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Home My WebLink About03-04-10 5056051058 --~ REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN ,? ~ l ', I /~ , Po sox 28oso1 RESIDENT DECEDENT ~ ~ ~ ~,l - Hartisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELODate of Death Social Security Number ' 299-36-7258 '; 10/29/2009 Suffix -, Decedent's Last Name , r--- i j~ i DeHart ____ -- (If Applicable) Enter Surviving Spouse's Information Below Suffix -: Spouse's Last Name i~ 4 ~i DeHart _________- Date of Birth ~' '~, 02/14/1925 Decedent's First Name , MI i ' + ~iR : Emma ,_.; !-.___, MI Spouse's First Name _______-____-, ----.I I Charles ~ ~~ E ~ Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ' REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 2 Supplemental Return ,"-"s 3. Remainder Return (date of death ~ 1. Original Return prior to 12-13-82) 4a. Future Interest Compromise (date of :~ 5. Federal Estate Tax Return Required -; 4. Limited Estate death after 12-12-82) ~;, 7. Decedent Maintained a Living Trust ____ 8. Total Number of Safe Deposit Boxes r,-, ~-- 6. Decedent Died Testate (A~~ Copy of Trust) (Attach Copy of Will) 11. Election to tax under Sec. 9113(A) 9. Litigation Proceeds Received 10. Spousal PoveAy Credit (date of death t (Attach Sch. O) between 12-31-91 and 1-1-95) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIALDTAytimFe TelephoneHNumber DIRECTED T0: Name j '; (717) 243-012 ~_ Rnnalcl E- Johnson, Esq Firm Name (If Appucao~ei Andrews & Johnson First line of address j 78 West Pomfret Street Second line of address City or Post Office ~I Carlisle _ _ :~ ..aa.e~~• reiohnson@pa.net Correspond .. ___ _ -..a ~., rtio hnst of my knowledge and belief, enalNes of Perjury, I dedare that I have P _~.,.e.i.,.. ~E d this return, induding accompanying sCneauiw a, ~~ aw•-• ••_• er has any knowleoge. other than the personal representative is based on all Information of which Pry naTE It IS tnle, COreG[ anu wagn..•-• -- - SIG^TL~E O~~RSON RESPANSI~ FOR REGISTER OS USE O ~ _'_~ ~ ~ ~ =~ 7;7 = ~' - cn =' C"7 C7 'C3 ,~~^-~Q -:~a '•J ~ ~~ ~~ DATE FILED ~.-, , _, -x`~ c a S~, _. `. J ~~ ...._, r,-~ ;-~~ ~-.. .~.t -, __;., ___° -z i .--.•> r~ Y ..~ r~ I ` ~~ State ZIP Code 'PA l ;17013 Side 1 15056051058 15056051058 15056052059 REV-1500 EX Emma R DeHalt pgpep8nis wm„a. ___... RECAPITULATION .......... . L ...................... 1. Real estate (Schedule A)............ r--- •••• 2 2. Stocks andBonds(ScheduleB)•••••••••••••••"""""'••••~ 1°"'" 3. Closely Heid Corporetion, Partnership or Sole-Proprietorship (Schedule C) ..... 3.~ ,~ .............. 4. Mortgages 8 Notes Receivable (Schedule D) ............... 4.~~ I Schedule E) ... • • • • • 5. Cash, Bank Deposits ~ Miscellaneous Personal Property 5• Jointly Owned Property (Schedule F) Separate Billing Requested ....... 6 6. ~~ . 7. Inter-Vivos Transfers & Miscellaneous Noon-PS pareaterBilling Requested........ 7. (Schedule G) ~' ............................... 8. Total Gross Assets (total Lines 1-7).... s. ! g. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. '~ ~ 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .... • • • • • • • • • • • • i, 10. ,^ ~ 11. Total Deductions (total Lines 9 8 10) .................................. 11. j . r ' .. 12. Net Value of Estate (Line 6 minus Line 11) ..... ts/Sec 9113 Trusts for which . 12. x, ~~ 13. Charitable and Governmental Beques not been made (Schedule J) ............. • . • • • • • • • h 13 ' as an election to tax I ........................ 14.I~ 14. Net Value Subject to Tax (Line 12 minus Line 13) TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or ~~ transfers under Sec. 9116 166.85 ' 15. j 16. Amount of Line 14 taxable 30,055.10 '. at lineal rate X .0 45 1 s. 17. Amount of Line 14 taxable 17. at sibling rate X .12 16. Amounl of Line 14 taxable 16. at collateral rate X .15 -- .............. ... 