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Home My WebLink About10-22-091505607120 --~ REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN ~ I I_ U (~ ~j PO 60X.280601 RESIDENT DECEDENT U ' ` ` Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELODate of Death Date of Birth Social Security Number 201 18 3734 01 06 2006 01 13 1927 Suffix Decedent's First Name MI Decedent's Last Name s D~RIS HERR (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last N~rrte HERR ~ ~ I°1;C3.1~~ ~ ~ I I ~ g Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW X 1. Original Return 4. Limited Estate 6 Decedent Died Testate - (Attach Copy of Wilp 9. Litigation Proceeds Received Suffix Spouse's First Name STEPHEN THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Return 4a. Future Interest Compromise - (date of death after 12-12-82) ~, 7 Decedent Maintained a Living Trust _. _, (Attach Copy of Trust) ~' 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) MI L 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 0 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 CONFIDENTIADaytimeFTelephone NumberBE DIRECTED TO: Name 717 540 4332 MARCI S. MILLER ~ - _ ~_ Firm Name (If Applicable) REGISTERrOF~~LLS USF~~NLY -, r I , -, ..,.~ ~. _. HAZEN ELDER LAW I ~ 7 ~ ~ .~' Iw , . ~ --t First line of address NN `-' ,, 4 2000 LINGLESTaWN ROAD "I =~ - .:~. - -=~ Second line of address - - .. ....~ S U I T E 2 0 2 DATE FILED __._ City or Post Office State ZIP Code pE, 1 ~' i i u HARRISBURG Correspondent'se-mail address: mmiller@haZenelderlaW.COm It s trueecorrlect andecoumpletde cDeclahati I nav prepares odthe than the persoinalaepresentative is based on d nformation~ of wh~ h prepares has any knowledge.belief, DATE SI TUR OF PERSON RESPO SIBLE R I G RETURN Judith E. Dress r ADD i 126 Lancaster Blvd Mechanicsburg, PA 17055 DATE SIG ATURE F REPAR R O HE~THAN REPRESENTATIVE `~ ~!~ /''P ~P .' 111 Marci S. Miller 1 U ~ Z ADDRESS ' -'" " 2000 Linglestown Road, Harrisburg, PA 17110 1505607120 Side 1 1505607120 1505607220 REV-1500 EX Decedent's Social Security Number Decedent's Name i~ U ~ I S S. Herr 2 0 1 1 8 3 7 3 4 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. Jointl Owned Property (Schedule F) ~ _' Separate Billing Requested ... Y .......... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ~ Separate Billing Requested .. ........... 7. 1 2 4 6 9 0 6 __ (Schedule G) $ 12,469. 06 g. Total Gross Assets (total Lines 1-7) ............................................................ .... 9. Funeral Expenses & Administrative Costs (Schedule H) .............................. ........... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule t) .................... ............ 10. 0. 00 11. Total Deductions (total Lines 9 & 10) .......................................................... ............ 11. 12,469. 06 12. Net Value of Estate (Line 8 minus Line 11) ................................................ ............. 12. Charitable and Governmental Bequests/Sec 9113 Trusts for which 13 13 , an election to tax has not been made (Schedule J) ............................ . 12 469. 06 14. Net Value Subject to Tax (Line 12 minus Line 1 ........ __ - 14. - TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 1 2 4 6 9 0 6 15. 0 0 0 (a)(1.2) X .00 16. Amount of Line 14 taxable 0 0 0 16• 0 O 0 at lineal rate X .045 17. Amount of Line 14 taxable X 0 0 17, 0 0 0 at sibling rate X 12 18. Amount of Line 14 taxable Q 0 0 18. 0 0 0 at collateral rate X .15 19. 0. 00 19. Tax Due ...................................................................................................... .......... 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505607220 1505607220 J REV-1500 EX Page 3 Decedent's Complete Address: File Number Doris S. Herr STREET ADDRESS I CITY STATE ZIP PA Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InteresUPenalty if applicable p. Interest E Penalty _ __ 0.00 Total Credits (A + B + C) Total InteresUPenalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. 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. A. Enter the interest on the tax due. g. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT (1) 0.00 (2> 0.00 (3) (4) (5) 0.00 (5A) (56) ~.