HomeMy WebLinkAbout07-07-09 (2)1505607121
REV-1500 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes
PO BOX 280601 INHERITANCE TAX RETURN
2 1 0 8 0 0 2 2 0
Hamsburg, ~A 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
1 9 5 2 2 9 6 8 5 1 0 2 1 2 0 0 4 0 9 1 6 1 9 2 7
Decedent's Last Name Suffix Decedent's First Name MI
B R I N K L U C Y 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
0 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)
~
Q 6. Decedent Died Testate 8. Total Number of Safe Deposit Boxes
~ 7. Decedent Maintained a Living Trust
(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)
S
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O
c
.
)
between 12-31-91 and 1-1-95) (Attach
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
H ANTHONY ADAMS 7 1 7 5~~2 3?'7 0 ~-,
Firm Name (If Applicable)
First line of address
4 g WEST ORANGE
Second line of address
S U I T E 3
City or Post Office
SHt PPENSBURG
S T R E E T
State ZIP Code
REGISTER FUSE ~ ~ ~ '~ Ji
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DATE FILED
P A 1 7 2 5 7
Correspondent's a-mail address: htadamsjaw embargmail corn
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. D eclaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE Oi~RSON.RESPONSIBLE FO~I~IN~TURNL ~ /QAT~~ ~--,
~~
1505607121
Side 1
1505607121
J C
ADDRESS ~ '""~ ~ ~
REV-1500 EX
LUCY L. BRINK
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 8~ Notes Receivable (Schedule D) ...................
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested .
8. Total Gross Assets (total Lines1-7) •••••~•••~•~••••••••~ ..... 4.
..... 5.
..... 6•
...... 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.
Charitable and Governmental Bequests/Sec 9113 Trusts for which
13
.
an election to tax has not been made (Schedule J) ... • • • • • 13.
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 Q ~ 0 Q 15.
16. Amount of Line 14 taxable 1 2 8 3 0. 0 6 1s
at lineal rate X .045 .
17. Amount of Line 14 taxable 0 ~ 0 0 17.
at sibling rate X .12
18. Amount of Line 14 taxable 0 0 0 18.
at collateral rate X .15
19.
19. Tax Due ................................................
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
1505607221
1505607221
Side 2
Decedent's Social Security Number
1 9 5 2 2 9 6 8 5
2 0 0 0 0.0 0
2 0 0 0 0. 0 0
5 7 6 1. 7 3
1 4 0 8. 2 7
7 1 7 0, 0 0
1 2 8 3 0. 0 6
1 2 8 3 0. 0 6
0. 0 0
5 8 1.7 7
0. 0 0
0. 0 0
5 8 1.7 7
1505607221
File Number
REV-1500 EX Page 3 21 08 00220
Decedent's Complete Address:
DECEDENT'S NAME
LUCY L. BRINK_ ___ _ _____. __---
STREETADDRESS
273 NEWBURG ROAD ___ - - -- -
CITY _ - ~ STATE ZIP
NEWBURG IPA ~ 17240
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit -
B. Prior Payments _
C. Discount
581.77
(3) 157.96
(4) 0.00
(5) 739.83
(5A)
(5B) 739.83
(1)
581.77
Total Credits (A + B + C) (2)
3. Interest/Penalty if applicable 157.96
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.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable fo: REGISTER OF WILLS, AGENT
PLEASE ANSWER i HE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
I . Did decedent make a transfer and: Yes
^ No
a. retain the use ur income of the property transferred : ................................................................. ..... X
b. retain the right to designate who shall use the property transferred or its income; .......................... .....
. ^ 0
c. retain a reversionary interest; or ...........................................................................................
...
? ....
...... ^ 0
..............................................
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
^ X
^
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
. ^
X
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.
Fcr 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.