19. . 19. TAX DUE ....................................... 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 Decedent's Social Security Number 299-36-7258 166.85 '; 43,109.10 43,275.95 '; 13,054.00 13,054.00 '; 30,221.95 ', 30,221.95 !, 0.00 '. 1,352.48 1,352.48 !. ---------= 15056052059 File Number„_ . ,,..:_..:, ......•.., REV 1500 EX Page 3 Decedent's Complete Address: DECEDENTS SOCIAL SECURITY NUMBER DECEDENTS NAME 299-36-7258 Emma R DeHart STREET ADDRESS 134 Horners Road CITY "" `PA 17015 Carlisle Tax Payments and Credits: (1) 1,352.48 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. InterestlPenalty if applicable D. Interest E. Penalty Total InteresUPenalty (D + E) (3) Llne 0 to request a refund~e ~yERpAYMENT. (4) 4. If Line 2 is grea e 2 n Pa l tii , g o n ova Fill (5) If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. 5 . (5A) A. Enter the interest on the tax due. (5B) 1,352.48 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT LACING AN "X" IN THE APPROPRIATE BLOCKS SWER THE FOLLOWING QUESTIONS BY P AN N PLEASE ves o Did decedent make a transfer and: ••.••••• 1 . a. retain the use or income of the property transferred :.....................• ht to designate who shall use the property transferred or its income : ::::.::::::: ~:::; ~;:::-::°;°;::; ~:;:: ri g b. retain the retain a reversionary interest; or.. ....... . c. d. receive the promise for life of either payments benefits. or care? .............................................................. 1982, did decedent transfer property within one year of death December 12 ft 0 , er 2. If death occurred a ......... ...................................................................................... without receiving adequate consideration? ........... • ath7........•••• at his or rit . •• ^ y 3. Did decedent own an intrust for" or payable upon death bank account or secu which or other non-probate property annuity t Account , , 4. Did decedent own an Individual Retiremen ^ contains a beneficiary designation .......................•••• THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. IF s 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 , For date is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. g po rcent For dates of death on or after January 1,1995, the tax rate imnsferto a surviving spousetfrom tax t and the statutory requirements for d sclosure of a0sse~ts and [72 P.S. §9116 (a) (1.1) (ii)]. The statute do~~ not exempt a tra filing a tax return are still applicable even ff 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 duce 2 FS hi191 6(a~ 2)] years of age or younger at death to or for the use of a natural paren , an adoptive parent, or a stepparent of the child is zero (0) perce [7 § 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)]. A siblin is defined, under The tax rate imposed on the net value of transf { one o arent in common with the decedelntg, wh helr by blood oradopt on. §9116(a)(1.3)]. 9 Section 9102, as an individual who has at leas p SCHEDULE E CASH, BANK DEPOSITS AND MISCELLANIOUS PERSONAL PROPERTY FILE NUMBER ESTATE OF 1 V 1 HL ~,uw ~,, ,,,,,,,,, ,,--- - Emma R. DeHart T_,.,..ao rhP „rnceeds of litigation and the date the proceeds were received by the estate _ _. ., __ o.~.ed..l. F SCHEDULE G TRANSFERs ESTATE OF r T1..T1.,..F 1,"jjljll'LL 1\. Lviaw. This schedule to be completed and filed if the answe TOTAL VALUE eDECD.% EXCLUSION ITEM DESCRIPTION OF PROPERTY INCLUDETfH:NAMEOFTHETRpNSFEREE.THE~RE[wTIONSF34'TODECIDEN'r OF ASSET INT (if applicable) NUMBER AND TES DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE FILE NUMBER TAXABLE VALUE 1 Checking acct no: 2891026225-Sovereign Bank Transferred 8/10/09 from Emma R DeHart or R DeHart or Charles Charles E. DeHart to Emma DeHart or William R DeHart. Charles E. DeHart E . is the spouse of Emma R DeHart. William R $813.54 $4,881.26 1/6 DeHart is their son 2 Savings acct no: 2894014576-Sovereign Bank ferred 8/10/09 from Emma R DeHart to Emma 73 1/2 $2,822.37 4 Trans R Dehart or William R DeHart (son) $5,64 . 