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Home My WebLink About12-31-091505607121 REV-1500 EX (06-05) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po sox 280601 INHERITANCE TAX RETURN 2 1 0 9 0 3 7 4 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 9 5 3 8 9 2 1 9 0 3 1 3 2 0 0 9 0 8 1 7 1 9 5 0 Decedent's Last Name FOSTER Suffix Decedent's First Name DOROTHY (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number MI A MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW O 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) ^X 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 MARK A MATEYA ESQ 71 7 241 6500 Firm Name (If Applicable) MATEYA LAW F I R M First line of address P O BOX Second line of address 1 2 7 City or Post Office B O I L t N G S P R I N G S r REGISTER ~VYI SUSLL E f~dY -~-', - a .- ~ I.,~Tn ~ ~ j a s,~ 1 n~ -- '-:~ ~ O -Z7 ` ~~'~ c3,. ~ i ;-, ~ i ~ ''` ~~ iTE FILED State ZIP Code ~- -- - - -~yr~ h C:~ .rG` ' r~ P A 1 7 0 0 7 Correspondent's a-mail address: MAMt'c~MATEYALAW.COM Under penalties of perjury, I declare that I have examined this return, including aarompanying 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. SIGNATURE Ot=~ERSONibESPONS181E FOR FILING RETURN nerG ADDRESS ' ' 420 3RD STREET ENOLA PA 17025 SIGNATURE OF PREPA ER THEJ ~TR~ H~Py~-J REPRESENTATIVE DATE /~ Q~ J~ I~e1i. r 'Z I '-a P.O. BOX 127 BOILING SPRINGS PA 17007 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505607121 1505607121 ~`11 1505607221 REV-1500 EX Decedent's Social Security Number Decedents Name: DQROTHY A. FOSTER 1 9 5 3 8 9 2 1 9 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. 1 1 9 6 7 ~ 1 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ..... .. 5. . 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. 1 1 9 6 7, 0 1 9. Funeral Expenses & Administrative Costs (Schedule H) ......... ..... .. 9. 1 1 7 2 4. 6 6 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ..... ..... .. 10. 2 3 1 ~ • 4 5 11. Total Deductions (total Lines 9 & 10) .................... ..... .. 11. 1 4 0 3 5. 1 1 12. Net Value of Estate (Line 8 minus Line 11) .................. ..... .. 12. - 2 ~ 6 8 . 1 0 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 ~ 6 8 • 1 0 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 _ ~ ~ O 15. 0. 0 16. Amount of Line 14 taxable 0 ~ ~ 0 ~ 0 _ at lineal rate X . 1g • 17. Amount of Line 14 taxable Q ~ ~ ~ at sibling rate X .12 17. . 18. Amount of Line 14 taxable ~ ~ ~ ~ 0 at collateral rate X .15 18 • 19. Tax Due .......................................... .... ..19. ~ . 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^ Side 2 1505607221 1505607221 J REV-1500 EX Page 3 Qecede~nt's Complete Address: File Number 21 09 0374 DECEDENT'S NAME DOROTHY A. FOSTER _ _ _ _ STREET ADDRESS 420 3RD STREET _- - - CITY ,STATE i ZIP ENOLA ' PA ~, 17025 Tax Payments and Credits: ~• Tax Due (Page 2 Line 19) (1) 0.00 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + g + C) (2) 0.00 3. InteresUPenalty if applicable D. Interest E. Penalty Total InteresUPenalty (D + E) (3) 0.00 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. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 0.00 Make Check Payable fo: 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; ............................... ^ 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? ....................................................................................... 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? .................................................................................................. ^ 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 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 childtwenty-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 CASH BANK DEPOSITS & MISC. COMMONWEALTH OF PENNSYLVANIA , , INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER DOROTHY A. FOSTER 21 09 0374 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. MEMBERS 1ST FEDERAL CREDIT UNION 31.33 SAVINGS ACCOUNT NO. 328484-00 2. MEMBERS 1ST FEDERAL CREDIT UNION 3,599.81 CHECKING ACCOUNT NO. 328484-11 3. MEMBERS 1ST FEDERAL CREDIT UNION 3.34 INVESTMENT SAVINGS ACCOUNT NO. 328484-05 4. MEMBERS 1ST FEDERAL CREDIT UNION 25.93 VISA ACCOUNT NO. XXX)UUUCXXX)U(4848 5. PURITY ABSTRACT CO. 316.30 BALANCE OF ESCROW FOR SEPTIC REPAIR FROM SALE OF HOME ON 2/2/09 6. U.S. TREASURY 2,137.00 2008 INCOME TAX REFUND 7. PROGRESSIVE INSURANCE 26.00 REFUND OF INSURANCE PREMIUM POLICY NO. 57096327-7 8 SATURN VUE AUTOMOBILE 4,500.00 YEAR - 2002 KELLY BLUE BOOK VALUE -PRIVATE PARTY 9. PERSONAUHOUSEHOLD ITEMS 1,000.00 10. LIBERTY MUTUAL 293.00 REFUND FOR CANCELLATION OF INSURANCE POLICY NO. H32-281-173638-609 CHECK NO. 05315738 11. PRUDENTIAL 34.30 DIVIDEND ON ACCOUNT NO. 00018673053 TOTAL (Also enter on line 5, Recapitulation) ~ ~ ~ ~ aa~ n~ (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES Br INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF - FILE NUMBER DOROTHY A. FOSTER 21 09 0374 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOFFMAN ROTH FUNERAL HOME 10,319.88 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Street Address City State Zip Year(s) Commission Paid: 2, AttomeyFees MATEYA LAW FIRM 1,000.00 3, Family Exemption: (If decedents 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 91.00 5 Accountant's Fees 6. Tax Retum Preparers Fees 7. CUMBERLAND LAW JOURNAL -LEGAL ADVERTISEMENT 75.00 8. THE SENTINEL -LEGAL ADVERTISMENT 208.78 9. CUMBERLAND CO. REGISTER OF WILLS -FILING FEE INH. TAX & INVENTORY 30.00 TOTAL (Also enter on line 9, Recapitulation) I E 11, 724.66 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER DOROTHY A. FOSTER 21 09 0374 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbwrsed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. CHASE CARDMEMBER SERVICES 112.59 CREDIT CARD ACCOUNT NO. XXXX XXXX XXXX 3851 2. PULMONARY & CRITICAL CARE MEDICINE ASSOCIATES P.C. 415.00 MEDICAL SERVICES ACCOUNT NO. 14279 3. CARLISLE DIGESTIVE DISEASE ASSOCIATES LTD 65.00 MEDICAL SERVICES 4. CARLISLE MEDICAL PATHOLOGY PC 235.00 MEDICAL SERVICES ACCOUNT NO. a267-0008407-01 5. CARLISLE REGIONAL MEDICAL CENTER 1,346.79 MEDICAL SERVICES ACCOUNT NO. 9422523 6. BLUE MOUNTAIN ANESTHESIA ASSOC. 136.07 MEDICAL SERVICES ACCOUNT NO. 12007-G 7. TOTAL (Also enter on line 10, Recapitulation) I S (If more space is needed, insert additional sheets of the same size) REV-1513 EX + (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER DOROTH Y A. FOSTER 21 09 0374 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustees) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. KATHERINE RIFE Lineal 420 3RD STREET ENOLA, PA 17025 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 $ (If more space is needed, insert additional sheets of the same size)