HomeMy WebLinkAbout01-06-10
1505607120
p
R~-1500
EX (06-OS) OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes county cme veer File Number
Po Box.zaosot INHERITANCE TAX RETURN
Harrisburg, PA t7128.060t RESIDENT DECEDENT 21 0 8 10 5 5
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
10 03 2008 06 24 1933
Decedent's Last Name Suffix Decedent's First Name MI
KELLEY JACK
F
(If Applicable) Enter Surviving Spouse's Inform ation Below
Spouse's Last Name Suffer 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 Retum ^ 2. Supplemental Return ^ 3. Remaintler Retum (tlate of death
Dnor to 12-13-82)
^
4. Limited Estate ^ qa, Future Interest Compmmlae
(Oats ar tleeth seer 12-12-e2) ^ 5. Federel Estate lax Retum Required
5. Decedent Died Testate ^
(nsacn Capy ar wiip T Decetlent Maintained a Living Trust
(aaacn copy m in,ab 1 e. Total Number of Safe Deposh Boxes
^ 9. Litigatlon Proceeds Received ^ 10. Spousal PavMy credo (oats ar deern ^ t t, Election to tax antler Sec. 9173(A)
between 72-31 1 arM 1-i-BS
(Attach Sch. 0)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
TRACEY B . GRINESTAFF (717 ~ 626 491
Firm Name (If Applicable) .;~ O o ,-,, _;.~
~._
GIBBEL RRAYBILL 6 IiE
SS LLP p~
~
REGIST~cr ILLS~EOI~Y''-
,
Flret line of address >m I ,,, .
c ~ ~'? Oti r ' ; ;
~
~
P.O. BOB 16 ~%~~~ b. ~!
'
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C: ~ ~ :';
Second line of address ~ ~ '~' '_
[
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City or Post Office State ZIP Code DATE FILED
LITITZ PA 17543
Correspondent's a-mail address:
P.O. Box 76, Lititz, PA 77543
Side 7
1505607120 15D5607120 J lti'
~`~.'
1505607220
REV-1500 EX
oe~a,m•. Name: Jack F. Kelley
Decedent's Social Security Number
RECAPITULATION
1 . Real Estate (Schedule A) ...................................................................................... .... 1. 1 9 2, 9 5 0. 0 0
2 . Stocks and Bonds (Schedule B) ........................................................................... .... 2. 2 3, 0 4 2. 9 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. 2 8 , 9 2 4 . 3 7
6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested .......... ... 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ~ Separate Billing Requested ........... .. 7. 2 2 5, 0 1 5. 0 0
8. Total Gross Assets (total Lines 1-7) ..................................................................... .. 8. 4 6 9, 9 3 2. 2 9
9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... .. 9. 3 5 , 6 8 2 . 5 9
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. .. 10. 1 , 3 2 7 . 6 5
11. Total Deductions (total Lines 9 & 10) .................................................................... .. 11. 3 7 , 0 1 0 . 2 4
12. Net Value of Estate (line 6 minus Line 11) ........................................................... .. 12. 4 3 2 , 9 2 2 . 0 5
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to taz has not been made (Schedule J) ................................................ . 19.
14. Net Value Subject to Tax (Line 12 minus Line 13) ................................................ . 14. 4 3 2 , 9 2 2 . 0 5
i cuc o(1mruTAnDN -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(t.2) x .OO 0 . 0 0
16. Amount of Line 14 taxable
at lineal rate X .045 4 3 2, 9 2 2. 0 5
17. Amount of Line 14 taxable
at sibling rate X .12 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X .15 0 . 0 0
19. Tax Due
15.
16.
17.
18.
19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505607220
0.00
19,481.49
0.00
0.00
19,481.49
15D5607220 J
REV•1500 EX Page 3
Decedent's Complete Address:
File Number 21-08-1055
DECEDENTS NAME
Jack F. Kelley
STREET ADDRESS
9 Kitt;zell Drive
err
Carlisle STATE ZIP
PA 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line t9) (t) 19,481.49
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments 18,158.75
C. Dismount 955.25
3. InteresUPenalry if applicable Total Credits (A + B + C) (2) 1 9,125.00
D. Interest
E. Penalty
Tptal lnteresUPenalry (D+E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
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) 356.49
A. Enter the interest on the tax due.
(5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) 3 5 6.49
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decadent 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 Irfe of either payments, benefits or care? ................. .
