HomeMy WebLinkAbout12-22-09' ~ REV-1500 EX (D5-D4)
PA Department of Revenue
Bureau of Individual Taxes
Dept. 280601
Hartisburg, PA 17128-0601
15056041046
INHERITANCE TAX RETURN county Code Year File Number
RESIDENT DECEDENT j n
Date of Birth
~ ~ ®~ Y ~ ~
Decedents First Name MI
,act e m
Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Odginal Retum O 2. Supplemental Retum
O 3. Remainder Return (tlate of death
O 4. Limited Estate pdor to 12-13-82)
O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Requiretl
death after 12-12-62)
O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ,
(Attach Copy of Will) _ 8. Total Number of Safe Deposit Bozes
(Attach Copy of Trust)
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 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 INFOR
Name MATION SHOULD BE DIRECTED TO:
~
. ~~
D A v IQ c 6 '~
~ Daytime Telephone Number ~°
7 f 7.
s
~
n
~~~
Finn Name (If Applicable) - ''" "" °"` a
Y o~ 5 5 33
First line of address
Second line of address
City or Post Office ~---._ -~n...,.~..
c ~ s ~ e ~m
Correspondent's e-mail address:
Under penalties of perjury, I declare that I have examined this return, it
it is true, correct and complete. DaGaration of preparer other than me
OF PERS/O~N RESPONSIBLE FOR
~. Q ~
SIGNATURE OF PREPARER OTHER
tia~7a~
State ZIP Code
REGISTE~F WILLS US~NLY
O .o -
~~n n -
m `~
l7 IV :. i'
~L~ ~.
~ 70. ~;
;
>
JS -
-Y._7
1'DATE FILED r- _~~
I'rl
.~ .,,
P IF , l 7- a t 3 R
.. euo~es ana srarements, and tome best of my knowledge
is based on all information of which preparer has any knrn
DATE
~a-as-
DATE
~'
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056041046 15056[741[]46
J~~
J
REV-1500 EX
RECAPITULATION
Social
1. Real estate (Schedule A) ............................................. 1, r
2. Stocks and Bonds (Schedule B) ........... ............................ 2,
3. Closely Held Corporation, Partnership or Sole-Propdetprship (Schedule 0) ..... 3.
4. Mortgages $ Notes Receivable (Schedule D) ............... q.
5. Cash, Bank Deposits $ Miscellaneous Personal Property (Schedule E) ........ 5. - O D
6. Jointly Owned Property (Schedule F) ®Separate Billing Requested ....... 6.
7
Infer-VIVO
T
f
$ S TJ ~
.
S
rans
ers
Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7.
8. Total Gross Assets (total Lines 1-7) ............................... .
9. Funeral Expenses $ Administrative Costs (Schedule H).......... ,. . , g, 7 6 y ci O O
10. Debts of Decedent, Mortgage Liabilities, $ Liens (Schedule I) ................ 10.
11. Total Deductions (total Lines 9 $ 10) ................................... 11. 7 0 ~( O (~ a
12. Net Value of Estate (Line 8 minus Line 11) .............................. 12.
13. Charitable and Governm
nt
l B
e
a
equests/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.
TeY eniuor rrwr~nu W J' ~ " ' ~ b O'
- ~••-•- -.-~......,...v nv~w rvrc Arrul.ACLE IiArES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 "!"~"iY11°"'!'°°"P'°" ~r°°~'
/16. Amount of Line 14 taxa le
at lineal rate X .0~ '~ D O l O b ~
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
15056042047
15.
16.
17.
18.