REV-1507 EX + (6-9®)
SCHEDULE D
COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES
INHERITANCE TAX RETURN RECEIVABLE
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
LUCY L. BRINK 21 08 00220
All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
~. Mortgage Not of Thomas S. Brink and Lisa A. Brink dated July 12, 2000 20,000.00
in principal amount of $20,000.00
TOTAL (Also enter on line 4, Recapitulation) $ 20,000.00
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (10-06)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
LUCY L. BRINK 21 08 00220
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Fogelsanger-Briicker Funeral Home 4,148.73
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s) Thomas Brink 500.00
Street Address 89 County View Estates
City Newburg State PA zip 17240
Year(s) Commission Paid: 2009
2 AttomeyFees H. ANTHONY 1,000.00
3. Family Exemption: (If decedents address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 113.00
5 Accountant's Fees
6, Tax Retum Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $ 5.761.73
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX + (12 A3)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
LUCY L. BRINK 21 08 00220
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. Sovereign Bank -Account #ILN-6817195446 1,228.76
2. Sprint #717-423-5507-739 42.34
3. Americas # 3236001675 22.00
4. Penelec #100013509649 115.17
TOTAL (Also enter on line 10, Recapitulation) I $ 1,408.27
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX + (9-00)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
LUCY L. BRINK 21 08 00220
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. Linda Brink Schuppert Lineal 12,830.06
P.O. 947
Archer, FL 32618
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
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)
NOTE
Borrower: THOMAS BRINK & LISA BRINK
Lender: ISSAC T. BRINK & LUCY L. BRINK
Date:
Address: 273 NEWBURG ROAD, NEWBURG PA 17240
Borrower's Promise to Pay
In return for a loan that I have received, I promise to pay the Principal amount of THENTY-
THOUSAND DOLLARS ($ 20,000.00), plus interest, to the order of the Lender identified above or any
successive Note Holder. I understand that the Lender may transfer this Note. The Lender or anyone who
takes this Note by transfer and who is entitled to receive payments under this Note is called the "Note Holder."
Interest
Interest will be charged on unpaid principal until the full amount of principal has been paid. I will pay
interest at a yearly rate of EIGHT PERCENT (5%). The interest rate required by this Section 2 is the rate I
will pay both before and after any default described in Section 6(B) of this Note.
Payments
a. Time and Place of Payments:
(1) I will pay principal and interest by making payments every month.
(2) I will make my monthly payments beginning within 30 days of demand by Lender or 30
days from the date of Lender's death whichever occurs first. I will make these payments every month until I
have paid all of the principal and interest and any other charges described below that !may awe under this
Note. My monthly payments will be applied to interest before principal. If, 120 months from the first payment,
I still owe amounts under this Note, l will pay those amounts in full on that date, which is called the "maturity
date."
(3) I will make my monthly payments at 273 Newburg Road, Newburg, Pennsylvania or at
a different place if required by the Note Holder.
b. Amount of Monthly Payments: My monthly payment will be in the amount of $ 212.13.
Borrower's Right to Prepay
I have the right to make payments of principal at any time before they are due. A payment of principal
only is known as a "prepayment." When I make a prepayment, I will tell the Note Holder in writing that I am
doing so. I may make a full prepayment or partial prepayments without paying any prepayment charge. The
Note Holder will use all of my prepayments to reduce the amount of principal that I owe under this Note. If
I make a partial prepayment, there will be no changes in the due date or in the amount of my monthly payment
unless the Note Holder agrees in writing to those changes,
Loan Charges
If a law, which applies to this loan and which sets maximum loan charges, is finally interpreted so that
the interest or other loan charges collected or to be collected in connection with this loan exceed the permitted
limits, then: (i) any such loan charge shall be reduced by the amount necessary to reduce the charge to the
permitted limit; and (ii) any sums already collected from me which exceeded permitted limits will be refunded
to me. The Note Holder may choose to make this refund by reducing the principal I owe under this Note or
by making a direct payment to me. If a refund reduces principal, the reduction will be treated as a partial
prepayment.
Borrower's Failure to Pay as Required
a. Late Charge for Overdue Payments: If the Note Holder has not received the full amount
of any monthly payment by the end of FIFTEEN calendar days after the date it is due, I will pay a late charge
to the Note Holder. The amount of the charge will be 5.00% of my overdue payment of principal and interest.