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without x
receiving adequate wnsideretion? ....................... ^ ^
................................................................................................
3. Did decedent own an "in trust for" or payable upon death bank awount or security at his or her death7.........
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ...................................... ^ ^
...................................................
.............................
THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE O 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 p2 P.S. §9116 (a) (1.t) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the not value of transfers to or for the use of the surviving spouse is zero
(O) percent p2 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 N 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 iwentyone years of age or younger at Eeath 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) p2 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 defned under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
Rav-1603 EX+177-0E) ,
SCHEDULE A
REAL ESTATE
COAMONy.EALTN OF PENNariVPNIA
INXERITANOE TA%RETURN -
REEIDENi DECEDENr
ESTATE OF FILE NUMBER
Kelley, Jack F. 21-08-1055
All roel progrty ownstl wlsly or u a temm In common must G nportetl et hlr market valve. Fair mallet value is Oegnatl ea tM pnce at which property woultl be
exchangetl between a wIIRp buyer and a willing aelbr, ne0har beMp wmpelletl to buy or sell, boN having retaonebb Imowletlpe of Me nlavam foals.
Reel Properly whlch h lolrltly.ovmetl whh dgM of aunlwnhip must ba tllseloeatl on uhstlula F.
Attach a copy of the settlement sheet y the property has been soltl.
ITEM Indutle a copy or the deetl shovAng tlecetlent's interost H ownetl as tenant m common.
NUMBER DESCRIPTION '. VALUE AT DATE
OF DEATH
Tract of land with dwelling thereon erected at 56 Partridge Circle, South Middleton
Township, Carlisle - as more fully described in Deed recorded In the Office of the
Recorder of Deeds in and for Cumberland County, Book 162, page 123. Value per
sale price. One-half value reported in spouse's estate.
Tract of land with dwelling thereon erected at 9 Kitszell Drive, South Middleton
Township, Carlisle - as more fully described in Deed recorded in the Office of the
Recorder of Deeds in and for Cumberland County, Book K-36, page 679. Value per
sale price. One-half value reported in spouse's estate.
68,950.00
124,000.00
TOTAL (Also enter on Line 1, Recapitulation) I 192.950.00
(If more space is needed, add'N"onal pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 11-08)
Rev-1603 EX~ JB-88)
SCHEDULE B
STOCKS & BONDS
cwronoNwFUTH or gENNSnvaNw
INHER?PNLE TAY gETURN
RESIDENT DECEDENT
ESTATE OF
Kelley, Jack F. FILE NUMBER
21-08 1055
All propertytolntly-ownetl whh fight o/ euMVOnhip must be tlleclasetl on Schedule F.
ITEM CUSIP
NUMBER
NUMBER
DESCRIPTION
UNIT VALUE VALUE AT DATE
OF DEATH
1 188 shares of Banco Santander, S.A. -one-half value 15.65 2
942
20
reported. in spouse's estate ,
.
FIDELITY BROKERAGE ACCOUNT#614-456926
2 773.01 shares of Loomis Sayles Bond Instl -one-half 11.58 8
951
46
value reported in spouse's estate ,
.
3 370.8525 shares of Pimco Total Return Fund -one-half 10.36 3
842
03
value reported in spouse's estate .
.
4 22.183 shares of Dodge B Cox Stock Fund -one-half 91.95 2
039
73
value reported in spouse's estate ,
.
5 Fidelity Municipal Money Market -one-half value
reported in spouse's estate 5.267.50
TOTAL (Also enter on Line 2, Recapitulation) I 23 042 92
(If more space Is nestled, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98)
Rav-0508 EX+(9.99(
coemioNV,sxTN Or rENNer~vauw
mHER?ANDE TAX RENRN
RE910ENi DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ca I n t c yr (FILE NUMBER
Kelley, Jack F. 27-08 1055
InUUtle Ne praceetls of Iltipatlon entl the Bate the prOCeetls viero receivetl OY the eatele.