/19. TAX DUE ......................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
O
Side 2
15056042047 15056042047 J
REV-1500 EX Page 3
Decedent's Complete Address:
Fits Number
DECE ENT'S NAME
/2Rc e L w1 , oY ~~2
STREET ADDRESS -
u6 /f eiSltmlrn~ 44N• Dv't U~
CR ut>,~ ~ (~ lop l-(o t3
CITY STATE ZIP
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. InteresVPenalty if applicable
D. Interest
E. Penalty
(i)
TotalCredits(A+B+C) (2)
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.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3)
(4)
(5)
(5A)
(5B)
22So.oo
2Ztio.oo
Make Check Payable to: REGISTER OF WILLS, AGENT
t
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a Vansier 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 :............................................ ^
c. retain a reversionary interest; or .......................................................................................................................... ^
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? .............................................................................................................. ^
3. Did decedent own an "intrust 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?
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN
REV-1502 EX+ (8-98)
SCNEDYLE A
COMMONWEALTH OF PENNSYLVANIA REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE
All real property owned solely or as a tenant In common must W reported at talr market value. Fair marker val„n .a ,lar„e,r s~
p, ,,,~,o ayaw ,a neeuw, InSBn a001[IOnal SnBBIB Ot the Same eize)
REV-1508 Ex.llsn
SCHEDULE E p ~+
CDMMDNWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MSC.
INHRESIDENT DECEDENT RN PERSONAL PROPERTY
ESTATE OF
R A C H'!~ [ ~- »~ O ,y ~ F2 FILE NUMBER
I'dude the proceeds of litlgadon and the date the pra~eds were receNed by the estate. All property Jointlyovmed vAM the right of survivorship must be dlsebsed on Schedub F.
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
' f3F}N it ~G~ Q~.Vr-' nn ee'+.(~~'r ~ l
,~ ~; 0 a
s°~irt~r Davvo s'7 60 4
TOTAL (Also enter on line 5 Recapitulation) I S ~ 5' O r"~
(If more space Is needed, Insert addlhonal sheets of the same size)
ntv.,we ex.nen
SCHEDULE F
' COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN -
RESIDENT DECEDENT
ESTATE OF
(L iF C !'h/~ Q L Ir . O `/ LC ~ FILE NUMBER
If an assts was made joint wehin ons year of the decedent's data of death, K must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME y~DDRESs
_ RELATIONSHIP TO DECEDENT
A. pA~ ~ D C. u~i LE(L
Igor 1-FetsgrxPr,v Ct00t $orJ
tA21~h~~ PiF ~ l`1or3
B.
C.
JOINTLY-0WNED PROPERTY:
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PRDPERTY
InChrtle nano o/flnalcial irlstigdon and trenk axant numherar 6impa idaltltyinp number. Aaach
dead (aldntly-held reel esteb
DATE OF DEATH
VALUE OF ASSET %OF
DECD'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
1. A. fJN (JLE ~I- Tt~rta_ 13 ae~V`DD M ~1 7
U~f ..J~ C ^y,
/3 M
J v ~~
TOTAL (Also enter on line 6 Recapitulation) I S 50 S y s 0 0
(If more space Is needed, inseA additional sheets of the same size)
REV-1511 EX+(10-08)
SC
HEDULE M
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN
RESIDENT DECEDENT ADMINISTRATIVE COSTS
ESTATE OF
-„ FILE
Debts of decedent must be reported on Schedule L
ITEM
DUMBER DESCRIPTION
A. FUNERAL EXPENSES.
1.
~vyD, od
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Sheet Address
City Shte Zip
Year(s) Commission Paid:
2~ Attorney Fees
S. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
B. Tax Retum Preparer's Fees
7.
TOTAL (Also enter on line 9 Recapitulation) I$ 7 0 y D O O
(If more space Is needed, Insert atlditional sheets of the same size)
__ _ ___.
PAYABLE TO
FAN K. SOLLENBERGER, TAX COLL
5 HILL DRIVE (717)24&0747
CARLISLE, Pq 17013 Aaeeaee
values
oEacfllPnon
AS~
ryO
2 Homestead
CI1Rl~I8l.EA
,
•
9003140 Rates
MAP NO: 29-17-1586-208 BCHOOL R/8
HwBeetead I
1808 HEISHMAN GARDEN DRIVE
ACRES .160 DEED 0028R/00030
HEISHAN GARDENS
LOT 3 PB 38 PO 70
Residen881 BulWing
RESIDENTIAL
TA%PAVEfl
Yb LER, RACHAEL M & DAVID C
1808 HEISHMAN GARDEN DRIVE
CARLISLE PA 17013
OFFICENWfl3
FfAI~APFf-JUL-AUG TOES 10.4 & THUR
10-6; MAYJUN-SEP-OCT THURS 10-6
APPT23NLY JAN-FEB-NOV-DEC
CALL FOR HOURS LAST WEEK OF DISC
TAX PAYER COPY &II No: 2W~
„~~ ~ s__, ___ _ _ _ Control No: 029. 003140 '
25,000 61,370 0 rocai
:luaion 86,370
B.D. 9 75!
