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HomeMy WebLinkAbout01-29-10 (2)t , 15056041046 REV-1500 EX (05-04) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Dept.28oso1 INHERITANCE TAX RETURN "~ ~ /` ~ ~ lJ ~ j `l Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~ ~ a ~ ~ 4 ~~ ~3 i ~ 3 t zoo$ 05 ~ ~ ~ ~ ~ 3 Decedent's Last Name Suffix Decedents Firs t Name MI ~A~~i rJSGn1 ~~~~ ~ ~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffx Spouse's First Name MI Spouses Social Security Number FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS O 2. Supplemental Return O 3. Remainder Rdturn (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 Number Firm Name (If Applicable) First line of address g33 ~ ~.v ~~ ~ s Second line of address City or Post Office State C~At2C_ts~~ Ply REGISTER OF WILLS USE ON~ n ~ ~ c~ +~ t73~ I ~-, --: ~ 7.5s _> m N ~~~ ~ 7 ~~ ~T7 ~ ~~ ~*- -- ZIF Cude L ~7©r3 _ ~"~! t ~7 r ~ 7 C_- F _~.~ - r-i - -.~t ~~ fir..-::. f'°.i 1 i.,7 ; - -ti: Correspondent's a-mail address: Under penalties of perjury, I eclare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, e, correct and c mpl te. De aration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNET OF PER N RESP NSIBLE FOR FILING RETURN ~ ~~TE _` SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056041046 15056041046 J _, 11'1 J 15056042047 REV-1500 EX Decedent's Social Security Number Decedent's Name: ~, ..,,ti,, _. RECAPITULATION 1. Real estate (Schedule A) ............................................. 1. c ~- 2. Stocks and Bonds (Schedule B) 2. 1 ~ ` ~5 ~' `-~ ' ....................................... _ ,. __, ~J.Yr .4_ti`~~ 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . , ... 3. E r 4. Mortgages & Notes 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 (Schedule G) C Separate Billing Requested........ 7. . ~ , . 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 an election to tax has not been made (Schedule J) .................. ...... 13. 14'. Net Value Subject to Tax (Line 12 minus Line 13) .................. ...... 14. 1. ~~ ~ ~ ~~ q r~ I ~,`f;:~~~~ TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers and r ec. 9116 (a)(1.2) X .0 15. 11 ~ ~ l 16. Amount of Line 14 taxable at lineal rate X .0 _ . 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. `~`. 18. Amount of Line 14 taxable at collateral rate X .15 ~ 18. ~' L ~G ~ 19. TAX DUE ..................................................... ....19. ... ~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 15056042047 15056042047 REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME -- ----------- STREETADDRESS 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. Interest/Penalty if applicable D. Interest E. Penalty (1) ~a t.53 Total Credits (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) (56) 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 :.................................................................................... ...... ^ [~ 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? ................................................................ ...... ^ Q 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 "in trust 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 I4S 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 isdefined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCl~EpVLE N FUNERAL EXPENSES 8~ ADMINISTRATIVE COSTS EST FILE NUMBER Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: e. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) (:laimanf State Zip Street Address City State _ Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's fees 6. Tax Retum Preparer's Fees 7. Zip ~~© ~ d4. r TOTAL (Also enter on line 9, Recapitulation) I $ `'? ~ (o ~ `~ (If more space is needed, insert additional sheets of the same size) a~v.,soe ex. I,an COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ,. m+rt c3,~~ ~~ ~ ~c-r -# t s o o y a ~ 0 9 a I o I ~ - cr+ ~~ ~ ~t ~ o ~ . © t (1n -+-r ~A rJ1~ A cc r ~ ~ O ~ ro a ~ O - c++K~ ~ a ~ 5 (YI P~ Ue~~ ~D~ ~ rn ~ i3 P~03 ~r6 ~%~~ 4~ 1 ~ ~ 4 (~, ~~~~~~ 335 6864403 c~ ~ c~ . a ~ a Go. Ua TOTAL (Also enter on line 5, Recapitulation) I S ~ I f Raj ~ , _ (If more space is needed, insert additional sheets of the same size) REV-1503 EX+ (6-98) SCHEDULE 6 COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Ali property jointty-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert addiBonal sheets of the same size) - ,- .,_~ ~- ~' _ ~' TITLE` !' A - - _ E OF a _ ~~ ~ ~~ ~~ i ~r~ ; ~, ~ .,/~; ,--r -' _ ,_.. x~ VEHI - N R CO 1 ~~ >~~ .. __ . i~ - i . ~ . -- :.r ' ~ . $. rc .. _ I ES s'~; - FIRST NAME - >. -' , w ,.-- ,..,_.. ,~ - r , I ~~ _ I ~e w 'm ~,~. .-ter, COSE ER ' ` ,~ .zr , ~~..-~~JFV... :. ' (,` '..~ .-F- DUE T...... E~, ~1SI ESS ' E) FIRST NAirtE E NAMQ PA;pUp. ... ~ ) ~ ~ ~~ iteva.e> ,. . , "`>_- ORS ~ ' v ~ _ I ~ - ~ ~ ~ ~ ~ ~ ~~ ~ i /~ 7 -~~ ~ i ~ / - W O~ RLASPNAME .- ,. DLE NAME PA H ID# D BIiFF3i ~. Mlp ',.. -'y; ,~>: a 'V , k. . r _ ~ ~ , , ,..._ ST -- -- a ,. -. ~ ~ .~. ~ ~ .! ~ .e . :,~ -. - .... " _: 1797.E FEE -- `~ ~ .`. ' . ~~ :^ CI - ,z,.,,~•-" ST ~E DATE ACpUIREDb ~ y ~_ .. ,~. R6raER.TA000NTY CODbS `} - i - ` - .~;,:. tlS~.., NSE SIDE ~° ~' - 'r-- ,.. .. ,, ,-~- . - ,.- - s6 ~_..: - ~ _, - _ ~ CO~U NAME ' fill ~ fiNAME PA~DLlPH6T0-IG~k' - UAWE": Bl ~..,,. _ _ ~~~ ~ m ~ !~ ~- ...~i..~":. ~ FEE EXEMPT NUMBER. ~ A$ ASSIGNED BY „~, .- C! . U. . - r,- S. ._ ~' = - ~ G :-.. ~ MIRED/ :' ~~ - <~ .. ~~ k ,;~~. ~ ~ SED REF - ~ .p.. _ ._ YELLO ." ,> _ "~ . MAID ,: ~ yE _.. .. -zr~ ~,. -. , ., . _ - ~ ~ _, ~_,. - -. .' t , ~w ~ A -. - ~ , F -... -. .~ USCY#SSUEDPLATE .. `. ~ :. ° ...:. - ) -. O `PLATE ~ `!SY :.., - -~ . . M ~ ~ » - - , - ~ l~M " `I~CgALAF PLATE DEP F OF .. w~ ~r - {~~ _ p^ ~, ~ E TRANSF ~ ~ EMENT O , F -' -- _ tj ~.~) '- - . ,~ = ... .~ '. x. , ~ F ~ - , . N O NEI41zR'~ECEIVED~(Loat in Maff~ .. - _.. - - ZE'#>~5U ' ~'"_ • _ _ ~ - .., 6 ~ _ ,,.. ... ` NOTE: K YJEVER'R~1K ~ ;.,. tlA,'aicent,~muslaornpfBt9~ortn MV~4. BYF-FJLL AGF3IT ~' __ .~ YeaF .:. ." ~ ..." ~ - au,. ' '- LL p d FROM TITLE NO. :. _. - -::: *,... VIN - - _ ;._, , a F -... -:. - ....- -... "~ ~ ~ __ 3 _. IPTO ~ _. 31. ... RE SIGR!1_f~ERE ".; .. ~ ~ -~., : WE G ~ , c -,:.. ..-,.. ,.+.. " '' -. ~~_'. f Ci -.... POLICY NO, Ca ~. .. w ~ _. F t~_ e~-. ~ ENT {P INT NAME) '.. T- ~y'°~ 9,~~5 _ ~ j - `' - ~ ~ ~ ]~ `•,~ -~ ^ TEMPO TDTh1 UU~fi, SCANT IN . • ~ - - INFORMAA _ ~.WI11i ALL ~ QVISIONSAF:TFIE VEHICLE A ~ TELEP ..., I - ' - " i ~.~ _.,. u DEPARTM - _ G' _ VW ~ ~47ATI/VR~ HAV Ep AND SIGNED THIS FORM AFTC~~S CDMPC~TION AND THAT THE INE. ON ~C" M1~'[(pN ISaCLAIME4, P ~ R.FURTH~R GER79 EIS AUTHORIZED TO G' ~.I;THIS PTION. . ~ - ~ ~ LOSE ql ~ U ~°'~ GE H ~~ - _ N(Pt FN{,URE~.A,t 19t41'IEULL. $PONSl61 7HE G~E,.~tTtY RE(~ F - ~ ACIBVGtNLEDG~ zz . 8ESI9BJE6Y T(3A FlNE'NOT E'kE'LEDING ~ ~ f~ILA7T "I MORE'THAN TWO YEARS FORftI~`FN~S~STA~H-IEF'Ff'~ Fl~S` FORM - .. "-, r . ,. -: : ~~ , ~• . ~ Tele .. _ No. ~~: :y.. ,' 1ST ~r or.. .-._-...,,r,- _-_,,,_-~s~... ,.. - ~:~ ~. R AMENTN urifiaser ~ oT~.Signer - (1/) ''.