The URL can be used to link to this page

Home My WebLink About11-05-09 (2) 1505607121 06 05 RED'-1500 EX ( - ) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 County Code Year File Number Harrisbum, PA 17128-0601 RESIDENT DECEDENT 2 1 0 9 0 0 6 4 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 8 5 0 1 0 3 3 8 0 1 1 0 2 0 0 9 1 1 1 6 1 9 1 3 Decedent's Last Name Suffix Decedent's First Name MI K E E S E MA N MI L D R E D S (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 ^X 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) QX 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of V1Vill) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death hotwcan 17_44_O~ ~nrl ~_~_~~~ ~ 11. Election to tax under Sec. 9113(A) inu....~, c~,.~. n~ CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number H ANTHONY A DAMS Firm Name (If Applicable) `~ :~x:: REGIST ~!(VILLS U ~" ;_`~ ~ `-`~ ~ ~ ~C ~ ~ ~ ' ~ ~~ First line of address + _ ~• -, ~~ r-~ ~ ~ ~ Ut ~ . -T,, - - 4 9 WEST ORAN GE STRE ET Second line of address ~-~ ~ -~r-ti ~ - ~: -- ~ ~ ~ SUI TE 3 tJ ~ ~ _.~ ~ r ~ "S 1 ~ ~.., -:. ; City or Post Office State ZIP Code D~rE FILED ~ , .~ ~ S H I P P E hJ S B UR G P A 1 7 2 5 7 Correspondent's a-mail address: htadamSlaW@ embargmall.COm SIGNA U O T ENTATIVE DATE ADDRE S ~ P SE USE OR INAL FORM Side 1 1505607121 1505607121 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, :~ :w M ~~. wwwwi.{ wwa ....«.wlw~w I'lwwtw.wtiww wt wmww.... wN,w. •I,ww •L.w ww.wwwwl ...w.,.wwwawa...w :w Lwww.1 ww wu :..iw....wa:......i ...L:_L .-w__~- L.- _.-.. 1._....1_J__ _ _ _ r- 1505607221 REV-1500 EX Decedents Name: MILDRED S. KEESEMAN Decedent's Social Security Number 1 8 5 0 1 0 3 3 8 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. 1 6 0 3 3. 6 3 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. • 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ....... 7. 8. Total Gross Assets (total Lines 1-7) ........................... 8. 1 6 0 3 3, 6 3 9. Funeral Expenses 8~ Administrative Costs (Schedule H) ................ 9. 8 6 3 . 0 0 10. Debts of Decedent, Mort a e Liabilities, & Liens Schedule I 9 9 ( ) ............ 10. 4 3 2 3 . 3 9 11. Total Deductions (total Lines 9 & 10) ........................... 11. 5 1 8 6. 3 9 12. Net Value of Estate (Line 8 minus Line 11) ......................... 12. 1 0 8 4 7 . 2 4 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. 1 0 8 4 7 • 2 4 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 .0 0 0 0 15. 16. Amount of Line 14 taxable t li l t X ~ 0 0 0 nea ra a e • __ 16. 17. Amount of Line 14 t~+xable 0 0 0 at sibling rate X .12 17. 18. Amount of Line 14 taxable 1 0 8 4 7 2 4 at collateral rate x. ~~5 . 18. 19. Tax Due .............. ........................... ..... ..19. 20. FILL IN THE OVAL fF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 0. 0 0 0. 0 0 0. 0 0 1 6 2 7. 0 9 1 6 2 7. 0 9 Side 2 1505607221 1505607221 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 09 0064 DECEDENT'S NAME MILDRED S. KEESE_MAN STREET ADDRESS ----_- 210 BIG SPRING ROAD CITY NEWVILLE STATE PA ZIP 17241 Tax Payments and Credits: ~ • Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 1,627.09 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. 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. 0.00 (3) 0.00 (4) 0.00 (5) 1,627.09 (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 1,627.09 Make Check Payable fo: REGISTER OF WILLS, AGENT PLEASE ANSWER 'SHE 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 : ...................................................................... ^ Q b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q c. retain a reversionary interest; or ................................................................................................ ^ d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ Q 3. Did decedent own~an "intrust for" or payable upon death bank account or security at his or her death? ......... ^ Q 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................. ^ 0 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 Juty 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 1,1.995, 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)j. 