HomeMy WebLinkAbout12-04-09J
REV-1500 EX (OB-05)
PA Depadment of Revenue
Bureau of IMIvIduaLTaxes
PO BOX2B0801
Hartisbu , Pq 17128-0801 RESIDENT'-C
ENTER DECEDENT INFORMATION BELOW
Sodal Sacurlt Number
) ;1 1 2 0
Decedent's Last Name
SuA9x
D a s he r
(IiAPpllcibte) Enter 8urvlvlnp.3pouse's InforrnaNOn Below
Spouse's Last Name
Suffix
Spouse's Sodel Secud Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH 7HE
FILL IN APPROPRIATE OVALS BELOW
~ 1. Odginal Return - O
O 4. Limped Estate
~ 8. Decedent Died Testate
(Attach Copy of Will)
O 9. LiBgatlon. Proceeds Received
Cnoeren.....-
^~rn I -THIS SECTION
15056051047
OFFICIAL USE ONLY
INHERITANCE TAX RETURN Coup ode Year File Number
~~
REGISTER OF WILLS
2. Supplemental Retum~
O 4a. Future Interest Compromise (date of
death after 12.12.82)
O 1. Decedent Maintained a Living Trust
(AUech'Copy of TrusQ
O 10. Spousal Poverty Credtt (date of death
between 72.31-81 end 1.1-95)
COMPLETED. ALL CORRESPONDENCE AND CONFIDENTUIL
INFORMATION SHOULD
_ _
~.
~ t.~
Date of Birth -
Decedent's First Name
M a r ~~"~r"T'r'-1
j„J,.1..L..1..~ H
S use's Firet Name
MI
O 3. Remainder Return (date of death
prior to 12-13-82)
O 5. Federal Estate Tax Retum Required
~ 8. Total Number of Safe Deposit Boxes
O 11. Election to tax under Sec. 9113(q)
(Attach Sch. p)
15056051047 J
U_ "'~
Cortespondent's e-mail ad~l.eee.
L Slde 7
15056051047
J
REV-1500 EX
Decstlent's Name:
1. Real estate (Schedule A) ......................... . .... .
..... .. .. ..... 1.
2. Stocks and Bonda(Schedule B) .............................
.......... 2.
3. Closely Held Corporatbn, Partnership or Sole-P,ryprietprship (Schedule C) .... , 3,
4. Mortgages & Notes Receivable ($chedule D) ..........
................... 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5,
6. JolnBy Owned Property (Schedule F) p Sepaate Billing Requested ..... , . 8,
7. Inter-Vlvos Transfers 8` Miscellaneous Nan-Probate Property
(Schedule G) p Separate Billing Requested........ 7, I
8. Total-Gross A;sets (total.Lines 7-71
~• ~ m,mai cxpenses 8 Adminlatratlve Costs (Schedule H) . ..:.......... .
..... 9.
10. Debts of Decedent, Mortgage Llabllities, 8 Liens (Schedule I) ..... . . . . . . . . . . 10
it. Total Deductions-(total Ltnes 9 & 10) ....... . ...... . .... .
............. 11.
12.~ NefValpti of Estate{Una 8 minus Llne 11) .... , , , , , 12
13. Chadtabis and Governmental Bequests/Sec 8113 Trusts for which
an elec8on to taxhes not been made (Schedule J) .............. . ..... . ... 13.
14. Net VaWe SubJeet to Tax (Line 12 minus Line 13)
TAx COMPUTATION -SEE INSTRUCTIONS FOR API
15. Amount of Llne 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0_
18. Amount of Line 14 fax~ble
at lineal rate X .0 _
17. Amount of Line 14 taxable
aE sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
15
18.
17.
18.
19. TAX DUE ...................
..........................:.......... 19.
20. FILL IN THE OVAL IF YOU ARE REQUf~871N1i A-'REPVt4O'OF"ykN~OVERpgYMENT ~ ~ ~ ~.,
DecedenPs Social Security Number
O
1 Side 2
1~ 15056052048
15056052048
]r5O56O52U48
REV-1500 EX Pape 3
Decedent's Complete Address:
Martha H. Dasher
Flle Number
21-08-1217
~u,rrDerlana Crossing
L~„ysaorr way
Tax Payments and Credits
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. InteresUPenalty if applicable
D. Interest
E. Penalty
-0-
_$59.21
-0-
I 17015
(1) $3,859.09
Total Credits (A + B + C) (2) - 0
4. If Line 2 is greater than Line.1 + Line 3 enter the difference. 7hls I EOth Vels RpAYMENT.
Total InteresVPenalty (D + E) (9) 5 9.21
Fill In oval on Page 2, Llne 20 to request a refund.
