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Home My WebLink About11-10-09 (3)-~ 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 BOX.280601 21 0 9 0 1 7 6 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 229205531 02092009 10241925 Decedent's Last Name Suffix Decedent's First Name MI SAMPLE BEVERLY (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 ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required (date of death after 12-12-82) ® g Decedent Died Testate (Attach Copy of Will) ^ ~ Decedent Maintained a Living Trust (Attach Copy of Trust) 8. Total Number of Safe De osi p t BOXes ^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 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 Name : Daytime Telephone Number JEAN D SEIBERT 7172369301 Firm Name (If Applicable) WION, ZULLI AND SEIBERT First line of address 109 LOCUST STREET Second line of address City or Post Office HARRISBURG State ZIP Code PA 17101 Correspondent's a-mail address: w z s@ m i n d s p r i n g. c o m REGISTER LS USE ~LY -~ ~ ~. .~ ~~ __._ . ., e. , _, f i ~, r T t ,L ~+» 1..".,. ~ ...... ~ r ~...r' C`j C'y ~'--~ ~ -~"'1 c ~ _. ~..; /y.-. l-..+ ~ ~ ! ~ ~ f .. . ~~_~ ~~ :; .~ ...;, .~ ~. ;~, "C' T c ~ a ,;;,.f unaer 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. ®eclaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ~~/,t~,-~~nJ ~'~ ~~~i~:~~, ~XE~ _ Janie A. Jackson ; . fir; /_ ADDRESS U (~ / 6631 Conway Road, Harrisburg, PA 17111 JICiNA I UKE REPARER OTHER AN REPRESENTATIVE DATE Jean D Seibert ~, , ADDRESS 109 Locust Street, Harrisburg, PA 17101 d~ Lsos6n~lzo Side 1 Lsos6o712o J J 1505607220 REV-1500 EX Decedent's Social Security Number Decedent's Name: SAMPLE , BEVERLY 2 2 9 2 0 5 5 31 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 8~ Miscellaneous Personal Property (Schedule E) ................ 5. 6 3 , 915.18 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. 6 3 , 915.18 9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 5 , 8 0 0 . 7 8 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10. 4 , 2 0 4 . 6 7 11. Total Deductions (total Lines 9 & 10) ...................................................................... 11. 1 0 , 0 0 5 . 4 5 12. Net Value of Estate (Line 8 minus Line 11) ............................................................. 12. 5 3 , 9 0 9 . 7 3 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. 5 3 , 9 0 9 . 7 3 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 at lineal rate x .045 8, 6 7 6. 9 5 1s. 3 9 0. 4 6 17. Amount of Line 14 taxable at sibling rate X ,12 17. 18. Amount of Line 14 taxable at collateral rate x .15 4 5, 2 3 2. 7 8 18. 6, 7 8 4. 9 2 19. Tax Due ..................................................................................................................... 19. 7 , 17 5 . 3 8 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 21 - 09 - 0176 D N NAME Sample, Beverly STREET ADDRESS 12 Marshal Drive I-6 CITY Camp Hill STATE PA ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 7,175.38 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments 7 , 0 0 0.0 0 C. Discount 358.77 3. Total Credits (A + B + C) Interest/Penalty if applicable (2) 7,358.77 p. Interest E. Penalty Total Interest/Penalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) 18 3.3 9 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) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) ~ . ~ ~ Make Check Payable to: REGISTER OF WILLS, AGENT .. ~_ •" "1' g..t .. f-/,y .,sf n ° . PLEASE ANSWER THE 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 :.................................................................................. ^ b. retain the right to designate who shall use the property transferred or its income :.................................... ^ a 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?......... ^ 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 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)]. 