~'`J ' `~ 2ND -~. a -:.: •- -.,, ..... _., ">:• ,.-' _ - ~ , ~:~,T - ' , . - ASSIGN- .. :~.x> _ _ :- , H ~~ $~ IFACO~PURCFlAS YOUR SPOW iSTED AND- -LfiE.7T~i3BE LISTI~Q~~ ~HT.OF SWRWWpRSHIP'(ON.DEATH OFONE DINNER; .. ~ ~ ~ ~ . ~ m w ~ -E ~ T1 ~~~ ER:) CHECK;N7"~..: THE ~ 71 {531~ED~AS 'fENj" CMIMON` "EAT}l~OF ONE OWNER. INTEREST-Y9F'DECEASED OWNER `~. ~ _ "F~j5r19ER HEIRS OR•ESTA7F,~ "`^•'-~ -- ~ '-~ - -.- .-~- _ _: ~OTE: IF TNE.>£ISSO BE USED ASADAILYRENTAtid~~EE,4SED VEl1i'CCF'bHE~81iQ`C~r~~1CifiCK IS-CHEGkL~D,.COMPCfTE"ANyGH:FOR6f~MV-1 L. a .a ,:; .... ,.. ~.~ ikPPWIC~IT'~7"I'~MPORkft9~ REGIST~.I~IQM (@YP0 ,-y~~„ , MetLife BNY Mellon Shareowner Services P.O. Box 358420 Pittsburgh, PA 15252-8420 Account Registration: 3208 01 0000178 0000355 ~, The MetLife Policyholder Trust ("Trust") ~~ Transfer Transaction Advice ,,..~ RETAIN THIS DOCUMENT FOR YOUR. RECORDS rir 0000176 02 t~ 0.696 •~AUTO T3 0 3258 17013-261833 COl B1MAI - 23 - Date' 2/12/2009 IIIIIilllll 11 111 11 111 l1111111111111111111111111111111111111111 .. \j~ DEAN HANKINSON 1{1~„rY . a / ,, 833 E LOUTHER ST -f,Ab~ ~ ~ ~;•y `~' CARLISLE PA 17013 p ~DK_' ,~ ~P 1~ ~(~ ~ !/ r ~. For information concerning this statement, please call BNY Mellon Shareowner Services, MetLife, Inc.'s Transfer Agent, toll free at 1-800-649-3593 - - - ____ __.---_ ~ _ --- _.._~ :~~. _:,-~ .~ .ter , ~:~~. >,,:~. ..:.~.-mom Trust Interests (Shares) 32.0000 CUSFP Number 59156R10 Transaction Date 02/11/2009 Transaction Advice Number 0002249241 Investor ID 1251 0959 3743 This Transaction Advice is your record of the indicated Trust Interests being credited to an account on the books of the referenced transfer agent. The Transaction Advice should be kept with your important documents as a record of your. ownership of these securities. These Trust Interests are transferable only as permitted under The MetLife Policyholder Trust. Please read the important information on the back of this form and in the .Purchase and Sale Brochure. If you wish to request a purchase or sale transaction, detach coupon at the perforation and complete the applicable side of the form. PLEASE BE SURE THIS ADDRESS APPEARS IN THE ENVELOPE WINDOW FOR PURCHASES ONLY Purchase Instructions 12 51 09 5 9 3 7 4 3 Change of Address: (See reverse side to SELL) DEAN HANKINSON BNY Mellon Shareowner Services P.O. Box 382200 Pittsburgh, PA 15250-8200 In111r11Iu1IlIl(111IIInInFnIIIIIIn111n1IIrn(In1I1nII Signature (if address is being changed) Make check in U.S. dollars, payable to: MetLrfe Purchase Program Amount Enclosed Minimum investment 5250 (except as described in the Purchase and Sale Brochure) 0000101 1[]2 ..7,25109593?43 6 II EMPLOYEE NUMBER r " ' GF-2aa (tuon ~ ORIGINATING T ~, ~ ~ I ~ ; ~ ~~ ~, IT: WIP TRA DEB ~ION ~SpC . r.... -~ ~ cos CENTER J ) AUTHORIZATION ~,'~(c.~i~~ r DATES = ~ } SU CT ACCgLINT # ~ ('~ `" GUSTO ME (PRINT) DESCRIPTION ~ 1 I~_'~~'~~1~ ~ ~-+t n . ~' ?. Original -Processing Work "' / /-~i .~ ~ ~ Copy -Branch CUSTOMER SIGNATURE ORIGINATING G/L NO. POSFfNG COST GTR. UUAN DATE COST CENTER SEQ. NO. 2 1 9 0 7 8 7 ~ ~ -~ ~.' v w~ ;' ' i. AMOUNT I r I - I i ORIGINATING~oi COST LPL- CENTER `' j sus o 1~ Accour I DESCRI N ~~.~ A 1~ I { Original -Processing Work j Copy -Branch l I I i ~._ !I p c GF-269 (fl/07) ,, EMPLOY~~NUAA~ER f~ Q~vORIZATIOF~I{'~~ ~~NVT'ON. (!!!! ~~S ~'t ~ Y~' ~ ° .DATE I' 1... Cr1 - J _ ~ CUSTOMER NAM INT) ~ 0 ~c ,-~ 1 a V CUSTOMER SIG E " ........ .. _ ORIGINATING . G/L NO. POSTING COST GTR. JULIAN DATE COST CENTER SEO. NO. AMOUNT c