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Home My WebLink About03-19-10 (2)15056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Po Box 28oso1 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 21 09 0932 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 180-28-2072 ! 07/20/2009 11/04/1917 Decedent's Last Name Suffix Decedent's First Name MI Melvin Mary R (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE 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 v X 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 DIRECTED T0: Name Daytime Telephone Number James W. Kollas (717) 731-1600 Firm Name (If Applicable) -" -" REGISTERrO~D WILLS US r.a " E ~}~Y r-' ~ 'S' Kollas and Kennedy ! C ~ ~ ~ 1 ~_~ , First line of address _ _ _ _ _ r l -~ C7 :C? c . ., t ~ =~~. r- Tt - ... -- ~.. 1104 Fernwood Avenue r -~ ( "` ~ ~~ ~ ._ ~ -' _ , ~ _ ;: ` Second line of address ~ ~', C~ 4 ~. _ : ~"-i 1." Suite 104 .._..; r..._ _".' ~ y .. - o _,_ 7 r~i DA F L ~l ~. ~ ~' City or Post Office ED State ZIP Code - - ; ~ _ _ ....,j Camp Hill PA 17011 Correspondent's a-mail address: jameS@kOllaSandkennedy.COm 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 pr~eparer othert#aan the personal representative is based on all information of which preparer has anv knowledge. Side 1 15056051058 15056051058 - ----Cloy ~e,-n ~-I~~..~' .~~_ Caw, r f~,'~/ ~.-~ / ~~/ PLEASE USE ORIGINAL FORM ONLY J 15056052059 REV-1500 EX Decedent's Social Security Number Decedent's Name: Mary R Melvin m~..~ ..~w.w...~ .,.~~. _a, I~~I 180-28-2072 .. ~~... RECAPITULATION ..v....W.. _ ____._. 1. Real estate (Schedule A). ............................................ 1. ` 0.00 2. Stocks and Bonds (Schedule B) 2. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00 4. Mort a es & Notes Receivable Schedule D 9 9 ( ) ............................ 4. ' 0.00 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 25,915.68 6. Jointly Owned Property (Schedule F) ..u Separate Billing Requested ....... 6. 8,876.60 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property (Schedule G) `~"~-~ Separate Billing Requested........ 7. 0.00 8. Total Gross Assets (total Lines 1-7) .................................... 8. 34,792.28 9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. '; 8,021.23 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ 10. ;I, 360.38 11. Total Deductions (total Lines 9 & 10) ................................... 11. ', 8,381.61 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. ', 26,410.67 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 26,410.67 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 45 26,410.67 '' 16. 1,188.48 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. 1,188.48 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 21 09 ~ 0932 DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER Mary R Melvin 180-28-2072 STREET ADDRESS 4837 East Trindle Road CITY Mechanicsburg STATE PA ZIP 17050-3680 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 1,188.48 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 0.00 3. InterestlPenalty if applicable D. Interest E. Penalty Total InterestlPenalty (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) 1,188.48 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 1,188.48 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? .............. ^ 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 1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDtlLE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Mary R. Melvin 21-09-0932 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 Mary R. Melvin 21-09-0932 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. Elaine D. Connolly 51 W. Main Street New Kingston, PA 17072 B C JOINTLY-OWNED PROPERTY: Grandchild 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 % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. 04129104 PNC Bank NA 2,517.78 50 1,258.89 Checking Account: 5004823605 2• A. 04/29/04 PNC Bank NA 15,235.42 50 7,617.71 Checking Account: 5004577723 TOTAL (Also enter on line 6, Recapitulation) I $ 8,876.60 (If more space is needed, insert additional sheets of the same size) PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D Po Box z8o6o1 TAXPAYER RESPONSE HARRISBURG PA 17128-0601 may-1543 IX AFP C08-08) FILE N0. 21 09-0932 ACN 09169266 DATE 10-26-2009 EST. OF MARY R MELVIN SSN 180-28-2072 DATE OF DEATH 07-20-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS ® CHECKING TRUST CERTIF. ELAINE D CONNOLLY 51 W MAIN ST NEW KINGSTOWN PA 17072 PNC BANK NA provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a ]oint owner/beneficiary of this account If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 000005004823605 Date 04-29-2004 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 2, 5 1 7 ' 78 payment to the Register of Wills. Make check " payable to Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to Tax 1 , 258.89 NOTE: If tax payments are made within three months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Potential Tax Due $ 56.65 Any Inheritance Tax due will become delinquent nine months after the date of death. PART TAXPAYER RESPONSE , YSC:'` yy °: f'0':r::;.'•',.~:f';i4:{i": f:, ::..»:::;;;:.::i::r,:%::6;..::;':;:.; ~v l~xri.