3 Money Market acct no: 2894076622-Sovereign nsferred 8/10/09 from Emma R DeHart T 000.00 $4,070.35 1/2 $3 ra Bank. to Emma R Dehart or William R DeHart (son) , $14,140.69 4 Money Market acct no: 2894076622-Sovereign sferred 8/10/09 from Charles E. De T ran Bank. or Emma R DeHart to Charles E. DeHart or William R DeHart (son) $6,312 $37,871.37 1/6 Emma R DeHart or $29,090.94 Western National Life Insurance Co. Annuity $29,090.94 5 Policy no: Vp22106 payable equally to William R DeHart (son) Shirley L. Boggs (daughter) Evelyn E. Fields (daughter) and Judy H. Molter (daughter) SEE LETTER ATTACHED FOR THE ABOVE $43,109.10 •r'nT Ai. (also on line 7, Recapitulation) Sovereign Bank ESTATE OF Emma R DeHart SOCIAL SECURITY #: 199-36-7258 DATE OF DEATH: October 29, 2009 Checkin Open date: 11/27/1982 Account #: 2891026225 Type: g In the name of: Emma R Dehart or Charles E Dehart or William R Dehart $4,881.26 Date of Death Balance: 10/7/2009 $2.18 Int.(YTD) from 1/1/2009 to $0.19 Accrued interest to date of death: Other Info: William R Dehart added 8/10/09 Savin s Open date: 4/16/1992 Account #: 2894014576 Type: g In the name of: Emma R Dehart or William R Dehart $5,644.73 Date of Death Balance: 10/7/2009 $8.26 Int.(YTD) from 1/1/2009 to $0.67 Accrued interest to date of death: Other Info: William R Dehart added 8/l0/09 Club Open date: 12/4/2000 Account #: 2894021100 Type: In the name of: Emma R Dehart or William R Dehart $0 00 Date of Death Balance: 10/15/2009 $0.25 Int.(YTD) from 1/1/2009 to $0.00 Accrued interest to date of death: Other Info: check disbursed for $410.25 on 10/15/09-William R Dehart added 8/10/09 Mone Market Open date: 4/27/2007 Account #: 2894076622 Type: Y In the name of: Emma R Dehart or William R Dehart $14,140.69 Date of Death Balance: ~--10/'1/2009 $123.66 Int.(YTD) from 1/1/2009 to $5.72 Accrued interest to date of death: Other Info: William R Dehart added 8/10/09 e; Money Market Open date: 4/27/2007 Account #: 2894076630 TYP In the name of: Charles E Dehart or Emma R Dehart or William R Dehart $37,871.37 _ Date of Death Balance: 10/20/2009 $383.67 Int.(YTD) from 1/1/2009 to $5.72 Accrued interest to date of death: Other Info: William R Dehart added 8/'10/09 ._ page 1 of 1 02/05010 17:47 8063426966 WM.. vALIe ~, PAGE 02 WESTERN ~ NATiIONAL 5, 2010 fife I n s u r o n c B C o m p a n y CO.Ro:cB/1 Atn.ui110,TCXL 7~1R5•f1f~'1 i 1.6dOrs2~~~1990 i i ald Charles ~Cillia~a , Fax: 717.2~F3-5907 Policy Nuxnbert V)?221026 Deceased: Emma R De Hart ~ lvbc. TCillian. , r ard4ag the r~ezex-ced ~riuity contract. Tt is our gleasure to snk you for y our rece~ ~rq~Y cS ~ to ri;s and to you>c teque~. o£'service tv you. ~c yvou]d like to take this opppxhua'ty P sh Value as of Date of Aeatla on l O1Z9/20U9: $29,090.94 an uestians please contact our customer service representatives, at 1.800-424-990. you have y q 'e apprECiate this oppo~tY to sexvc you. ; ,n~4a~a J ~ ^~ >iana Rodney :taims Exa>~aiu~' AIG Annuity De~ erred Annuity Application INSURANCE COMPANY C~'Flexible Premium ^ Single Premiumv AIG Annuity Insurance Company A Stock Company 205 East 10th Avenue Amarillo, Texas 79101-3546 Telephone: 800.424.4990 OWNER (All Policyholder c rrespondence will be sent to this address.) ~ ~~ DOB: ~-1 ~'l ~ ~S. C/~/¢iL- Sex: Age: Name: ~p - 7Z Marital Status: ~ SSN: ~' Address: ~ 3 ~ ~ ~ 5 „ ~ ~~~ _ ~~C~.3 ~ , _ , , , „~ ~ l~/"~, r ~ Daytime Phone: ~~ 7 JOINT OWNER (Optional. Non-Qualified Annuities only.) Sex: Age: DOB: Name: Marital Status: SSN: Daytime Phone: ANNUITANT (if diffe'~h nt30 da s of thOe death oftthe Annuitant tthe OwneAwill beco eythe Annuitant ignate a new Annuitant. If no designation is made w Y Sex: Age: DOB: Name: Daytime Phone: SSN: Address: Relationship to Owner: OWNER'S BENEFICIARY DESIGNATION - In the event of death of Owner, surviving Joint Owner becomes Primary Beneficiary. ^ If you do not want the Joint.Ovgner , bet Primary Beneficiary,. check here and name Beneficiary below. f ~~l ~ ~ ~ ~ ~j Af~T Relationship: Primary Beneficiary: Name: ~ .