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" -.~ r~ "'k ~ ~ .. r" i '~, ` .. l~io -~i- ~7~ 15056051058 REV-15 O O EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 I NHERITANCE TAX RETURN ~ 1 ' ~~ C~®'~~ Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 191-24-1301 ' 12/12/2008 03/29/1931 Decedent's Last Name Suffix Decedent's First Name MI HOSTETTER '. BETTY ' ~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI HOSTETTER ' MELVIN E Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 190-12-8995 REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW ~ 1. Original Return 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death 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 DIR~ED TO: Name.. Daytime Telephc~ Number ~"~=' { CYNTHIA L. MERCURI •; .. ~ ~ ~ -~ (610) 291-0?~ ~ ~ Firm Name (If Applicable) ~ °~~ ;` i --~ f,,`7 ~ _ _ _ ~ ~: ', REGISTERrf3~ ~S-I~j.+,~ U5E {1DtLY ~ , _ ,~ ._ ,. - c.1~ First line of address ~ f r --''~-~ ~~' i '~" :' 26 SADDLEBROOK LANE , _ _~~ .:~' ~ = s- __ ~ Second line of address .. `L~. f~ C,"'t City or Post Office _ State .......ZIP Code DATE FILED PHOENIXVILLE PA ' 19460 Correspondent's a-mail ad ~ ~ Cyl1@V@CIZOC1.11@t Under penaltie e d are at I have examined s retur ,including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, co ct and co pl e. D claration of preparer her th the personal representative is based on all information of which preparer has any knowledge. SIGNAT E OF P RE NSIBLE F FI G RE URN DATE ~ /L/ c ADDRESS =" .r ~~ _ ~ /~.~E_/~(L~ . - J~/-~~~~tl./ ~ °r.~i ~i~~ ~~LK~ ~~ ~ `'7 "~iLGL_J SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ADDRESS DATE PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 J 15056052059 REV-1500 EX Decedent's Social Security Number BETTY J HOSTETTER ' 191-24-1301 Decedent s Name: .. ,.... RECAPITULATION 1. Real estate (Schedule A) . ....................................... ..... 1. ', 2. Stocks and Bonds (Schedule B) .................................. ..... 2. ' 31,164.80 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. ', 4. Mortgages & Notes Receivable (Schedule D) ........................ ..... 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ... ..... 5. 5,690.03 6. Jointly Owned Property (Schedule F) Separate Billing Requested .. ..... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) _ Separate Billing Requested... ..... 7. 117,095.60 8. Total Gross Assets (total Lines 1-7) ............................... ..... 8. ' 153,950.31 ': 9. Funeral Expenses 8~ Administrative Costs (Schedule H) ................ ..... 9. ', 16,721.00 ', 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ........... ..... 10. 11. Total Deductions (total Lines 9 & 10) .............................. ..... 11. 16,721.00 ', 12. Net Value of Estate (Line 8 minus Line 11) ......................... ..... 12. 137,229.31 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. 137,229.31 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable __ at lineal rate X .0 45 16, 6,175.32 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 ' ' 18. 19. TAX DUE .................................................... ..... 19. 6,175.32 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: File Number ,_ DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER BETTY J HOSTETTER 191-24-1301 STREET ADDRESS 42 CENTER DRIVE CITY CAMP HILL STATE PA ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 6,175.32 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments 323.91 C. Discount Total Credits (A + B + C) (2) 323.91 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 0.00 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. (5) 5,851.41 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 5,851.41 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? ...................................................................... ^ 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? .............. ^ ^x 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ ^x ^ 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. REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER BETTY J. HOSTETTER ~/~ ~~~ All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER BETTY J. HOSTETTER ~"~Q~._ ~~~' Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY OWNED PROPERTY ESTATE OF FILE NUMBER BETTY J. HOSTETTER ~~~- ~~~ If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A• CYNTHIA L. MERCURI 26 SADDLEBROOK LN, PHOENIXVILLE, PA 19460 DAUGHTER B. C ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET °/a OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. JOINTLY-OWNED PROPERTY: TOTAL (Also enter on line 6, Recapitulation) I ~ (If more space is needed, insert additional sheets of the same size) 0.00 REV-1737-6 EX + (6-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN NONRESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & Use Schedule G, Part 2, ONLY for proportionate method of tax computation. MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER BETTY J. HOSTETTER ~/OC~_..,. ~!~l Part 1 must include all transfers of real estate and tangible personal property located in Pennsylvania. Complete Part 2 ONLY when the proportionate method of tax computation is elected. Include in the description of property the date the transfer was made and the name and relationship of the transferee. This schedule must be completed and filed if the answer to questions 1 through 4 on the reverse side of the REV-1737 cover sheet is yes. DESCRIPTION OF PROPERTY ITEM Include the name of the transferee, the relationship to Decedent and the date of transfer. DATE OF DEATH % OF DECD'S EXCLUSION NUMBER Attach a copy of the deed for real estate. VALUE OF ASSET INTEREST (IF APPLICABLE) TAXABLE VALUE ~• COMMERCE BANK 14,395.70 50 7,197.8 2. IRA FBO BETTY HOSTETTER (PERSHING LLC) 109,897.75 100 109,897.7 PART 1 TOTAL $ $ $ 117,095.6 ~ ., - DESCRIPTION OF PROPERTY ITEM Include the name of the transferee, the relationship to Decedent and the date of transfer. DATE OF DEATH % OF DECD'S EXCLUSION NUMBER Attach a copy of the deed for real estate. VALUE OF ASSET INTEREST (IF APPLICABLE) TAXABLE VALUE 1. PART S TOTAL $ $ $ 0.0( TOTAL (Also enter on Line 7, Recapitulation.) I $ 117,095.60 (If more space is needed, use additional sheets of paper of the same size) • REV-1737-6 EX + (6-08) REVERSE ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN NONRESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & Use Schedule H ONLY for proportionate method of tax computation. ADMINISTRATIVE COSTS --- ___ ESTATE OF FILE NUMBER BETTY J. HOSTETTER ~ ~ ~~~.- '- ~~17 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT q. FUNERAL EXPENSES: ~' PARTHEMORE FUNERAL HOME 7,706.00 B. ADMINISTRATIVE COSTS: 7. Personal Representative's Commission(s) 5,000.00 Name(s) of Personal Representative(s) CYNTHIA L. MERCURI (Submit requested information for additional personal representative's on additional sheets) Social Security Number(s) or EIN Number(s) of Personal Representative(s) Street Address(es) 26 SADDLEBROOK LANE City(ies) PHOENIXVILLE State(s) PA ZIP(s) 19460 Year(s) Commission Paid 2009 2. ~ Attorney Fees 3• Probate Fees 115.00 4• Accountant's Fees 400.00 5. Tax Return Preparer's Fees 6. Miscellaneous Expenses FAMILY EXEMPTION: MELVIN E. HOSTETTER (SPOUSE) 3,500.00 16,721.00 TOTAL (Also enter on Line 9, Recapitulation.) $ (If more space is needed, use additional sheets of paper of the same size) F~EV-3.513 EX+ 11-0£} ~ pennsylvania SCHEDULE ] DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER BETTY J. HOSTETTER ~/Q~'-~~`~ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a} (1.2}.] 1. CYNTHIA L. MERCURI DAUGHTER 33.34 26 SADDLEBROOK LANE, PHOENIXVILLE, PA 19460 2. KURTIS A. HOSTETTER SON 33.33 3624 SIMONTON PLACE, LAKE MARY, FL 32746 3. KERRY A. HOSTETTER SON 33.33 19100 E. SHELBY ROAD, NEW KNOXVILLE, OH 45871 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, insert additional sheets of the same size. ~N dueQaU~ ~~~ ~~ c'% ~ ~a c~