Zip Year(s) Commission paid 2. Attorney's Fees Wion, Zulli & Seibert 3. I Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant ii Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees Register of Wills Additional Probate Fee Filing Fee 5. I~' Accountant's Fees 6. Tax Return Preparer's Fees I 7, Other Administrative Costs 1 Commonwealth of PA -DOT -title transfer 1,050.00 252.00 50.00 ' 30.00 ' 28.50 __ -.-- TOTAL (Also enter on line 9, Recapitulation) 3,800.50 SCHEDULEI DEBTS OF DECEDENT, MORTGAGE COMMONWEALTH OF PENNSYLVANIA LIABILITIES, & LIENS INHERITANCE TAX RETURN '. RESIDENT DECEDENT _- _ _ _. _r-_.-_ _:._.. FILE NUMBER ESTATE OF Campisi, JOhn I21 - 09 - 0311 Include unreimbursed medical expenses. ITEM DESCRIPTION NUMBER 1 Wachovia Bank Visa Account No. 1143 2 Verizon -Phone 3 Essex House -Rent 4 Vasccular Assoc. -Medical Bill 5 US Treasury -Fed Income Tax 2008 ---- TOTAL (Also enter on Line 10, Recapitulation) AMOUNT 64.29 8.98 1,095.67 6.91 59.00 1,234.85 REV-1513 EX+ (9.00) ' SCHEDULE J ~, COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES '~~ INHERITANCE TAX RETURN ~ _ _ - RESIDENT DECEDENT --- __-- `- - --- - - - ~, FILE NUMBER ESTATE OF Campisi, John 21 -09-0311 I~ ~- - -- RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY Do Not ust trustee(s) p - - - ~ _ ~ I. 'TAXABLE DISTRIBUTIONStli stnbutionsr~ antd transfers ~ under Sec. 9116 (a) (1.2)] ue 1 I Daughter 100 /o of Resld 1 Lauren C. Fulton 138 North 25th Street 'Camp Hill, PA 17011 j ~i i I ' '' ~! I~ 'Enter dollar amounts for distributions shown above on lines 115 through 18, as appropriate, on Rev 1500 cover sheet NON-TAXABLE DISTRIBUTIONS: II II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE I I 1 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 I TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00