All property lolntly-evmetl vAM the nght o/ suMVOnhlp must N tlleclosetl on sehetlula F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1 AAA Financial Services Account#4264296024063783 -refund
182.74
2 Comcast -refund
38.59
3 Embarq -refund
19.43
4 Erie Insurance -premium refund (auto insurance)
213.00
5 Erie Insurance -property damage settlement
10,387.79
6 Genworth -premium refund (long term care)
638.43
7 Highmark Blut# Shield -premium refund
103.42
8 Hoffman-Roth Funeral Home -refund
100.00
9 Members 1st Federal Credit Union CD Account #2467846 -one-half value reported
' 5
675
70
in spouse
s estate ,
.
Accrued interest on Item 9 through date of death 1 58
10 Orrstown Bank Checking Account #402362 -one-half value reported in spouse's 2,191.07
estate
11 Orrstown Bank Christmas Club Account#450295 -one-half value reported in 480.00
spouse's estate
Accrued interest on Item 11 through date of death 2.37
Total of Continuation Schedule
See attached page
TOTAL (Also enter on Line 5, Recapitulation) 28,924.37
pr more space Is neetle4 additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1800 Schedule E (Rev. 6-98)
Rev-1808 EX+ (8-88(
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COlRADNWEPITH of PENNSYLVMIW continued
INHERRANCE TFX RETINtN
RESIDENT DECEDENT
ESTATE OF
Jack F.
LE NUMBER
21-08-1055
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
12 Sale of real estate -prorated reimbursement of taxes (one-half value reported in
' 704
45
spouse
s estate) .
13 Sale of real estate -prorated reimbursement of taxes (one-half value reported in
' 418
36
spouse
s estate) .
14 Sovereign Bank CD Account #1675208807 -one-half value reported in spouse's 5
033
55
estate ,
.
Accrued interest on Item 14 through date of death
2 89
15 Sovereign Bank Checking Account #0351059087 -one-half value reported in
' 106
39
spouse
s estate .
Accrued interest on Item 15 through date of death
0.04
16 Sovereign Bank Money Market Account #1674062206 -one-half value reported in
' 1
791
63
spouse
s estate ,
.
Accrued interest on Item 15 through date of death
0.30
17 The Sentinel -subscription refund
11.52
18 United States Treasury -Social Security payments for September (one-half value 399
00
reported in spouse's estate) .
19 Waste Management Authority -refund
31.82
20 Personal property -one-half value reported in spouse's estate
452.50
TOTAL (Also enter on Line 5, Recapitulation) ~ 28,924.37
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA•1500 Schedule E (Rev. 6-98)
Rsv-1510 G7N (8-a B)
SCHEDULE 6
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMApNWEgLTH OF PENNSriVPNIA
INHERmANCE TA%RETURN
RE510EMCECEOENr
ESTATE OF FILE NUMBER
Kelley, Jack F. 21-08-1055
This scnetlub must be complete0 en0 Oletl H the answer to any of queatlona 1 Mmuyh 4 on the revene aide Of the REV-7500 COVER SHEET le yes.
