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HomeMy WebLinkAbout12-11-09 . .REV-150 PA Department of Revenue Bureau of Individual Taxes Dept. 280601 Harrisburg, PA 17128-0801 0 EX (05-04) 15056041046 OFFICIAL USE ONLY County Code Year File Number INHERITANCE TAX RETURN '' RESIDENT DECEDENT ~ ~ ~ 9 O O ~ j ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ogdyo~9`~'9yo 06~ ~~0~9 08 ~ y ~ 9~~ Decedents Last Name Suffix Decedent's First Name MI SU C,..C..A .D o L o~ E S ~~ (If Applicable) Enter Surviving Spouse 's Information Below Spouse's Lasl Name Suffix Spouse's First Name MI Spouses Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (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 INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Numher .Q :: Firm Name IlfApplicable) . "-` -r; ~~~ REGISTEI~_ LLS US~ILY f' ` <~~ ;.? First line of address ~- ~f"j' -'Z~7 r t f ~ t'1 (_~ ,~ .~ _I 1 C~ ~---, ~ Second Ilne of address ~ ---i .. a ~~ ~3 •~` t ~ ~~ Gity or Post Office Slate ZIP Code DATE FILED Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of parer other t he personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RE9*~ R TURN / p/~ G ADDR~ SIGNATURE OF ADDRESS 15056041046 Side 1 15056041046 J J __ _ _. . 15056042047 REV-1500 EX Decedent's Soocial F, ^ -,: our 9pra'"ia I~I w N~,P~~o /o/2E S ~ • .Sur%Cr9 Gf G RECAPITULATION e, 1. Real estate (Schedule A) ........................................... .. 1. `_ ~r~~ 2. Stocks and Bonds (Schedule B) ..................................... .. 2. \~y ~_+.= ~~ ~ti 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. ~ , ~'' 4. Mortgages & Nokes Receivable (Schedule D) ........................... .. 4. _ ; ,.'; 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. ' 6. Jointly Owned Property (Schedule F) C Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property -. ~t-~:, (Schedule G) C Separate Billing Requested...... .. 7. , i ? k 3 :.V .. 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. ; 9. Funeral Expenses & Administrative Costs (Schedule H) ...... .............. 9. 10. Debts of Decedent, Mortgage Liabilities, ~ Liens (Schedule I) ................ 10. 11. Total Deductions (total Lines 9 & 10) ................................... 11. ..*. 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which lection to tax has not been made (Schedule J) 13 . ,. ~ '~ s~~ ~''`'~'_ r ~ ~ '..*;»~ ~~a ~ l a~ Aides" v :~:~: ..~..--~i~-- ~ an a ... ................... .. ~ 0' 14. Net Value Subject to Tax (Line 12 minus Line 13) ... ................... .. 14. .~, , TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLIC ABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 y (a)(1.2) X .0_ ~ 15. ~ ~ 16. Amount of Line 14 taxable at lineal rate X .0~ s • ~ .__.~ ~ `~ 16• ~~~ • `~ ~ ~ ~ ~ i ~ ~~ ~ 17. Amount of Line 14 taxable 12 ' 17 } ~ at sibling rate X . a . ~ ~~ , ~. ~,,, ~~ .~ _, 18. Amount of Line 14 taxable at collateral rate X .15 ~ 18. ,,, a ~ ~,, ~ .