~0 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS Yes No 1. Did decedent make a transfer and: p p y p x a. retain the uge or inco ge of the ro ert transferred :................................................................ x c retain ahrevehsionary interest oo shall use the roperty transferred or its income :.......... .. ~ X ................ d. receive the promise for life of either payments, benefits or care? ......................... r 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without x receiving adequate consideration? ............................................ .. 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? ..... .................... .. ......... 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 J 1n1 ary 1 ~ The st t to doesenot exemat a transfer to a sure v ng spouser frorm taxsa d the statultory equirementsro (0) percent [72 P.S. §9116 (a) ( ) ()) Iicable even if the surviving spouse is the only beneficiary. for disclosure of assets and filing a tax return are still app 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 o 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)]. A siblino 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-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RFFmFNT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Herr. Doris S. FILE NUMBER This schedule must be completed and fled if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM DE RIPTI N OF PROPtK I Y DATE OF DEATH % OF DECD'S EXCLUSION NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. 1 MetLife IRA Annuity Contract #A2052696 - 3,954.07 100.000 Beneficiary is Stephen L. Herr, spouse 2 MetLife Nonqualified Annuity Contract #A2052527 -Beneficiary is Stephen L. Herr, spouse TOTAL (Also enter on Line 7, Recapitulation) 8,514.99 ~ 100.000 TAXABLE VALUE 3,954.07 8,514.99 12,469.06 (If more space is needed, additional pages of the same size) Form PA-1500 Schedule G (Rev. 6-98) Copyright (c) 2002 form software only The Lackner Group, Inc. REV-1513 EX+ (9.00) COMMONWEALTH OF PENNSYLVANIA IN RESIDENTEDECEDENTRN SCHEDULE J BENEFICIARIES ESTATE OF Herr, Doris S. NAME AND ADDRESS OF NUMBER PERSON(S) RECEIVING PROPERTY Tevnoi c nlcT[71 RI ITIrINS (include outright spc I. II. Stephen L. Herr 350 Willow Ave. Camp Hill, PA 17011 under Sec. 911 FILE NUMt3tK RELATIONSHIP TO I SHARE OF ESTATE DECEDENT (Words) Do Not List Trustee(s) f OF ESTATE ($$$) Spouse 1100% I I Total 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS V.VV TATAI nG vnRT II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET _ c nog - - - - roan rr+-iaw ~~„~..,.,., ., ~...,.. - --~ Copyright (c) 2002 form software only The Lackner Group, Inc. MetLife Investors USA P.O. Box 14593 Des, Moines IA 50306-3593 MetLife September 14, 2009 MARCI MILLER C/O HAZEN ELDER LAW 2000 LINGLESTOWN RD STE 202 HARRISBURG PA 17110 RE: METl.tFE INVESTORS USA tNSURANCt= CC}MPA,NY CONTRACT A2052596 OWNER Doris Herr, Estate of Stephen Herr Beneficiary Dear Ms. Miller: Thank you for your recent inquiry regarding the contract referenced above. Our records indicate that the date of death and the account value on that date are: Date of Death: January 6, 2006 Account Value: $3,954.07 If you have any questions, please contact your representative or call our Customer Service Center at 1-800-284-4536 Monday through Friday between 8:30 a.m. and 6:30 p.m., ET. Sincerely, Michael Irving Sr. Annuity Representative -Post Issue Processing MetLife Annuity Operations and Services MetLife Investors USA P.O. Box 14593 Des Moines IA 50306-3593 MetLife September 14, 2009 MARCI MILLER C/O HAZEN ELDER LAW 2000 LINGLESTOWN RD STE 202 HARRISBURG PA 17110 MIETLIFE lN~ESTORS IlSA-lNSURANG~E GOMRANY CON?RAC? A2Q~s2527 OWNER Doris Herr, Estate of Stephen Herr Beneficiary Dear Ms. Miller: Thank you for your recent inquiry regarding the contract referenced above. Our records indicate that the date of death and the account value on that date are: Date of Death: January 6, 2006 Account Value: $8,514.99 If you have any questions, please contact your representative or call our Customer Service Center at 1-800-284-4536 Monday through Friday between 8:30 a.m. and 6:30 p.m., ET. Sincerely, Michael Irving Sr. Annuity Representative -Post Issue Processing MetLife Annuity Operations and Services HlU].SU) KEV l/U~ This is to cert$.fy that the information here given is correctly cohied from an original certificate of deat u y > e wt me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 ~.