S. If Line 1 + Line 3 Is greater than Line 2, enter the difference. This is the TAX DUE. (4)
A. Enter the interest on the tax due. (5) 3 , 8 5 9.0 9
B. Enter the topl of Line 5 + 5A. This is the BALANCE DUE. (5A) 5 9.21
(5B) $3,918.30
Make Cheek Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a hansfer and:
a. retain the use or Income of the property transferred;,,,,,,,,,,,,, Yes
b. retain the dght to designate who shall use the No
c. retain a reversionary interest, or ....................... ~~~ transfened or Its income; ....................
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 conslderefion9 .............................................................................................................. ^
3. Did decedent own an 'in host for'.or payable upon death bank account or secudty at his or her death7 ..............
4. Did decedent own an Individual Retirement Account, annuity, or other nonprobate property which
contains a beneficiary designation?
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G-AND FILE i^T AS PART OF THE RETURN.
is three (3) percent [72 P.S. §9116 (a) (1.1 t ,
For dates of death on or after July i, 1994 and before January 1, 1995, th~ tax rate imposed on the net value of trensfers to or for the use of the surviving spouse
(~)]
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of hansfers to or for the use of the surviving spouse is zero (0) percent
fl ng a to§9etumaerelstlll apjplicable even if the s (vipouse Isfthe only beoefic'aryou~ from tax, and the statutory requirements for disclosure of assets and
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twentyone 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 [/2 P.S. §9}16(a)(1.2)j.
72 P.S. §9116(1.2) [72 P.S. §9116(a)(i11,
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
Section 9102mas andindividual who has at least one parenthn common withh eadecedentgwhethervbybIood or adoption.
( )percent [72 P.S. §9116(a)(1.3)j. Asibling is defined, under
REV-1502 EX+ (8-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Martha H. Dasher
real property owned aolety or as a tenant In comn
exchanged between a willing buyer and a wlllin~,
Raal properly which Is
ITEM
NUMBER
t• NONE
SCNEptlLE A
REAL ESTATE
21-08-1217
't be roported at fair market value. Fair market value is defined u the price et which property would be
neNher being compelled to buy or sell, bom having reasonable knowledge of the relevant facts.
owned wim right of survtvonehlp must be dlecloasd on gchaduls F.
TOTAL (Nso enter on Ilne 1, Recapitulation) s -0-
(If more space Is needed, Insert addNbnal sheets of the same elze)
REV-1503 EX+ (8-98)
COMMONWEALTH OF PENNSYLVANIA SCHEpYLE B
INHERITANCE TAX RETURN STOCKS 8c BONDS
RESIDENT DECEDENT
VF
Martha H. Dasher FILE NUMBER
21-08-1217
All property Jolntty~owned with right of survivorship must be dlselosed on Schedule F.
NONE
A7
-0-
TOTAL (Also enter on Ilne 2 RecapRulation) ~ g - 0
(II more apace is needed insert edddbnal sheets of the same srze)
PFAI9N IX•(tin.
SCHEDULE C
MPENNSYLVANU CLOSELY•HELDCORPORATION,
rAx N~rurw PARTNERSHIP or SOLE•PROPRIETORSHIP
NT
Martha H. Dasher FILENUN~$ER
21-08-1217
Sdbdub Gi ar G2 (Indudirp all supportlrp inionnatbn) must be atlached for each
See Inseuclb,p for the aupportlng Ntortnetlon ~ Ba submiCed foraob-propdebreh "~~ corporetloNpeMerehip inbred of the decedent otherthan a sde~ropdetorehip.
NUMBER DESCRIPTION VALUE AT DA
~' NONE OF DEATH
-0-
TOTAL (Also enter on line 3 Recapitulation) I = - 0 -
(Ifmore apace Is needed Insert additional sheets of the same size)
REV-1507 EXa (1-97)
COMMONWEALTH OF pENNSVLVANIA
INHERITANCE TAX RETURN
RESIDEM DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
Martha H. Dasher
All property Jointly-owned with right of survivorship must be disclosed on hedulOeB-' 21 7
NONE
-0-
TOTAL (Also enter on line 4, Recapitulation) ; _
(It more space is needed, insert additional sheets of the same size) _ O
AEy.ieaEx.liarl
COMMONWEALTH OF PENNSY
INHEPoTANCE TA% RETNi
SCHEDULE E
CASH_BANK DEPOSITS, & MISC.