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. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER ESTATE OF Samp{e, Beverly 21 - 09 - 0176 Include the proceeds of litigation and the date the proceeds were received by the estate. AI{ property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM DESCRIPTION VALUE AT DATE OF DEATH NUMBER 1 M&T Bank Checking Account No. 9838681964 22,989.02 Accrued Interest 0.71 2 M&T Bank Certificate of Deposit No. 31003917029538 27,023.24 Accrued Interest 445.45 3 Toyota 10, 525.00 4 Rings 130.00 5 Income Tax Refund 1,007.00 6 Federal Retirement Pension 670.70 7 Comcast Refund 16.41 8 Rent Refund 441.00 9 Debt owed to estate for rent paid by decedent's estate for Beneficiary, Benjamin F. Jackson 666.65 after lease for decedent had ended. TOTAL (Also enter on Line 5, Recapitulation) ~ 63,915.18 SCF~DIJI~ H FUNERAL DCPEI~ES & COMMONWEALTH OF PENNSYLVANIA ~~~ INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF Sample, Beverly 21 - 09 - 0176 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER FUNERAL EXPENSES: A. 1 Hooper Memorial 329.00 B. I 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 4,375.00 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 Register of Wills 204.00 Register of Wills 40.00 Register of Wills 8.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1 Cumberland Law Journal -advertising 75.00 TOTAL (Also enter on line 9, Recapitulation) 5,800.78 Schedule H Funeral E & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ~ .n~~N ~~ I~IIQIIYG RESIDENT DECEDENT FILE NUMBER ESTATE OF Sample, Beverly 21 - 09 - 0176 2 The Sentinel -advertising 208.78 3 Appraisal for rings 5.00 4 Travelers Auto Insurance 220.00 5 Penn Dot -Registration 36.00 6 Travelers Auto Insurance 225.00 7 Reserve for postage, copies, etc. 75.00 Page 2 of Schedule H SCHEDULE I DEBTS OF DECEDENT, MORTGAGE COMMONWEALTH OF PENNSYLVANIA LIABILITIES, & LIENS INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF Sample, Beverly 21 - 09 - 0176 Include unreimbursed medical expenses. DESCRIPTION AMOUNT NUM ER 1 Outstanding checks from DOD balance $20.00, 17.28 and 24.00 61.28 2 Comcast 16.00 3 Oxygen 135.50 4 PPL 60.14 5 CAC -Ambulance 813.00 6 East Pennsboro Amublance Serivice 607.20 7 West Shore EMS 558.04 8 VGM Homelink 364.50 9 Verizon 57.61 10 Travelers Car Insurance 470.00 11 The Apartment Store -Rent March 441.00 12 James Hess, CPA -Income Tax Preparation 76.00 13 Pinnacle Health Hospitals 360.00 14 VGM Homelink 11.00 15 Debbie Lupold, TC -Personal Tax 4.90 16 VGM Homelink 135.50 TOTAL (Also enter on Line 10, Recapitulation) ~ 4,204.67 SCHEDULEI DEBTS OF DECEDENT, MORTGAGE COMMONWEALTH OF PENNSYLVANIA LIABILITIES & LIENS INHERITANCE TAX RETURN ~ RESIDENT DECEDENT continued ESTATE OF Sample, Beverly FILE NUMBER 21 -09-0176 Include unreimbursed medical expenses. ITEM DESCRIPTION NUMBER AMOUNT 17 Holy Spirit Hospital 33.00 Page 2 of Schedule I REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Sample, Beverly 21 - 09 - 0176 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY Do Not List Trustee(s) I TAXABLE DISTRIBUTIONS [include outright spousal ' distributions, and transfers under Sec. 9116 (a) (1.2)] 1 Diane Napier Niece 1/5th of Residue 335 Market Street, Apt. 1 E Harrisburg, PA 17101 2 Bernice Childs Niece 1/5th of Residue 4601 West Northern Parkway #308 Baltimore, MD 21215 3 Lucy M. Jones Niece 1/5th of Residue P.O. Box 17 Thornburg, VA 22565-0017 Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES continued INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Sample, Beverly 21 - 09 - 0176 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY Do Not Llst Trustee(s) I ' TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 4 Benjamin F. Jackson Grandson 1/5th of Residue 12 Marshall Drive, Apt.1-6 Camp Hill, PA 17011 5 Janie A. Jackson Sister-in-Law Automobi{e and 6631 Conway Road 1/5th of Residue Harrisburg, PA 17111 Page 2 of Schedu{e J