~~~~7® No. Local Registrar JAN 1 1 2006 Date (3 ; l3 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS sTAre FILE NuAASea CERTIFICATE OF DEATH 2. Sex 3. Sodel Secunly NUrrper 4. Dale alD»N(MOMh, de T.e.~~i 201- 18 X734 1 /6/2006 ~iI .Cumberland 'S 1L. DecadeM's Uwal Occ alion KAq of Work v T 9c. c;dy,mro, iYm.«r,mm Carlisle 350 Willow Ave. Camp. hill, PA 17011 Fepafs Name (Pill. nidele, bSl) Lawrence Strickler . lalbaeaM'aName (TYDe4rAa) Stephen L. Herr McUod d paposAbn. to eurbt O Crerrenon ^ Removal nom Shla ^ DonaAon le Marta 23a<anN wMn ce ~ aq m is not weAebb et Gre adearn of '9E, Fec3ily Nerre (Il na'AteAution, gne su»l and remna) .. . ~ ______... _.. -.. -Cuban, No ^ Yes (Ryes, spady Mexican. Puedo Rkan, alc.l W 1 t e Carlisle Regional Medical 12. Was Decedent ever b Ina Us 13. DecedanrsEducafion. o 1a. Marini Slabs: Marred, Ne»r named. ts. SurviYhg 9pousa.(d . plus m EMnanuryrsewrwary lo-lz) CaAew(u«s+) wabwed. D'anreed (speranA ""'°dF"e~? Married Ste.-hen. L f ^ Yes No pid pecedenl DeoetleM~s X71 c a n i a tN.? ITC. o Yes. DandeM LNetl n ACIUa RBSidercB 178. Stile ra nd.1~ No, DecedeMLNed waAAr Car l i s l e ~ ., a Acl»tLaMb o1 47b. CounlYr-s.a+ar 19. Mahels Name (FASL middle; widen sums Nellie Wilson 2pb. FbmaMS McRrq Atldrass (sues, cAyAwm, eub, tip coda) 350 Willow Ave. Camp Hill, PA 17011 zlc. PbaaDb9osabnlNameaeNnelwy:cremaar«on^rpbssl 21a. Loalbnlc9rno.n.sute.xo~l zib. Daher DispoaAibn 1: Mar. v»r1 1./'14/2006 Mt. Ho11y Springs.Cem. Mt.Holly S rims P; 22b: tiwnee NUriMr 12c. Name and Address of FeciAy 011589E H 1lingerFH&CrematoryMt.HollySprings,PA 17065 2'3b. Lkeree Number 29c. Dalas7~(MOMh.dW.Y»r) ieim:24-28 mMM wrrpleled by Damon I24.7hne olD»in w,...-....,___~_,..___-... der or«aurcea a»m. (' 13 P M ) (~° ~ (~ CAUSE OF OEATN ISee Insbuabra and a»mpus) Ppproxinale Nrurvah oreabamtll tam T7. Part L 61te1 the ^ ~ a wenb-daeesee, Varies. «mmpkaY9nra-tlal dAedNcaused Aa d»m. WNOT Baer unMnel w»b such es eaMee arrest, mpietuy anent.«veMrivM~ (MdMean wMua anoe^9 Ne eAobQl~ DO NOT ahbrwiale. EMet aMY one ceu» aha Ana. IMMEDIATE CAUSE (Paul disx»or Ch 2Dt A-C M1-2YrAtMrh zrdAioa rawAegbdelh) ~ e' Duebl«uawraequarce o7 $pwNisAy Aq walitlone, it airy. b. bedn9laaa eau»fsW oeL'me a. Dueb(«es acoreeTance oA: EMa tla UrpERLYNG CAUSE c (dsxse«hjay gal ilAinbdthe ~ Duab(«asa coasealww.+M1: , werl4.rauMn9 in dearh) EASY. d 3db. Were AubpsY Faldage 31. Manner of Deatl~. 32a. Dale ofinAry (~~ daY. Year) 32b. DascrAa how Al ape Wes sn AUbpsy Psdormed? AvaAabM Pd« u CDn4leilon ~ NehaBl ^ Nomkde aCau»Ot09eM? 17 Aaidenl ^ Pendsp krve39Wtion 32d. Tare a Ad«Y 32e. Vary al Wark'/ 321. ^ Yes ~ No ^ Ye5 ^ No ^ SIdc10e ^ Cap Na Fk Oadtl'hled ^ Yes ^ No M. 330: 33e, Cmdflas (chadt onNane). • CsrrlNl^9PM'aklan(PAYSbien cer91YV1caa»ae»th wlron anaMrpnysiconnas praaurcaadslh and compktad lam zs). i ..~~._..._._ _.J.-.- .,_..----.-..0 To Wetxsl of mY Inlobbd90. d»1h aarRaad due to the ausNsl arrtl trotaaras sWetl ~..._ ~:. • prdneWKelpam DeAirYAr9 phyaiaan(Physidan ban pronaarcin9 deeN endcertAyAgbuaseddealhj _..-....-,_..._..~C To1M east or my errowbdpe, deaM occurred at the time, date, aria place, aMsue rothe quays) am manrer as ahted._--..- • Matlka eaamlrlmbomrer M ce, arN due to the aueysl and mamier as shred -.~.0 ~. On the blab of examelatbn and/or InYestlyaWn, N my opubn, death acumd at the tang date, a pla u nam FAed fMOntli. derv. Year) O w z (See instructions and examples on reverse) _ Txy Dars«o ^ Yas Q Nd.. Part II: Enter alMr 2s. DM Tabetsa U» Corrlrbrae b D»ih? Da not resMYp h dw unaerNilq n'tte t•ir^^ h Part I. ^ No ^ Uaaawn 29. AF»aie: ^ NaprepuMIYAIYn pest Year ^ Prepaid alN lea oideap~ ^ Na prepua, hrAprepaM wdhn 42 days oltlealh ^ Na pregaeM, bu pepnaM 13 daYS b 1 yam habredaA~ If TrarepartaAon VUrY (Speayr ^ DrmeaDP•~aror ^ Pasaen9ar ^ -petleaU6n ^ Otlw-5pedY. spal«e an~dTAb~ofcM~ifiw/~ n lkenae NUrrb« MD ov4tv~L n -tit ~er~r a5 c,ap-r.a tic 1+osplrtlr Cit-M1{i S-Le PR ne shed • d.Y, rain 1/~~~