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Home My WebLink About11-03-091505607120 REV-7 500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO 80X.280601 21 0 9 0 7 5 7 Harrisburg, PA 17128-OSO~ RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 383 12 6436 08 06 2009 03 01 1919 Decedent's Last Name Suffix Decedent's First Name MI JOHNSON HELEN B (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW X^ 1. Original Return 4. Limited Estate 6. Decedent Died Testate (Attach copy of wu> MI THIS RETURN MUST BE FILED IN DUPLICI4TE WITH THE REGISTER OF WILLS 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 1~-13«82) qa. Future Interest compromise ~ 5. Federal Estate Tax Return Required (dale of death aRer 12-12-82) ~, DecedeM Maintained a Living Trust 1 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31- 1 and i-1-95) (Attach SCh.'O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFOR A ON SHOULD BE DIRECTED TO: Name Daytime Tel~phpne Number GARY L. JAMES ESQ. 717 533' 3280 Firm Name (If Applicable) JAMES, SMITH, DIETTERICK & CONNELLY, L First line of address 134 SIPS AVENIIE Second line of address City or Post Office HIIMMELSTOWN Correspondent's e-mail address: 9 U ~1 S d C. C O m State ZIP Code PA 17036 REGISTEI$ O USE ~~ ~~ t t W .z ,=i .~I ri pA1ILED "~.? 'C-~.~i _~~'..~+ Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to th bust of my knowledge and belief, k is true, correct and complete. Declaration of preparer other than the personal representative Is based on all information of which Iprep~arer has any knowledge. SIGMAry~E OF PERSON PONSIBLE FOR FILING RETURN DATE /~t~rp,~.t ~r,~s,,,.,., Barbara J. Brumagim 0 ~t• 30 ~ .Zooy ADDRESS 1658 The Hideout, Lake Ariel, PA 18436 SIGNAT+IRE OF PREPARER OTHER THAN REPRESENTATIVE DATE Gary L. James Esq. fa - 3-~- ~-~r mmelstown, PA 17036 Side 1 1505607120 15056017120 1505607220 REV-1500 EX Decedent's Social Security Number oecedenes Name: Helen B. Johnson 3 8 3 1~ 6 4 3 6 RECAPITULATION 1. Real Estate (Schedule A) .......................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................... 2. 0 . O 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3. 4. 5• 6. 7. 8. Mortgages & Notes Receivable (Schedule D) .......................................................... Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ Jointly Owned Property (Schedule F) ~ Separate Billing Requested ............. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ............. Total Gross Assets (total Lines 1-7) ....................................................................... 4. 5. 6. 7, 8. 1 , 7 9 5 . 9 7 2 5 2 , $ 2 7 . 2 4 2 5 4 , 6 2 3.21 9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 12 , 4 2 4 . 5 5 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10. 2 , 5 5 0 . 9 8 11. Total Deductions (total Lines 9 8~ 10) ...................................................................... 11, 14 , 9 7 5 . 5 3 12. Net Value of Estate (Line 8 minus Line 11) ............................................................. 12. 2 3 9 , 6 4 7 . 6 8 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................................................. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ................................................. 14. 2 3 9 , 6 4 7 . 6 $ TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (ax1.2) x .o0 0. 0 0 15• 0. 0 0 16. Amount of Line 14 taxable at linealrateX .045 239, 647.68 16• 10, 784.15 17. Amount of Line 14 taxable at sibling rate X .12 O. O O 17• O. 0 0 18. Amount of Line 14 taxable at collateral rate X .15 O. O O 18• O. 0 0 19. Tax Due ..................................................................................................................... 19. 1 O . 7 8 4.15 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 L 1505607220 15056a7~20 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-09-0757 DECEDENTS NAME Helen B. Johnson STREET ADDRESS 5225 Wilson Lane Suite 304 CITY Mechanicsburg STATE PA ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty if applicable p, Interest E. Penalty 539.21 Total Credits (A + B + C) (1) 10,784.15 Total Interest/Penalty (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. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT (2) 539.21 (3) (4) (5) 10,244.94 (5A) (5B) 10,244.94 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APP~tCdPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retairi the use or income of the property transferred :.................................................................................. ~ ^ b. retain the right to designate who shall use the property transferred or its income :.................................... ^x ^ c. retain a reversionary interest: or ......................................................................................:........................... ^x ^ 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? ...........................................................................................................:........... ^ 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 contains a beneficiary designation? ...................................................................................................................... ^ ^x 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 tq 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)]. 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 B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA EVHERRANCE TAX RETURN RESX)ENT DECEDENT ESTATE OF FILE'NWMBER Johnson, Helen B. 2109-0757 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT V~WLUE VALUE AT DATE OF DEATH 1 20,000 shares of Daelyte Service Company B Preferred 0 0.00 Stock -security is worthless TOTAL (Also enter on Line 2, Recapitulation) 0.00 (rc more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form FAA 1500 Schedule B (Rev. 6-98) Rev-1506 EX+ (6.96) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY corrrtoNwEA~TH of PENNSV~vANu MHERRANCE TAX RETURN RESDENT DECEDENT ESTATE OF FILE NUMBER Johnson, Helen B. 21-09-0757 Include the proceeds of litigation and the date the proceeds were received by the estate. All properly Jointly-owned wkh the right of survivorship must be disclosed on schedule F. ITEM DESCRIPTION vAOF DEATHTE NUMBER 1 Personal Property -valued per executor 1,000.00 2 AARP -membership refund 17.57 3 Lititz Mutual Insurance Company -refund for apartment insurance 59.00 4 Patriot-News -subscriber refund 157.50 5 Verizon Benefits Center -dental benefit refund 561.90 TOTAL (Also enter on Line 5, Recapitulation) I 1,795.97 (If more space is needed, additional pages of the same size) Copyright (c} 2002 form software only The Lackner Group, Inc. Form SPA-1500 Schedule E (Rev. 6-98) Rev-1510 EJ(f (6.98) SCHEDULE G INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY cor,aaNwEALTH of aENNSVIVANIA MHERRANCETAX RETURN RESIDENT DECEDENT ESTATE OF FILE NWMBER Johnson, Helen B. 21.09-0757 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is, yes... ITEM NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD'S INTEREST r=xc~.usloN (IF1 APWLICABLE) TAXABLE VALUE 1 1,151.721 units of American High Income Trust 11,367.49 11,367.49 Class A -titled in the George C. Johnson and Helen B. Johnson Living Trust dated 0210111996; held in the M ~ T Securities Inc brokerage account # AZD-474740; valued per public listing 2 2,492.93 units of Bond Fund of America -titled in 28,544.05 28,544.05 the George C. Johnson and Helen B. Johnson Living Trust dated 0210111996; held in the M ~ T Securities Inc brokerage account # AZD-474740; valued per public listing 3 265.762 units of Capital Income Builder Fund 11,868.93 11,868.93 Class A -titled in the George C. Johnson and Helen B. Johnson Living Trust dated 02/0111996; held in the M & T Securities Inc brokerage account # AZD-474740; valued per public listing 4 1,272.273 units of Capital World Bond Fund 25,038.33 25,038.33 Class A -titled in the George C. Johnson and Helen B. Johnson Living Trust dated 0210111996; held in the M 8 T Securities Inc brokerage account # AZD-474740; valued per public listing 5 200 shares of Fulton Financial Corp -titled in the 1,500.00 1,500.00 George C. Johnson and Helen B. Johnson Living Trust dated 02/01/1996; held in the M ~ T Securities Inc brokerage account # AZD-474740; valued per public listing Total of Continuation Schedule ee attached page TOTAL (Also enter on Line 7, Recapitulation) 252,827.24 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form !?A-1500 Schedule G (Rev. 6-98) Rev-1510 EX+ (&98) SCHEDULE G INTER-VIVOS TRANSFERS ~ MISC. NON-PROBATE PROPERTY co~.wroNwEUTN of PENNSnvANw MHERRANCE TAX RETURN continued RESENT DECEDENT ESTATE OF FILE NWMBER Johnson, Helen B. 21+09-0757 ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET ~~ of DECD~s INTEREST ExGLUSION (II? APIPLICABLE) TAXABLE VALUE 6 M & T Bank Checking Account # 49486411 -titled 20,729.22 20,729.22 in the George C. Johnson and Helen