~ Relationship: Beneficiary: Name - ~ ""-~ INTEREST RATE (Interest is credited and compounded daily to achieve the annual rate. To achieve this rate, the premium must be left for a full year without any withdrawals.) 0 The Interest Rate on the (Initial/Single) Premium is ~,~ % for ( year(s). PU PLAN TYPE (required): Tax-Qualified Plans: Policy Number: V r ~ 210 2 6 Init//ial Premium Payment: $ ~ ~'i G~`A GIN -Qualified ^ Qualified Policy Date: •5 ~ ~ r Annuity Date: ~ ~~ on ^ Traditional IRA ^ SEP IRA ^ Roth IRA ^ 401 (Corporate Plan) O Transfer Check one: O Initial Contribution for Tax Year must be made payable to ^ 403(b) TSA ^ Other: ^ Rollover ^ Roth IRA Conversion Year Annuity Insurance Company Will t is annuity replace or be exchanged for existing life insurance or annuities? ^ Yes t ~f No 1 do ^ do not have existing policies or contrac s. I understand t e'nts and answersen this applic ton0 areecompleteyand true. Inhaverread and understand thel important deisclosuPesll orated on the that all statem reverse of this application. Joint Signed at (city/state): on (date): REPRESENTATIVE INFORMATION To the best of my knowledge and belief, this Appliofteach dis^closuee statement and aI listlof compan es involved a'nd Indic ted cost bas snuities. If lacement is involved, I hav attached a copy ? ~, ~ gency Name and Number Licen's/ed Agent's Signature X~~it~t.ae~ ~ Ib~ ~~L~ StateLic.#: Agent: ~L~~:-' Licensed Agent (Pant name) ~~.,,, ir~~_nn_n WHITE -Policyholder Copy YELLOW -Home Office Copy PINK -Agency Copy GOLD -Agent Copy SCHEDULE H FUNERAL EXPENSES, ADMII~IISTRATIVE COSTS AND MISCELLANEOUS EXPENSES FILE NUMBER ESTATE OF Emma R. DeHart Debts of decedent must be reported on Schedule L eMCli iNT ITEM NUMBER A. 1 2 B. 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 DESCRIPTION Funeral Expenses: Ewing Brothers Funeral Home Administrative Costs: Personal Representive Commissions Name of Personal Representative(s) Social Security Number of Personal Representative: Street Address: City: State: Zip: Year(s) commissions paid: Attnrnev fees to Andrews & Johnson Family Exemption Claimant Chazles E. DeHart Street: 134 Homers Road City: Carlisle State & Zip PA 17013 Relationship of Claimant to Decedent• spouse Probate Fees to Register of Wills Accountant Fees to Patricia Rosendale, CPA Tax Return prepazer's Fees Register of Wills -filing fee TOTAL (also online $8,519.00 $1,020.00 $3,500.00 $15.00 $13,054.00 SCHEDUI-E J BENEFICIAR~S FILE NUMBER ESTATE OF Emma R. DeHart ADDRESS OF BENEFICIARY RELATIONSHIP AMOUNT OR SHARE OF ESTATE ITEM NAME AND Do Not List Trustee(s) NLINIBER TAXABLE D15TRID~TIONS [umluda ouai¢ht spoasel diatribaGOm, ead uwfas radar Sec. 911K+X1.2) husband $166.85 I 1 Charles E. DeHart Carlisle, PA 17013 Road , 134 Homers $14,018.16 son 2 William R DeHart Carlisle, PA ]7013 Road , 134 Homers daughter $7,272 73 3 Shirley L. Boggs 241 South West Street, Carlisle, PA 17013 daughter 272'73 $7 4 Evelyn E. Fields Orrstown, PA 17244 Rd i ' , n 12300 Sandy Mounta daughter $7,272.74 5 Judy H. Molter 35 Ston Run Rd, Dillsbur , PA 17019 II NON-TAXABLE D~T(ZIgLI'IIONS: UTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE A SPOUSAL DISTRIB Cha[itable and GovemmmW BequesU: AND GO~RI`T~NT~, ggQUESTS (also enter online TOTAL c~T,d,BLE