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Home My WebLink About12-28-09 1505607121 REV-1500 Ex (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number PO BOX 280601 2 1 0 9 1 0 3 2 Hanisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 3 1 8 2 4 2 4 3 5 0 9 2 9 2 0 0 9 0 6 1 1 1 9 2 8 Decedent's Last Name Suffix Decedent's First Name MI J A N T Z E N D E N N I S H (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. Limned Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (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) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number M U R R E L W A L T E R S I I I E S Q 7 1? ~9 7 ~ 5 0~ Firm Name (If Applicable) ~ REGISTEIi~j ILLS US LY ~ ' '_-j r, ; ; . . i_.' ~ rn First line of address N ~: yi i ri a ~- ~ 00 _7 . 5 4 E A S T M A I N S T R E E T :..~ . J , ;i1 1 - :- ~~ ~^'~ ~ - ~, ~ ,,~ Second line of address : "' ~ ~ -~i N City Or POSt Office State ZIP Code DATE FILED M E C H A N I C S B U R G P A 1 7 0 5 5 Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, including acxompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATU F PERSON SPO SIBLE FOR FILING RETURN DATE ~~~, ~ l.2 ~3-a 9 REBECCA J NT EC, 9 SHADY LANE MECHANICSBURG PA 17050 SIGNATURE F P EP ~TH THAN REPRESENTATNE / ~TE ~ ,~ d MURRE`L `WALTERS AST MAIN ST MECHANICSBURG PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505607121 PA 1505607121 J ~~ ,~ 1505607221 REV-1500 EX Decedent's Social Security Number Decedent's Name: D E N N I S H• J A N T Z E N 3 1 8 2 4 2 4 3 5 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) ........................ 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5. 1 0 3 4 1. 0 1 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 5 5 6 1 7. 8 2 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ....... 7. 8. Total Gross Assets (total Lines 1-7) ........................... 8. 6 5 9 5 8. 8 3 9. Funeral Expenses 8 Administrative Costs (Schedule H) ................ 9• 1 8 6 3. 0 0 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............ 10. 8 8 8 . $ 2 11. Total Deductions (total Lines 9 & 10) ........................... 11. 2 7 5 1. 5 2 12 Net Value of Estate (Line 8 minus Line 11) 12. 6 3 2 0 7. 3 1 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) ......... ......... .. .. .... .... ... 13. ... 14. 6 3 2 0 7. 3 1 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.o _ 0. 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .045 6 3 2 0 7. 3 1 16. 2 8 4 4. 3 3 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17, 0. 0 0 18. Amount of Line 14 taxable at collateral rate X .15 0. 0 0 18. 0. 0 0 19. Tax Due ............................ ........... .. .... 19. .. 2 8 4 4. 3 3 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505607221 1505607221 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 09 1032 DECEDENTS NAME DENNIS H. JANT2EN STREET ADDRESS 9 SHADY LANE CITY MECHANICSBURG STATE PA ZIP 17050 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 142.22 3. Interest/Penalty if applicable D. Interest E. Penalty 4. 5. 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. 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. (1) 2,844.33 Total Credits (A + B + C) (2) 142.22 Total InteresUPenalty (D +E) (3) 0.00 (4) 0.00 (5) 2,702.11 (5A) B. Enter the total of Line 5 +SA. This is the BALANCE DUE. (5B) 2,702.11 Make Check Payable to: REGISTER OF WILLS, AGENT 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 : ...................................................................... ^ ^X b. retain the right to designate who shall use the property transferred or its income; ............................... ^ ^ c. retain a reversionary interest; or ................................................................................................ ^ 0 d. receive the promise for life of either payments, benefits or care? ....................................................... ^ X^ 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? ......... ^ Q 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which 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 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 exemot 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-1508 EX + (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER OENNIS H. JANTZEN 21 09 1032 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. SOVEREIGN BANK 1,041.01 CERTIFICATE 2 2006 TOYOTA COROLLA 9,300.00 KELLEY BLUE BOOK GOOD CONDITION TOTAL (Also enter on line 5, Recapitulation) ~ $ 10,341.01 (If more space is needed, insert addi~onal sheets of the same size) REV-1509 EX + (6-9a) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF NUMBER DENNIS H. JANTZEN 21 09 1032 Han asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. ADDRESS RELATIONSHIP TO DECEDENT SURVIVING JOINT TENANT(S) NAME A. REBECCA A JANTZEN B C JOINTLY-OWNED PROPERTY: 9 SHADY LANE MECHANICSBURG, PA 17050 DAUGHTER ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. 611199 SOVEREIGN BANK 5,039.04 50. 2,519.52 CERTIFICATE 2 A 8115/07 PENTAGON FEDERAL CREDIT UNION 105.52 50. 52.76 SHARE ACCOUNT 3 A 8115107 PENTAGON FEDERAL CREDIT UNION 65,442.81 50. 32,721.41 CERTIFICATE 4 A 8115107 PENTAGON FEDERAL CREDIT UNION 20,272.46 50. 10,136.23 CERTIFICATE 5 A 6/1199 SOVEREIGN BANK 7,583.83 50. 3,791.92 CHECKING 6 A 611199 SOVEREIGN BANK 12,791.95 50. 6,395.98 SAVINGS TOTAL (Also enter on line 6, Recapitulation) S 55 617.82 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8~ INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER DENNIS H. JANTZEN 21 09 1032 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. PREPAID B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) REBECCA A JANTZEN (renounced) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees MURREL R. WALTERS III 1,575.00 3, Family Exemption: (If decedent's address is not the same as claimants, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees CUMBERLAND COUNTY REGISTER OF WILLS 263.00 5 AocountanYs Fees 6. Tax Return Preparers Fees 7. I CUMBERLAND COUNTY CORONER I 25.00 TOTAL (Also enter on line 9, Recapitulation) I S (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN 'ATE SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE DENNIS H. JANTZEN 21 09 1032 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 PENTAGON FEDERAL CREDIT UNION CREDIT CARD BALANCE TOTAL (Also enter on line 10, Recapitulation) I S 888.52 (If more space is needed, insert addfional sheets of the same size) REV-1513 EX + (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE DENNIS H . JANTZEN 21 09 1032 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. MARY D. PRESTRIDGE Lineal 2,585.25 16728 HIGHWAY 5 NAUVOO, AL 35578 2 D. JAMES JANTZEN Lineal 2,585.25 41 WEST JOHNSON LAKE ROAD GWINN, MI 49841 3 SUSAN E. MARTIN Lineal 2,585.25 1675 COUNTY LINE ROAD YORK SPRINGS, PA 17372 4 REBECCA A.JANTZEN Lineal 55,451.56 9 SHADY LANE MECHANICSBURG, PA 17050 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 1. 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET S (If more space is needed, insert additional sheets of the same size)