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Home My WebLink About01-15-10r J 1505607120 REV-'I SOO EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code veer File Nwnber Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box.2aosot 21 0 9 0 4 0 6 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Blrth 204 28 1936 04 15 2009 04 ,,~'7 193 Decedent's Last Name ROMBERGER (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW X^ 1. Original Return 4. Limited Estate a 6. Decedent Died Testate ^ (Attacn copy or wdq Suffut Decedent's First Name MI JEAN i, Suffix Spouse's First Name MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Return ~ 3, Remainder Return (date of death prior fo 12-132) qa. Future Interact Compromise ~ 5. Federal Estate Tax Return Required (date d death after 12-12-92) 7. Decede~y ~ Tint) Living TNet 8. Total Number of Safe Deposit Boxes (Atfatlr 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date r# death ~ 11. Election to tax under Sec. 911 A between 12-31-9t and 7-7-95) (Attach Sch. O) ~ ) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number J. RONALDO LEGASPI (717) 234 4161 Firm Name (If Applicable) GOLDBERG KATZMAN, P.C. First Tine of address 320 MARKET STREET Second line of address 1268 City or Post Office HARRISBURG Correspondent's a-mall address: State ZIP Code PA 17108 REGISTER OF WILLS U^~F ONLY C7 o ~p • }, . . 7 -" t. z ~.. r t ~ ~ n ' r-y~~ ~ T ED ,.., ' ~t .. i . - ~:,,_ , V rti -~=i w Under penalties of perjury. I declare that I have examined this return, tndudtng atxbmpanNng 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 OF PERSON R PONSIBLE FOR FILING RETURN DATE ~„ ,d ~ ~L,g~.,~~c.r'~,~-~ Hans S. Romberger ~ ~~ ~ ~~ a ADDRESS 5225 Wilson Lane, Apt. 3139, Mechanicsburg, PA 77055 SIGNA O ER OTHER THAN REPRESENTATIVE DATE _~ J. Ronaldo Legaspi ~_ ~~ _ ~~~~~ 320 Market Street, Harrisburg, PA 17108 Side 1 1505607120 1505607120 J V v J REV-1500 EX oacedern•:wine: Jean L. Romberger 3. tECAPITULATION 1. Real Estate (Schedule A) .......................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................... 2. 3. Closely Held Corporation, PaMership or Sole-Proprietorship (Schedule C).......... 4. Mortgages & Notes Receivable (Schedule D) .......................................................... 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ............. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ............. 8. Total Gross Assets (total Lines 1-7) ....................................................................... Decedents Social Severity Number 204 28 1936 25,576.79 4. 5. 21,863.91 s. 44,268.82 ~. 67,257.73 a. 158,967.25 9. Funeral Expenses & Administretive Costs (Schedule H) ......................................... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10. 11. Total Deductions (total Lines 9 8 10) ...................................................................... 11. 12. Net Value of Estate (Line 8 minus Line 11) ............................................................. 12. 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, 10,231.12 2,507.05 12,738.17 146,229.08 146,229.08 TAX COMPUTATION - 3EE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or trensfers under Sec. 9116 (a)(1.2) X .00 0 . 0 0 16. Amount of Line 14 taxable at lineal rate X •045 0 . 0 0 17. Amount of Line 14 taxable at sibling rate X .12 14 6, 2 2 9. 0 8 18. Amount of Line 14 taxable at collateral rate X .15 0 . 0 0 19. Tax Due .................................................. ............................................................. 15. 0 . 0 0 1s. 0.00 t7. 17, 547 .49 1e. 0.00 19. 17, 547:49 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505607220 1505607220 1505607220 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-09-0406 DECEDENT'S NAME Jean L. Romberger STREET ADDRESS 5225 Wesley Drive CITY STATE ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interesf/Penalty if applicable D. Interest E. Penalty 17,055.00 877.37 Total Credits (A + B + C] (1) 17,547.49 (2) 17,932.37 (3) (a) 384.88 (5) (SA) (5B) TotallnteresVPenalty(D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This Is the OVERPAYMENT. Check box on Page 2 Llne 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. q, Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This Is the BALANCE DUE. Make Check Payable to: 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 care7 ....................................... ..................... x 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration7 ....................................................................................................................... ^ ^x 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... ^ O 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiarydesignation? ...................................................................................................................... ^ ^x IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE R 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 decedents siblings is twelve (12) percent [72 P.S. §9116 (a) (1.3)]. A sibling 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-7503 EXt (8-88) I SCHEDULE B STOCKS 8 BONDS cow/.