B. Johnson Living Trust dated February 1, 1996; valued per letter dated August 25, 2009 7 PNC Bank Checking Account # 5005297838 - 2,827.56 2,827.56 titled in the George C. Johnson and Helen B. Johnson Living Trust dated February 1, 1996; valued per letter dated August 28, 2009 8 $50,000 U.S. Treasury Bill maturity date 49,982.01 49,982.01 10H5/2009 -titled in the George C. Johnson and Helen B. Johnson Living Trust dated 02/01/1996; held in the Legacy Treasury Direct account # 4800-846-6873; valued per statement dated August 25, 2009, CUSIP #912795P70 9 576,000 U.S. Treasury Bill maturity date 75,972.66 75,972.66 10/22/2009 -titled in the George C. Johnson and Helen B. Johnson Living Trust dated 0210111996; held in the Legacy Treasury Direct account # 4800-846-6873; valued per statement dated August 25, 2009, CUSIP #912795S44 10 $25,000 U.S. Treasury Bill maturity date 8113/09 - 24,996.99 24,996.99 titled in the George C. Johnson and Helen B. Johnson Living Trust dated 02101/1996; held in the Legacy Treasury Direct account # 4800-846-6873; valued per statement dated August 25, 2009, CUSIP #912795N64 TOTAL (Also enter on Line 7, Recapitulation) I 252,827.24 Copyright (c) 2002 forrn software only The Lackner Group, Inc. Form pA-1500 Schedule G (Rev. 6-98) REV-1757 EX+(12-99) COMMONWEALTH OF PENNSYLVANIA INHERn'ANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Johnson, Helen B. 21-09-0757 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: See continuation schedule(s) attached 3,158.07 B. 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 James, Smith, Dietterick 8c Connelly, LLP 7,500.00 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 84.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1,682.48 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 12,424.55 Copyright (c) 2002 form software only The Lackner Group, Inc. Form pA-'1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE'NWMBER Johnson, Helen B. 21.090757 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Anna Royer -organist for memorial service 2 Neill Funeral Home -funeral 3 Peppermill Restuarant -post-memorial service luncheon 4 Reverend Jim Browning -memorial service 100.00 2,849.02 74.05 135.00 H-A Subtotal 3,158.07 Other Administrative Costs 5 Barbara J. Brumagim -reimbursement for mileage to administer estate; miscellaneous items purchased for decedent 6 Eileen Packer -apartment packer and mover 7 James Smith Dietterick 8~ Connelly LLP -reserve for estate administration closing costs 8 Karl Stine -mover 520.48 462.00 500.00 200.00 H-B7 Subtotal 1,6$2,4$ Copyright (c) 2002 form software only The Lackner Group, Inc. Form IPA-1500 Schedule H (Rev. 6-98) Rev-1572 FJ(+ (6.96) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, ~ LIENS COMMDNWEALTH OF PENNSYLVANIA NHERRANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NWMBER Johnson, Helen B. 21»090757 Include unrelmbursed medical expanses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Bethany Village Skilled Nursing -beauty charge for July 33.00 2 Bethany Village Skilled Nursing -final bill 1,673.95 3 Bethany Village Skilled Nursing -final bill for skilled nursing 292.00 4 Continuing Care Rx -prescription drugs 154.50 5 Continuing Care Rx -prescription drugs 38.00 6 Special Event Emergency Medical Services -ambulance from nursing home to 126.76 Bethany Village 7/6/09 7 West Shore EMS-BLS -ambulance from hospital to nursing home 6127109 232.77 TOTAL (Also enter on Line 10, Recapitulation) I 2,550.98 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form ~PA•1500 Schedule I (Rev. 6-98) REV-1513 EX+ (g.°°) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE WUMBER wnns~n, neten a. 21-09~-0 757 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT SHARE OF ESTATE (Words) AMOUNT OF ESTATE ($$$) Do NM List Trus s I~ TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116(a)(1.2)] 1 Barbara J. Brumagim Daughter 50% of residue 119,823.84 1658 The Hideout Lake Ariel, PA 18436 2 Ann K. Johnson Daughter 50% of resiiduie 119,823.84 427 Hogestown Road Mechanicsburg, PA 17055 Total 239,647.68 Enter dollar amounts for distributions shown above on lines 1 5 through 18, as appropri ate, on Rev 150 save r 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 TOTA L OF PART II -ENTER T(1TAI nlnni_TeYeRi ~ n~eT~im rnn~ic ~,~~ ~ ~.~~ ,~ .,~ ~~., . .. ~...k~_ - - - -- - - - - - - ... ~.. Y..~~ ~ v.vv Copyright (c) 2002 form software only The Lackner Group, Inc. Form ~A-'1500 Schedule J (Rev. 6-98)