~ 19. TAX DUE .................................... ................... ..19. >.,.s....i _s,:,; x d ~ ~' 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C~ Side 2 15056042047 15056042047 J REV-1500 EX Page 3 File Number Decedent's Complete Address: ~~ - D~J - ~jb6,3~ lelt(;tUtN I ;J NAMt ------ ------ ------ STREETADDRESS • ciTY C/~ie,(/ S,L~ STATE ~~ ZIP / ^ / a Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit _____ B. Prior Payments C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty (1) Total Credits (A + B + C) (2) Total Interest/Penalty (D + E) (3) 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) 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. (5A) (56) Make Check Payable to: REGISTER OF WILLS, AGENT -a,oa r-- C~, o 0 ~--- d , a ~ 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 :.................................................................................... ...... ^ 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. 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 exempt 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. r ~2FV t:OB FX . rt.yl; SCHEDULE E ~~MNN1NwEAiTHOFf'ENNSYIVANiA CASH, BANK DEPOSITS, 8c MfSC. !NMERITANCE TAX RETURN PERSONAL PROPERTY R NT ESTATE OF F14E NUMBER ,~G~ ~D .2.x.5' ~ e SvCC.r9 o,T' I ~ D4 ~ CEO ~ ~ include the txuceeds rst Ntlgatbn and the date the prctoeeds were recehred by the estate. A!1 properly pintly.uwltisd wkh Ctrs ripM of survivorship must be discbsad an Schedule F. ITEM ~ °'~ NUMBER ~ DESCRIPTION VALUE AT DATE /~ OF DEATH t ~ ,1~/J91'1'J atNl~ /Y / /'~I Gr >~ y,5"a, o0 /~GGr ~ l/oU7©- y« - J~ i 1 ~1 .3. ~ T/Z~/~lS ~ANIK S~4vitNa~fS lit CCGI~NT"" . ~ ~,c'-~~'~'nc~.,~T /~uRS,ovG ~~ric' /~=.?sv~,t lj~c~l~' 977 a~ TOTAL (Also enter on line 5, Recapitulation) ~ S /~ ~ ~~. r (If more space is needed., insert additional sheets of the same size) ~U M MGM 5 ~~~Gry ~totE 34 WEST MAIN STREET MECHANICSBURG. ?A 17055 ArrhtAl~At_ Phone, 717-766-9422 ArrttA~At_ Approisa) for: Estate of Delores A. SucccT October 12, 2009 1. t.ody's two-stone diamond ring. The ring has twa round diomonds set in o 14 karat white gold mounting. The diomonds care both older cuts vnd are about .3S points each. They are of good color, cut and imperfection grade Estate valve: $450.00 This appraixai constitutes our ccxetuNy stucifed ot~Inion at O the retai replacement cost tkrough ow tocNitiss IG the dBtress cabs rtahxe value of the o+ticblsi desatbed above Insofar as fhe mounting(s) have permitted observation. we assume no tiabiRty wHh respect to any actlOn ttwf may be tdcen on the basis of this approisd. i r _ Appralcer -`_ ~ scN~ou~ M COMMONWEALTH OF PEN;VSYLYANIA FUNERAL. EXPENSES 8e INHERITANCE TAX RETURN AL)MLNlSTRATIYE COSTS REStt~ENT DECEDENT" ESTATE OF FILE NUMBER ,7}0,l oR~s /9 • S~ ~ c,~ _ __ _ 021 - 0 9 -c2~6 3 ~ Debts of dscsWM Must bo rpoAed on 9dtadulo L ITEM NUMBE A. 1. R 2. 3. 4. 5. 6. 7. d. ,~0• // - DESCRIPTION 1 AMOUNT F4INERAL EXPENS"cS: ,,,~~ ~ fL~ ~~/~ C"~~6",,/(,,~" ~Gyy,E/Ti¢~- ,~~~L ~~ f ~ / ~f ~~.~2/G/ .Ti~/ L.i/Z6~ .~/~' J ADMINISTRATIVE CO5'iS: - Personal Representative's Commissions Name of Personal Representative(s) Ci'q .f0/ ~N ~ ~ ~~~' ~~~ A~ , . . ----- ..__ _ _ .._ . . , JJ ~~ / Street Address •!a .3 . /T'_/. ~[ _ ~ Iq l~L~ city 'j~'G°fi~A~C~~I~/1, ~ _.__-. state ~A .Tip ~~~~ !'