~ONwEAtrH of vENNSVwANw INHERRANCE TA%RETURN RESI)ENT DECEDENT ESTATE OF FILE NUMBER Romberger, Jean L. 21-09-0406 All property plndy~wned with right d eurvivonhip must be dleclosM on Schedule F. pr more space is neetletl, atltlidonal pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1508 F~(+ (e-fla) COMMONWEALTH OF PENNSTLVANl4 ~ INHERRANCE TA%RETURN RESDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Romberger, Jean L. 21-09-0406 Induda die prateede of Ntipatl0n and Ute date the proceeds were received q'the estate. Pdl properly iolntly-owned with tM rlpM of survlvorehip must bs dtselosed on sehwlule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Stifel Nicolaus -Money Market Account 846.17 2 Susquehanna Valley Federal Credit Union -Checking Account opened on 5/28/96 70,260.00 3 Susquehanna Valley Federal Credit Union -Savings Account opened on 9!16/77 10,374.86 4 Susquehanna Valley Federal Credit Union -Savings Account opened on 10/14/1998 382.88 TOTAL (Also enter on Line 5, Recapitulation) I 21 863.91 (If more space is needed, additional pages of the same slze) Copyright (c) 2002 form software only The LaGcner Group, Inc. Form PA-'1500 Schedule E (Rev. 6-98) Rw-1609 EX+ (6AE) COMMONWEALTH OF PENNSYLVANIA NNERRANCE TA%RETVRN RESDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER Romberger, Jean L. 21-09-0406 Man asaat was maM Joint within om ypr of the daoadenCa dab of death, It muK lw reported on uhadub G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Hans S. Romberger 5525 Wilson Lane Brother Mechanicsburg, PA 17055 B. C JOINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH % OF ' DATE OF DEATH NUMBER TENANT JOINT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR ALUE OF ASSE DECD S INTEREST VALUE OF DECEDENT'S INTEREST JOINTLY-HELD REAL ESTATE. 1 Lincoln Variable Annuity -Guaranteed 88.537.64 50.000% 44.268.82 Minimum Death Benefit Received TOTAL (Also enter on Line 6, Recapitulation) I 44,288.82 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-'1500 Schedule F (Rev. 6-98) e • Rav15701.X4 (6-aa) SCHEDULE G INTER-VIVOS TRANSFERS 8 MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANN RlHERRANCE TAX RETLRN RESIDENT DECEDENT ESTATE OF FILE NUMBER Romberger, Jean L. 21-09-0406 TNs schedule must Ue cpnpleted and filed if the answer to any of questions 1 through a on the reverse side of the REV-1500 COVER SHEET is yes. ITEM E I N P P RTY DATE OF DEATH x of DECD•s EXCLUSION TAXABLE NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE. 1 Thrivent Annuity -Settlement Agreement 27.083.84 27,083.84 9041877 2 US Allianz Qualified Annuity -Guaranteed 40,173.89 40.173.89 Minimum Death Benefit Received TOTAL (Also enter on Line 7, Recapitulation) I 67.257.73 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) REV-1757 Exa (1Z-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Jean L. FILE NUMBER 21-09-0406 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: See continuation schedule(s) attached B. 1 ADMINISTRATIVE COSTS: Personal Representatives Commissions SoGal Security Number(s) / EIN Number of Personal Representative(s): Street Address City State Zip Year(s) Commission paid 3,595.00 2. Attorney's Fees Goldberg Katzman, P.C. 5,300.00 3. Family Exemption: (If decedent's address is not the same as claimants, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 185.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1,151.12 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 10 231.12 SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS AMOUNT Copyright (c) 2002 form software only The Lackner Group, Inc. Fonn PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Romberger, Jean L. 21-09-0406 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Myers Funeral Home 3,595.00 H-A Subtotal 3,595.00 Other Administrative Costs 2 Cumberland Law Journal -Legal Advertising 75.00 3 The Sentinel -Legal advertising 198.16 4 Trinity Evangelical Lutheran Church -Funeral Luncheon 877.96 H-B7 subtotal 1,151.12 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rw-7572 EXa (6.981 COMAgNWEALTH OF PENNSYLVANN NHERRANCE TAX RETURN RE6GENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Romberger, Jean L. 21-09-0406 InUuda unrolmburoNl medial aXpsnsss. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Continuing Care Rx -Medical costs 1,507.05 2 Progressive Medical -Medical supplies for wheelchair 425.00 3 Waggoner, Frutiger and Daub -Tax Preparation 575.00 TOTAL (Also enter on Line 10, Recapitulation) I 2 507 05 (If more space is needed, addr6onal pages of the same size) ' Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) REV-151] Elft (e-00) COMMONWEALTH OF PENNSYLVANfA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Romberger, Jean L. NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Hans S. Romberger 5225 Wilson Lane Mechanicsburg, PA 17055 SCHEDULE J BENEFICIARIES 16(a)(1 FILE NUMBER 21-09-0406 ;ELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE DECEDENT (Words) ($$$) Do Noe Llat Trusea.lsl Brother 146,229.08 Total I 146,229.08 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 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) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98)