13.80000 13 _80000 13.80000 ~~ Fap
TAX AMOUNT DUE ~---> ~,g»,BB I ~~~ ~^~~
I! Pa1d On or Albr 7i0v Anna o nom,,.., -~--m
CLN TM PIBUREAU t~R COLLECTION ANLLD FlI.B~OI~A LIEN A(iA1N6T
T'O YOUR~MOR'POIAQ YC~Ot1~APA~E I=7.W FEAOWE FOp~~ OPIEB.
Your enclosed tax bill io ludes aFtax r~ucRion for~youEhomeatead and/or farmstead
Property, As an eligible homestead and/or farmstead property owner, you have received
tax relief through a homestead and/or tartnstead exclusion which has been provided
under the Pennsylvania Taxpayer Relief Act, a law passed by the Pennsylvania General
Assembly designed to reduce your properly taxes.
_,.___ _.. __._----__-__-. I
Hollinger Funeral Home & Crematory, Inc.
Eric L. Hollinger, Supervisor
501 North Baltimore Avenue
Mount Holly Springs, Pennsylvania 17065
STATEMENT OF FUNERAL: GOADS AND SERVICES SELECTED
Charges are only for those items that you selected or that are required. If we are required by law or by a~cemetery or crematory to use any items, we will
explain the reason in writing below.
If you selected a funeral that may require embalming, such as a funeral viewing, you may have to pay for embalming. You do not have to pay for embalm-
ing you did not approve selected arran~emer~uch as direct cremation or immediate burial. If we charged for embalming, we will explain why below.
For the Service of
A. CHARGE POE SERVICES SELECTED:
1. PROFESSIONAL SERVICES
Services of Funeral Dvector/Staff ...... $ /
Embalming .....................$ /
Qther prepamtlon of ~}'
r ~di r~~iiytl, f1+1'~PSS/.1X~ C~~,y ~l,'~r.rjr~..
9UB•TOTAL OF PROFESSIONAL SERVICES ..........Al S
2. FACILITiPS AND SERVICES
Use of facgitl services for
view' isitati e) ......... $ ~/'~
Use of fact 'es'a'n services~~// ~/
f
P
for funeml ceremony . H:'
l7... $~L
Use of facilities and servitts for
Memorial Servitt ............... $
Useof equipment and s
e
rvices
~
L
~~ //
for
raveside service!`~
r~
' ~ ~r
$
g
.
V.
~ J.G-
Other use of facilities /
.............................. 5
SUB-TOTAL OF FACH.1'I'1E5/EQU~MMEN7' . ....... ..A2 $
3. AUTOMOTIVE EQUIPMENT
Vehicle to transfer remains to Funeral Home
Local ......................... $- i~
Hearse (Casket Coach)
Local ......................... $_j„L
Limousine
Local ................... ...... $
Family car
Local ................ ......... $
Plower car or Floml disposition `
Local ......................... 5
Lead car/clergy car
Local ......................... $ L
Caz for pallbearers
Local ......................... $
Out of town [mnsportation .......... $
$
3UB-TOTAL OF AUTOMOTIVE EQUIItMENT ....... ..A3 $
TOTAL OP PROFESSIONAL SERVICES,
PACR17'IE,S AND AUTOMOTIVE
EQUIPMENT .....................