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 + {6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER MILDRED S. KEESEMAN 21 09 0064 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF' DEATH 1. CHECKING ACCOUNT # 15,068.10 M&T BANK 2. CASH 900.00 3. REFUND FROM HEALTH MANAGEMENT ASSOCIATES 65.53 TOTAL (Also enter on line 5, Recapitulation) ~ ~ 16,033.63 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MILDRED S. KEESEMAN FILE NUMBER 21 09 0064 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A, FUNERAL EXPENSES: 1. B. 1 2 3. 4. 5. 6. 7. SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS City State Zip Relations yip of Claimant to Decedent ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Street Address City State Year(s) Commission Paid: Attorney Fees Family Exemption: (!f decedent's address is not the same as claimants, attach explanation) Claimant Street Address Probate Fees Aax?untant's Fees Tax Return Preparer's Fees Zip 750.00 113.00 TOTAL (Also enter on line 9, Recapitulation) ~ ~ 863. (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE 1 DEBTS OF DECECENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER MILDRED S. KEESEMAN 21 09 0064 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. GREEN RIDGE VILLAGE 1,002.93 2. CARLISLE HMA PHYSICIANS MANAGMENT 318.38 3. CARLISLE REGIONAL MEDLCAL CENTER 1,024.00 4. BLUE MOUNTAIN ANESTHESIA 40.17 5. KINETIC IMAGI,iiG 405.59 6. MILLENNIUM PHARMACY EAST 36.00 7. CARLISLE MEDICAL PATHOLOGY 54.66 8. NEWVILLE COMMUNITY AMBULANCE 98.13 9. ALEXANDER SPRING EMERGENCY PHY 31.97 10. NEPHROLOGY ASSOCIATES 72 gg 11. CU NEPHROLCIGY ASSOCIATES 51.88 12. BARRY K. GUISTWITE 58.96 13. GRAHAM MEDLCAL CLINIC 192.77 14. MOFFITT HEART & VASCULAR 222.28 15. CARLISLE DIGESTIVE DISEASE ASSOCIATES 121.91 TOTAL (Also enter on line 10, Recapitulation) 13 4,323.39 (If more space is needed, insert additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent MiLDRED S. KEESEMAN 21 09 0064 Decedent's Name Page 1 File Number Schedule 1-Debts of Decedent, Mortgage Liabilities, & Liens ITEM NUMBER DESCRIPTION AMOUNT 16. MOHAMMAD ISMAIL 245.91 17. BRYANT GENERAL SURGERY 249.41 18. CUMBERLAND GOODWILL FIRE & RESCUE 66.38 19. CURRIE & HECHT 29.06 SUBTOTAL SCHEDULE I 590.76 GRAND TOTAL SCHEDULE I ~ 4,323.39 REV-1513 EX + (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVARIIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MII t~RFI~ S KFF~FMAN ~~ ~., ~.,~. 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 [indude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2JJ 1. JANET OMMERT Collateral 1,844.03 P.O.BOX 14 NEWBURG, PA 17240 2. JAY SHUMAN Collateral 922.01 151 TURNPIKE ROAD NEWBURG, PA 17240 3. PHILIP SHUMAN Collateral 922.01 120 H ILLTOP R OAD NEWBURG, PA 17240 4. THOMAS ARCHAMBEAU Collateral 461.00 068 BLUE JAY CIRCLE ORRSTOWN, PA 17244 5. LEO ARCHAMBEAU Collateral 461.00 310 EAST ORANGE STREET SHIPPENSBURG, PA 17257 6. LISA LEMMING Collateral 461.00 2199 ORRSTOWN ROAD SHIPPENSBURG, PA 17257 7. BERTIE MILLER Collateral 461.00 65 NORTHCREST tORIVE YORK HAVEN, PA 17370 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBl1TlONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTfON TO TAX IS NOT BEING MADE 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) Continuation of REV-1500 Inheritance Tax Return Resident Decedent .• MILDRED S. KEESEMAN 21 09 0064 Decedent's Name Page 2 File Number Schedule J -Beneficiaries -1 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS (include outright spousal distributions) 8. STEVEN SHUMAN Collateral 461.00 2537 FRIENDSHIP'CHURCH ROAD GRAY COURT, S.C. 29645 9. NANCY DAVEY Collateral 461.00 703 CHARLES STREET MECHANICSBURG, PA 17055 10. JOYCE O'HANELY Collateral 461.00 780 EBENEZER CHURCH ROAD GOLDSBORO, NC 27530 11. DIANE KOCH Collateral 461.00 6624 JONESTOWN ROAD HARRISBURG, Pa 17112 12. WAYNE STOUFFER Collateral 922.01 7588 ROXBURY ROAD SHIPPENSBURG, PA 17257 13. GENEVIEVE DONNELLY Collateral 922.01 107 WARREN STREET WALTERBORO, SC 29488