Martha H. Dasher FILE NUMBER
Indude Me Proceeds of Adgatbn and the date the 21 - 0 8 -121 7
ITEM Ploaeds were reawed ~ ~8 °S~~• ~ ProPary'klMlybwnW vMh the rpM of survivorship must be dhcbsed on SeheduM F.
NUMBER
DESCRIPTION VALUE AT DATE
~' Checking account, #33-23544, at F&M Trust, oFDEATH
Boiling Springs, PA $483.52
2• Checking account, #70-70098, at F&M Trust, 19 217.48
Boiling Springs, PA
3• Refund from Cumberland Crossing Retirement, 2 989.08
Carlisle, PA ,
TOTAL (Also enter on line 5, Recapitulation) I E 2 2, 6 9 0. 0 8
~V.,~~X.,,~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE F
JOINTLY•OWNED PROPERTY
Martha H. Dasher
If an asset was made joint within one year of the daeadenPS date of loth, h moat M npoRed on licheduN G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
A. Eddy B. Dasher 14 S. Ridge Road
Boiling Springs, PA 17007
B.
C.
21-08-1217
RELATIONSHIP TO DECEDENT
Son
JOINTLY-OWNED PROPERTY;
LETTER DATE DESCRIPTION OF PROPERTY
REM FOR JOIM MADE Include name Wflnendal lnatldltlon slid bank aadlM nlmAaadmPr klpl
NUMBER TENANT JOIM deed Talolnfly-heM real eeMte flhk1A numbs. AIMCh DATE OF DEATH %OF DATE OF DEATH
VALUE OFASSFT IM REST DECEDENTUS INTEREST
1. q. 2/10 07 Certificate of Deposit,
#016-2987579, at F&M Trust $67'811.31 508 $67,811.31
Boiling Springs, PA '
TGTAL (Also enter on IIDe 6 Regpitulation) I ; 6 7 , g 1 1 31
SDaCP Is Deeded m¢erf V,u ~I ~~_
--• M~a aiwu or Lyre 9SRle Size)
Rtvisio Fx.nan
CAMAIONWEALTH OF PENNSYLVANIA
INHERITANCE TA7( pETUgN
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC, NON-PROBATE PROPERTY
Martha H. Dasher
This schedule must t» 21 - 0 8 -1 21 7
conWleted and filed d the answer to any or quesffons 1 tl~louph q on the ~~ side o(Me REV•1500 COVER SHEET b yes.
ITEM uwwe nce iurss or nom, IPTION OF PROPERTY
~' ~ NONE
uharw~q,
DATE OF DEATH DECD'S EXCLUSION
-~_. VA IEO, A ET iNTFGCSr ._._ TAXABLE VALUE
-0-
TOTAL (Also enter on Iine 7 Recapitulation) I S
space Is needed Insert ~nm ~
-0-
same
REV-1511 Ex+(10.08)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Martha H. Dasher
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIyE COSTS
21-08-1217
Debts of deoeMnt must ba reported on Schedule L
A. FUNEflAL EXPENSES: DESCRIPTION
t Aver Cremation Services of Pennsylvania, Inc.