I will pay this late charge promptly but only once on each late payment.
b. Default: If I do not pay the full amount of each monthly payment on the date it is due,
I will be in default.
c. Notice of Default: If I am in default, the Note Holder may send me a written notice
telling me that if I do not pay the overdue amount by a certain date, the Note Holder may require me to pay
immediately the full amount of principal which has not been paid and all the interest that I owe on that amount.
That date must be at least 30 days after the date on which the notice is delivered or mailed to me.
d. No Waiver By Note Holder: Even if, at a time when I am in default, the Note Holder does
not require me to pay immediately in full as described above, the Note Holder will still have the right to do so
if I am in default at a later time.
~• Payment of Niite I"iCJIl7C1''S Cosis ana Cxpenses: if ine wore i-ioider has required me to pay
immediately in full as described above, the Note Holder will have the right to be paid back by me for all
reasonable costs and expenses in enforcing this Note to the extent not prohibited by applicable law. Those
expenses include, for example, reasonable attorney's fees.
7. Giving of Notices
Unless applicable law requires a different method, any notice that must be given to me under this
Note will be given by delivering it or by mailing it by first class mail, return receipt requested to me at the
Property Address above or at a different address if I give the Note Holder a notice of my different address.
8. Obligations of Persons Under this Note
If more than one person signs this Note, each person is fully and personally obligated to keep all of
the promises made in this Note, including the promise to pay the full amount owed. Any person who is a
guarantor, surety or endorser of this Note is also obligated to do these things. Any person who takes over
these obligations, including the obligations of a guarantor, surety or endorser of this Note, is also obligated
to keep all of the promises made in this Note. The Note Hoider may enforce its rights under this Note against
each person individually or against all of us together. This means that any one of us may be required to pay
all of the amounts owed under this Note.
9. Waivers
I and any other person who has obligations under this Note do not waive the rights of presentment
and notice of dishonor. "Presentment" means the right to require the Note Holder to demand payment of
amounts due. "Notice of dishonor" means the right to require the Note Holder to give notice to other persons
that amounts due have not been paid.
10. Uniform Secured Note
This Note is a uniform instrument with limited variations in some jurisdictions. In addition to the
protections given to the Note Holder under this Note, a Mortgage, Deed of Trust or Security Deed (the
"Security Instrument"), dated the same date as this Note, protects the Note Holder from possible losses which
might result if I do not keep the promises which I make in this Note. That Security Instrument describes how
and under what conditions I may be required to make immediate payment in full of all amounts I owe under
this Note. Some of those conditions are described as follows:
Transfer of the Property or a Beneficial Interest in Borrower. If all or any part of the Property or any
interest in it is sold or transferred (or if a beneficial interest in Borrower is sold or transferred and Borrower
is not a natural person) without Lender's prior written consent, Lender may, at its option, require immediate
payment in full of all sums secured by this Security Instrument. However, this option shall not be exercised
by Lender if exercise is prohibited by federal law as of the date of this Security Instrument.
If Lender exercises this option, Lender shall give Borrower notice of acceleration. The notice shall
provide a period of not less than 30 days from the date the notice is delivered or mailed within which Borrower
must pay all sums secured by this Security Instrument. If Borrower fails to pay these sums prior to the
expiration of this period, Lender may invoke any remedies permitted by this Security Instrument without further
notice or demand on Borrower.
WITNESS THE HANDS AND SEALS OF THE UNDERSIGNED.
THOMASNK ~ ~
A BRINK
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
ss.
On this -`~~~ day of , 2000, before me, the undersigned officer, personally
appeared THOMAS BRINK and LISA BRI ,known to me or satisfactorily proven to be the person whose
name is subscribed to the foregoing instrument, and acknowledged that he/she executed the instrument for
the purposes contained in it.
IN WITNESS WHEREOF, I hereto set my hand and official seal.
~, -~_
Notary Publi / ___r.-.---- -
Notarial Notary Public
Lisa M. Greason,
Carlisle Boro, CumbesiS pC9U20 2
My Commission Exp
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