~_ q Yea~is) Commission Fa,d: tai o'© / Attorney Fees FemBy Exemflt~n: (If decedenYS address is not the same as olaornant's, attach expianahon) Claimant Street Address , C'ty ,--..--.N_._.._ _.-__._.._ --------------------- ~-- State Zip _.. __ _ . _ . Relatwnship o! Gaimant to Decedent Probate Fees ~1, o0 Accountant's Fees Tax Return Preparer's Fees QQ~~ y a0 . ~~ .. /n~~ca~ „~NC~ 7~X F~,C~ G~ ~ ~~ , o 0 Pv~~3F,~ ,,~,vN~ .L.qv/ .-,Tm~2a At ~~ , 00 ~iE ,S,FNT-~.vc ~ ~ ~ 3, '20 TOTAL (Also enter an line 9, Recapitulation) S /~ ~gp(. ~p~ ;lf more Space is needed, ins6rt additional sheets of the same size) Jesse H. Geigle Funeral Home Mailing Address 3125 Walnut St. Harrisaur , FA 171 d9 Phone # 717-652-7701 13111 To John Sua:.a 103 Hill Lanz Mecfianicsburg, PA 3 7050 Invoice Dste invoice # 6rtsr2oo9 223 Oue Date Terms Client 7/l8/2009 vet 30 Dolores 9txca Quantity Description Rate Amount 15 Death Certificates 6•~ ~•~ Coroner Cremation Authorization F'ee 25.00 25.00 Obituary 20192 201.92 Professional Services of slat{"and directors. 1,791.05 3.,791.05 ~ J ~~ ~ + ~^F ~ ' `I , l ~,i ~~ ~~~lll ` Total sz,to7,y7 Paylrnelrtts/Credits s-1,952.sa ' s beta a plcaau>ne workyng w-itb gout It Balance Due s1ss.» COh1M(?NYkEA,TH OF FENNSY:VAM!A ;NNFRITANCE ?A7 R£"!R,~J occ: ~cuT nc r•znc ni" 3CMEpVLE 1 DEBTS OF DECEDENT, MORTGAGE UABIUTIES, & UENS EStATE OF y _ FILE NUMBER RepaR 3eists incurred by the deced®nt prior to dwth which rtmainttd unpaid a~ of the Bete of death, including unreimbursed msdiwl expsnsas. - ._-_~._.-..-__,r. _..__~._~_ - ': Er! ~ VALUE AT DA.7E Nl:M9FR _ --_--- CESCRtoT~ON~` _ ~ OF DEAT!1 ~omlr7oN y,r,E~~C'Tfi d~ /~C'NOY.Syy/,i,g~/ir¢ +~~ a cad. QS•. ~~~~~~XT of ~ 8 >/,~~~aa1 of ~L,4s5 ~ CL~ ss ..5' 1 c ~~ + m ~' c~Ain~ '~ 3 a, a3~ ~~' / ~d, i TOTAL 4„ ~~ z+ ~~ line '~ Reca ~ w~atio +1 3 ; ~ a a ~ ~ V, d~ !'• -sn> s;;an= :•, need?n nse{; aadr,+ona; ~.naets of !na >ame size - -----V---- ---------- REV-1513 EX+ (9-00) scMEOU« ~ COMMONWEALTH OF PENNSYLVANIA f BENEFICIARfES INHERITANCE TAX RETURN I R£SiDENT DECEDtNT ESTATE OF Q ~U.C blz~5 ~1 • .~U~C~ NUMBER I NAME AND ADDRcSS ~F PERSON{S) RECEIVING PRORERTY 1 i TAXABLE DISTRIBUTIONS (include outright spousal distributions, and transfers under ~ Sec. 9116 (a) (1.2f) 1. /yATifb~EE/V /~?, SvcGq .S3 c L A Y i N A ~R •, I?7E~KAJ/!CS/~v.Q~;~ 7cS~• I ~I .,7~a/jN L`, .Ti~Ctl1. ~EC~A~J,~~G~u?IC. ?O,~'0 ~ ~inu~v -T, s'~ccA '-ylo 3 ys V~ r~ ,~'~, -,/~ a~ i ,~,~~.~ G" ~Lc~4 ~- l' j ~2~D~G~E,4s,Ct~ J~/ol~,E,S J~. SuccR FILE NUMBER __ ~~-a~w 4T!ONSHIP TO DECEDENT Do Not List Truste~fs? ' 6R~~/'-~/6~r~2 G'i2~Aiya Jf1~.16.1~7 i s ,Sq~v s'Q.n1 s~~ ~o~J o ~! 3 8 AMOliN7 OR SHARE OF ESTATE ,r~NE ter u¢r'Naivl~ ~~N! dN~ p!A/iJt~ut/D .~•viE ,t'1f/~ /s1 //ZD /Qgs ~ ~y E o~ 9~~~2D /1,~x, ovk DN-~ ~ -~~/tD ~FS~ ~v~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, C7AI REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS' A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAY iS NOT BEING MADE 1. B. CHARITABLE ANO +3OVERNMENTAL DISTRIBUTIONS TOTAL OF PART I! -ENTER T07AL NON-TAXABLE DISTRIBUTIONS ON LINE 13 QF REV-1500 COVER SHEET 15 (if more space is needed, insert additiona~ sheets of the same size)