4100 Johnstown Road
Harrisburg, PA 17109
2. Carlisle Memorial Service, Inc.
41 South Bedford Street
Carlisle, PA 17013
e• ADMINISTRATIVE COSTS:
~ ~ Personal Representatlva's Commiaslons
Name of Personal Repreaentatlve(s)
Street Address
City
State Zlp
Year(s) Commission Paid: -----
2. AttomeyFees Anthony L. DeLuca, Esquire
S. Fatuity Exemptlon: (If decedent's address is not the same ae delmant's, ettaGl explanatbn)
Claimant
Street Address
City
State Zip
Relationship of Claimant to Decedent ~'---
4' Probate Feea
S• Accountant's Fees
8• Tax Retum Preparer's Feea
~ Filing Fee for Inheritance Tax and Inventory
8• Wayne Noss, Flowers
9. St. John Lutheran Church
10. Refreshments after church service
11. Motel Expense
T07AL rAl~„ e...e..._ ::
$320.17
185.00
3,000.00
103.00
500.00
30.00
85.86
300.00
75.00
80.00
(It more space Is needed, insen additional sheets of the same size)a' necapnulation) $ z r " ' ' • ~
REV-1514 EX+ (11.03)
CDMMDNWEAI.TH OF PENNSYLVANIA
INHERITANCE 7AX RETURN
RESIDENT DECEDENT
FcrATE
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILJTIES, & LIENS
OF
Martha H. Dasher h1B
21-08~~1217 ER
Report debts Incurred by the decedent prior fo death which remained unpaid as of the data of death, Including unreimbunad medical expenses.
TEM
AMBER
DESCRIPTION VALUE AT DATE
t' Continuing Care RX - Prescriptions OF DEATH
$34,83
2, Philhaven -medical
10.00
3. Yellow Breeches Family Practice -medical
10.00
4. Darrl K. Guistwite, Medical
10.00
TOTAL (Also enter on Ilne 10, Recapitulation) S 64.8 3
(If more apace Is needed, Insert addftlonal sheets of The same s@e)
REV-1513 EX+ (9-00)
COMMONWEgLTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
3
1.
Martha H. Dasher
SCHEDULE J
BENEFlCIARIES
~...~,.u~o ui31 HIBUTIONS pmdude ouMBht epoueal dlatn
Eddy B, Dasher•a11S(a)(1.z)]
14 S, Ridge Road
Boiling Springs, PA 17007
Barry L, Dasher
3075 Bay Oak Circle
Englewood, Florida 34223
Cathy D, Moore
226 Lakeside Drive
Monroe, Louisiana 71201
antl trenelero under
21-08-1217
ATIONSHIP TO DECEDENT AMOUM OR SHARE
Do Not Liat 7FUatee(a)
-"---~-~_ OF ESTATE
Son 1/3 Interest
Son
Daughter
1/3 Interest
1/3 Interest
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 1b TH TOUGH 18, AS APPROPRIATE, 0 I REV-1500 COVER SHEET
A ~SPO~L D STRIBUTIpry3 UNDER SECTION 8115 FpR WHICH AN ELECTION TO TAXIS NOT BEING MADE
NONE
I B. CHARITABLE AND GOVERNMENTAL~DISTRIBUTIONS
1.
TOTAL OF PART II -ENTER TOTAL NONTAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
pt more apace b needed, hlaert edd8bnel aheeU of the same eize)
-0-
~.,^,T :.... ,gat„ .r ~ _._- ~ ._ ~. _.__.
', , i%,~, n.Sl'R"., of Sa~t4 ~. d~letor Township, CU. :'?>.-land
County, Pern sy'w Baia, deci.^.n t'a is ':.r.s tx'~~,ent to b~^.y East ':*i11
and Test z*sent, in ma_nrer and fo^. _`ollow i:±~:
- ~ 1. I herat;o exure <, re~rr :. e;11 '....'s snd ~ a'...ci 7.s Freta-
-ore made by Te. -
2. I h~rn_by c' it-^_ct ^:y ';xecuter *_o pay a.1? ~^.y j^.:s~ ~bts,
funeral and administrative expenses cut of my esteta_, :'.s so cr. as
practicable after my death,
3. Should my husband, CLarence ~~. Dasher, s•,±rvive me for
a periad of thirty days following my death, I devise and bequeath
the remainder of my ?stag to Clarence C. Dasher.
k. Should my husband, Clsrence C, Dasher, predecease t~ or
die on or b_fore the t`:irtiath day folio-r~i.ng my death, devise
and bequeath tha remainder o° m;, estate to my issue '_ivin<, on
the thirty First day following my death, per stirpes.
5. I nnr.^.i.nate and appoint Cu[nbe rl and County *:at ianal, hank
And Trust Company, 6tew Cumberland, Fem?sy'.vania, Trustee of the
share of any bere£iciary who may be under the age of twenty-one
years. The income and T r principal of said trust may be accumu-
lated or expende3 for the ma.irtenance, education and support of
such beneficiary as my Trustee in its sole discretion may deter-
mine; and my Trustee, in the expenditure of income and%cr prin-
cipal for such purposes, may, at its discretion., alply tha sar.,e
directly without the ir.tervertien of a guardian or pay the sane
to any person having the care or control o° said beneficiary or
with w`~om the boneficiary resides, without duty ~-. tFe part of
the Trustee to supervise or i.ngrzire into the application of the
II funds by z.ny person tc cchatn any payment is so made. The balznee
;i of such irceme and/or principal shall be raid to such benef;_ciary
.,,.. ,.,,m.%~._. ,..