........... ~~ ~,.r~
...A Ss3Ga7d
B. CHARGE i~6 MERCHANDLSE SELECTED:
`
e
Casket/..•f/lAR
?il/ii . .............. ~~~C~
^^
$~!w'r
s
~
(Description)L~~I.S>xPE'l : ./.~ LIa~Nd ~`h',~4xr.t
I~nchr~~1~v L~.TC ./P®y
r 7-1fc'9ie`+.~
Other Receptacle ....... ..... ~
... $
(Description)
Outer burial contain 6!"Fr~iN!~ , , $
(D~/eTs$~r.iption) ~(ln/rS,If'/~C' ~Ni
~1~1 +(~d
fY
'~ .6.~A'°epd
.KCB
.+
t
Acknowledgement rds .....
'
~ $ r/'
Register book(s)/
tE1YA'.,~.~y
.AO~ $ /'
Memory folders .................. $ ~~
Pmyer cards .................... $
Temporary grave mazker ............ $
Burial cloRting ............ ...... $
Date
City
Other do[hing
Cremation urn ................... S
(llescnptlon)
OTHER $
S ~ y r~~
TOTAL MEECHANDISE SELECTED ....... .........B S.~'2d
C. SPECLAL CHARGES:
Forwarding of remains [o
$
(Funeral Home)
Receiving of remains from
(PLneral Home)
Immediate Burial ............ ..... $
Dvect Cremation ............. .....$
$
SUB-TOTAL OP SPECLIL CHAEGES ................C $
D. CASH ADVANCED
Opening Grave ................. . $
Cemetery Equipment
............. $~
.
Lo[ and Deed .... ~.....
~
' $ ~~r
~
Newspaper Notices-Loca$,,,~.
?Cl
.. . $
Newspaper Nodces-0u4of-town ..... . $
Telephone & Telegrams ...... ... . $
Airfare ,
Clergy/Mass Offedng .?r.~. , ~~ . , $
. $~
Pallbearers ..... ... ~y¢/
Certified Copies of the DeaRiU^ ~.(?Li, $
. $~
Certificate ..................... . $
Police Es/co7rt ('~,
lowers l"~.Jt~~G ~+-?f~~a'/~...
. $_~a
Vaut[ Service Charge ... A .......... . $
e! $
n CF's $
v
SUB-TOTAL OF ADVANCES .......................D $ .~7w7 D
We charge you for our services in obtaining:
(spedfy utsb advances that ore raarkerdtrp)
SUMMARY OP CHARGES
A. Professional Services, Facilities and
Equipment, and Automotive
Equipment .......... .........
$ d
B. Merchandise
C. Special Charges ..... ...........
D
Cash Advances . $
$~
.
.................
TOTAL OP ALL SECTIONS ....... .
.............. ~
.. $~ .'
PAID AT TENE OF OR PRIOR TO
ARRANGEMENTS .............. .............. .. $
.BALANCE DUE ................ .............. .. S
N FOR G
If any law, ce emry, or crematory requvements have requved the purchase
of any of the items hs bove, the law or requvement, isexplained ~ow.
I agree that I have examined the items of goads and services selected above and found them to be cortec[ and according ro Rte arrangements I have requested. I aclmowledge
receipt of a mpy of this Statement of Puneml Goods and Services Selected. I represent that I have sufficiem funds available for payment of the rash price for the goodsl'
and services selected. I ako agree to a payment of $ within <. ~Cl days. I agree to be jointly and severally liable with ~r~yone else who
signs below. A late charge of per month amounting [o .6~7 ~ per year will be applied [o the unpaid balance beginning ,_ti3~ days
from the date of this agreement I will also pay [o the Funeral Dveaor all reasonable costs paid by the Funeral Duector to collect amounts I owe under [kris agreement.
Those costs may include attorneys' fees, coon costs and other costs. Any additional services or merchandise ordered or requested after the date of this agreement will
be considered part of [ R agtremem ~a(n'd the cost thereof will be reBected on the fmal bill or statement.
(Seal) /ll U---rT ~ (y'. -"'~ y.• ~ .. ~~.
(Pure a) ~ fDa[e
(Purchaser) 'censed Funeral D' d
O Pw~syMnu Funml Diecao~a Aswcuam, Punml Dlrtcta YEn.OW Pw~wl DUx[rn PINK Glutomer
form -600 Revised 1/04