ITEM
NUMBER DESCRIPTION OF PR
THE DATE OFMTRANSF~ER.SATTACH AHCDPV OF THE DEEDTFOREREAL ESTATE. DATE OF DEATH
VALUE OF ASSET u of oeco~s
INTEREST ExctusloN
(IF APPLICABLE TAXABLE
) VALUE
1 Block camp -proceeds of ownership interest. 1
300
00
Beneficiaries: daughters ,
. 1,300.00
2 Fidelity Traditional IRA Account #613.351245 - 223
715
00
cash and marketable securities; beneficiaries: ,
. 223,715.00
daughters
TOTAL (Also enter on Line 7, Recapitulation) 225,015.00
(If more space Is needed, atldltlonal pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98)
REVdi61 EX~ t10-08)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ESTATE OF FILE NUMBER
_ Kelley, Jack F. 21-08-1055
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. I hUNERAL EXPENSES:
See continuation schedule(s) attached I 8,575.45
B. I ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name(s) of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission paid
2. Attorney's Fees Gibbel Kraybill & Hess LLP 11,095.00
3. Family F~cemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
Ciry State Zip
Relationship of Claimant to Decedent
4. Probate Fees 385.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 17,647.14
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 35,682.59
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 70-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Kelley, Jack F. 21-08-1055
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 George's Flowers 424.00
2 Hoffman-Roth Funeral Home -funeral services 5,548.01
3 Hoffman-Roth Funeral Home -air transport 503.44
H-A subtotal 6,575.45
Other Administrative Costs
4 Carl Cecil -household repairs 188.00
5 Cumberland Law Journal -estate notice 75.00
6 Fidelity Investments -advisor fee 255.85
7 Holechek Funeral Home -additional death certificates 55.00
8 Met-Ed -electric service during estate administration 51.58
9 Met-Ed -electric service during estate administration 23.74
10 Nebraska Accident Records Bureau -copy of accident report 8.00
11 Register of Wills -additional short certificates 40.00
12 Register of Wills -exemplification of record 40.00
13 Register of Wills -exemplification of record 40.00
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6.98)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Kelley, Jack F. 21-08-1055
ITEM
NUMBER DESCRIPTION AMOUNT
14 Reserve for closing costs
15 Sale of real estate -settlement charges (one-half value reported in spouse's estate)
15 Sale of real estate -settlement charges and seller assist (one-half value reported in
spouse's estate)
17 Susquehanna Bank -return item fee
18 The Sentinel -estate notice
79 UGI -household fuel during estate administration
20 UGI -household fuel during estate administration
21 UGI -household fuel during estate administration
22 UGI -household fuel during estate administration
23 Waste Management of Central PA
24 Woody's Lawn Care -lawn care during estate administration
H-B7 Subtotal
900.00
9,069.20
6,437.37
15.00
150.84
42.95
82.00
23.21
37.20
47.43
67.95
17,847.14
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1800 Schedule H (Rev. 6-98)
Rev-0612 E%F (72-0e)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
DOMMONWEALTN OF PENNSYLVAN W
INNERRANCE TNl RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kelley, Jack F. 21-08-1055
Rspotl tlabb Incumtl Dy the tleeetlaM prior to tlaath Nat romalnatl unpaltl at Na tlats of tleath, Inclutlln9 unnlmtrurwtl metllcal szpenwa.
ITEM
NUMBER
DESCRIPTION VALUE AT DATE
OF DEATH
1 AAA Financial Services Account #4264296024063783 360.12
2 Boscov's Credit Card 23,99
3 Checks clearing personal account after death -one-half value reported in spouse's 235.21
estate
4 Cumberland Valley Endo Center -medical services 33.57
5 Department of Veterans Affairs -medical services 120.00
6 Department of Veterans Affairs -medical services 15.00
7 Embarq -telephone service 32.74
8 Lebanon VA Medical Center -medical services 8.00
9 Met-Ed -electric service 48,84
10 North Middleton Authority - watedsewer (Partridge Circle) 82.30
11 South Middleton Township Municipal Authority -water/sewer 115.50
12 UGI -household fuel; one-half value reported in spouse's estate 17,18
13 Woody's Lawn Care -lawn care 235.22
TOTAL (Also enter on Line 70, Recapitulation) I 1,327.65
(If more space is needed, additional pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08)
REV-1610 EX+H1-001
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kelley, Jack F. 21-08-1055
NUMBER NAME AND ADDRESS OF RELATIONSHIP TO
DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE
PERSON(S) RECEIVING PROPERTY (Words) ($$$)
0o Na u.1 Tru.1
I. TAXABLE DISTRIBUTIONS [include outdght spousal
distnbutions and transfers
under Sec. ~116(a)(1.2)]
Debra A. Field Daughter 50% of residue
409 Lakeview Drive
Lititz, PA 17543
Pamela S. Garrett Daughter 50% of residue
56 Partridge Circle
Carlisle, PA 17013
Total
Enter dollar amounts for distributions shown above on lines 1 5 through 18 on Rev 150 0 cover sheet, as appro priate,
~- NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-7500 Schedule J (Rev. 11-08)
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