,.~
upon reach in the ale o£ tsae ray-one years, or to .., ,.oh 'cene`c-
ciary's estate in the evert o£ death prior ti:erto.
6. 2 nominate and aapoint my husband, Clarence C, DasiZer,
as °xecuter o£ thie my Last Lill an3 Testzner.t; and as s~bsti tote
^xecutors, r nominate and appoin*_ my sons, tarry L, Dash~'^ an3
i;ddy 3. Dasher .
7. I direr*_ that my personal representative =.n•'_ TrL'.=tee,
as we11 as their successors, sha.11 not be required to £i1e bcr,3
or sac~.rity in any jurisdiction. _
IN ?dITA7ESS Tr7I?E?'~OF, I have hereunto set my hand and seal
y,Ul l 1
this .Z ,~~„ -day o: {~ .:a. ~~"^"'"~^~ 1977,
~~~O~VL~a N ti~(Q~~~i NSF?.L)
frt. a H.. as er
P'ITNES S
.,~,, ~~ r~ ~-~ r
.~. r ..-.., ...t, ,
~--; --~
• t / ~~ ~jA ~t+.
Jr~ ya... ~'~~ ~6 /.'; ~L~ _.
- 2 -
~,:~f.x:~~~.~"
.. .
r;; ~rn:r~~i!.. G~.LmE cr v;N`~iSYT_1`. ?I'_„ _
. S5.
COUNTY OF CVi^B,?RF_A ND
1, b*artha H. ~a.sher, Tastatri;c, whose na^.:e is signed to the
attached or fo^=goin~ instr_i:*ent, hav i.n been duly cu^1 ~_f i.ed
accotvirg tc 1aw, do hereby ac!cr.ozeiedge that si.^n.ad ^nd e:cec*~-
ted tk:e irs tr:rert as my Last *aill; that I s~.~nod it w~. i. i.zr giy;
and that I sib ed it as ^~v free.
an;: vclrnt>r,:~act for t:~.2. pur-
poses therein~exoressed.
Sworn or affirmed to and aclcnowL dged before me, by ^'artha
H. Dasher, Testa±rix, this 'D_ i• ~'?ay c° j%~, ry..~~-_•~r , 197?,
i
estatri~-
JANlC'e c. tiERTZL_:;, NL'7ARY PU!~LIC ~„ ~ /~
Cumbe; Lnd County Carlisle, Pa. ``. ~ ~~- ~ (, ~~ /lam,
My Commission expires January 27, 1~y7`3 J
COM":'OAAP?:.A.LTii OF °EN'?SYLV:'~..iNIA
Pj
COL@7TY 09 CiJ.M;9EpS.d.ND
b.'e, Tom H. Bietsch and Boger M. Ntorgenthal, the wwitnesses
whose names are signed to the attached or foregaing i.nstrunent,
being duly Dual ified zecording tc ln_w, do depose a_nd say that we
were present and saw Testa*.rix, Martha H. Dasher, sign and
execute the instrument as her Last ?ti11; that she s~aned will-
ingly and that she executed it as her freee and voluntary act far
the purposes therein exoreased; *_hat both of us in the hearin~*
and sight of the Testatrix signed the wi11 as witnesses; and the.t
to the best of our knowledge the Testatrix was at that time 18
or more years of age, o£ sound^.ind end under no constraint or
undue influence.
Sworn or of fi*_med to and. subscribed to before me by Tom z?.
Bietsch and Fogey h?. P[orenthal, witnesses, this LL day
of r",,,~r.q,,,.,,~ , 1977.
`, ~ 7 rr
- ~ ~t r.>..y--~ .
oJitness
' i
` ~Ti.itness-~
JANICc t. HER?ZLi_ft, NOTARY ?Uti7L'u
Cumberland County Car;isle, r'a.
?rr.~ Commission Expires January ??. 1'"3
II - 3 -