~rw'ILYk.A(L.r~+Z`.`f~iLY`. L.f6.:.,.%i:.w..4.......::..va.c......e.. •x•::n::~::<.;:r::::.~.y::::.~:.........~:::::::::.~::::.~:.~:.::::. ~ : ............................ y...... .......:...:......::......._..,..............:..:.:::,n...,............. n.......::..:.:,:._ TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of 0 N E Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3~ below. ,. , .;: PART If indicating a different tax rate, please state 's~,tf `.~:,>;:;;,. ~~ ~~~~ ~'~-~~~>~~•Y=~~:•~}~~;;:~:~~` :~>~; ::. 2 relationship to decedent: .. ~.• ,.•' ~z: z~ OF TAX ON JOINT/TRUST ACCOUNTS 1 2 $ 3 X 4 5 - 6 $ 7 X 8 $ 7. Tax Rate 8. Tax Due PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMAl11JT DAT11 Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. H 0 ME C WORK C ~ TAXPAYER SIGNATURE TELEPHONE NUMBER DATE ~~~~ ~~~~~o~ ~~~ amine ~ or iax computation) S GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance Tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are fully taxable. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in Block A of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with a check for the amount of tax to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check Block C and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent who died afterl2/12/82, accounts the decedent put in joint names within one year of death are fully taxable. However, there is an exclusion not to exceed 53,000 per transferee, regardless of the value of the account or the number of accounts held. If a double asterisk (**) appears before your first name in the address portion of this notice, the 53,000 exclusion was deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons: 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7 percent (TAXABLE TO EACH SURVIVOR) B. The percentage taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED BY 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable Cline 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (Line 6) is determined by subtracting the debts and deductions (Line 5) from the amount subject to tax Cline 4). 7. Enter the appropriate tax rate (Line 7) as determined below. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent *The tax rate imposed on the net value of transfers from a deceased child 21 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 0 percent. The lineal class of heirs includes grandparents, parents, children and other lineal descendents. "Children" includes natural children whether or not then have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others; adopted descendents and their descendants; and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The Collateral class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You are legally responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after the death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use 8 1/2" x 11" sheet of paper. Proof of payment may be requested by the PA Department of Revenue. PENNSYLVANIA INHERITANCE T INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D PO BOX 280601 TAXPAYER RESPONSE HARRISBURG PA 17128-0601 REV-1543 IX AFP C08-08) FILE N0. 21 09-0932 ACN 09169267 DATE 10-26-2009 ELAINE D CONNOLLY 51 W MAIN ST NEW KINGSTOWN PA 17072 EST. OF MARY R MELVIN SSN 180-28-2072 DATE OF DEATH 07-20-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT ® SAVINGS CHECKING TRUST CERTIF. PN C BANK NA provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, You were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania: Please call X7171 787--8327 wit's questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 000005004577723 Date 04-29-2004 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 15, 235.42 Payment to the Register of Wills. Make check payable to Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax 7, 617.71 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Potential Tax Due $ 342. $0 Any Inheritance Tax due will become delinquent nine months after the date of death. PART TAXPAYER RESPONSE 1 d¢%` f •' :f>l ":`fl'.^. ...3 . ..1... fi:::'::.:..:51':>;:;::y..j<:::i:'t~R:r::;.:<:~:::::. :vr ` ': :s~:y:. :.::::.... +;.E•;c ;~ !s' :.:: '~ ~~ ::.a. .: '.:?:;: {:: ~~ ~., .:, :... ::~.:.::.. :.:~:.::: ii' I n~~f .. •i ~' :.F: A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, ar check box "A" and return this notice to the Register of 0 N E Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informa ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state 2^ relationship to decedent: TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 2 $ s X 4 $ 5 - 6 $ 7 X 8 $ PART DEBTS AND DEDUCTIONS CLAIMED a DATE PAID PAYEE DESCRIPTION eMniiur porn Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. H 0 ME C WORK C TAXPAYER SIGNATURE TELEPHONE NUMBER DATE ~~+~'+~ ~~n~ar vn s_ine 7 OT IaX computation) $ GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance Tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are fully taxable. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in Block A of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with a check for the amount of tax to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check Block C and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent who died afterl2/12/82, accounts the decedent put in joint names within one year of death are fully taxable. However, there is an exclusion not to exceed 53,000 per transferee, regardless of the value of the account or the number of accounts held. If a double asterisk (**) appears before your first name in the address portion of this notice, the 53,000 exclusion was deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons: 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7 percent (TAXABLE TO EACH SURVIVOR) B. The percentage taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED BY 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax Cline 4) is determined by multiplying the account balance (Line 2) by the percent taxable (Line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable Cline 6) is determined by subtracting the debts and deductions (Line 5) from the amount subject to tax (Line 4). 7. Enter the appropriate tax rate Cline 7) as determined below. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent =ins ~a,c r•a~e imposes on zne nez value or iransrers rrom a tleceasetl cn11tl Z1 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 0 percent. The lineal class of heirs includes grandparents, parents, children and other lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others; adopted descendents and their descendants; and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The Collateral class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You are legally responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after the death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use 8 1/2" x 11" sheet of paper. Proof of payment may be requested by the PA Department of Revenue. REV-1511 EX+ (10-09) ~~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Mary R. Melvin 21-09-0932 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Funeral Expenses - Malpezzi Funeral Home 2,512.00 2. Head Stone Inscription - Woodburn Memorials 162.00 3 Opening Gravesite - St. Bernard's Cemetery 200.00 B. 1. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Geraldine M. Melvin Street Address 51 W. Main Street city New Kingstown Year(s) Commission Paid: 2010 2,337.54 2, 337.54 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) 0.00 Claimant Street Address 4, 5, 6. ~. City State _ Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Preparer Fees: 472.15 0.00 0.00 TOTAL (Also enter on Line 9, Recapitulation) $ 8,021.23 If more space is needed, use additional sheets of paper of the same size. State PA ZIp 17072 ZIP REV-1512 EX+ (12-08) ~ Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Mary R. Melvin 21-09-0932 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (11-08) ~ pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF Mary R. Melvin FILE NUMBER 21-09-0932 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. Valerie M. Green Grandchild 1 /5 1926 Princeton Avenue, Camp Hill, PA 17011 2. Elaine D. Connolly Grandchild 1 /5 51 W. Main Street, New Kingstown, PA 17072 3. David L. Melvin Grandchild 1 /5 2014 Carlisle Road, Camp Hill, PA 17011 4. Sean Melvin Grandchild 1 /5 2014 Carlisle Road, Camp Hill, PA 17011 5. Greg Melvin Grandchild 1/5 819 W. Trindle Road, Mechanicsburg, PA 17055 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. LAST WILL AND TESTAMENT OF MARY R. MELVIN I, MARY R MELVIN, residing at Yeager Personal Home Care, 103 W. Keller Street, Mechanicsburg, Cumberland County, Pennsylvania, do make and declare this to be my last Will and Testament, hereby revoking all prior Wills and Codicils. FIRST: I direct that all my debts and funeral expenses be paid as soon after my death as maybe practicable. I further direct that all estate, inheritance, transfer, legacy, or succession taxes which maybe assessed to my estate, or any part of my estate, whether passing under my will, shall be paid out of my residuary estate as an expense of administration and without apportionment. SECOND: I give my personal property, tangible and intangible, and all the rest and residue of my estate in equal shares to my grandchildren, Valerie Green of Camp Hill, Pennsylvania; David Melvin of Camp Hill, Pennsylvania; Elaine Connolly of New Kingstown, Pennsylvania; Sean Melvin of Camp Hill, Pennsylvania; and Greg Melvin of Mechanicsburg, Pennsylvania, per stirpes. T~IIRD: I appoint GER.ALDINE M. MELVIN, of 51 W. Main Street, New Kingstown, Pennsylvania, Executrix of this Will. No Executrix acting hereunder shall be required to post bond or enter surety in any jurisdiction. FOURTH: In addition to having all the powers conferred by statute or by general rules of law, my Executrix, with respect to properties in my estate under this Will, subject to any limitations stated elsewhere in this Will, are specifically authorized and empowered: (a) To invest any funds of my estate in any corporate shazes, bonds, notes, or other securities or personal property, including any common or commingled funds maintained by my Executrix hereunder. This is to reflect my intention to give the broadest investment powers and discretion to my Executrix; (b) To sell or otherwise dispose of any property, real or personal, at any time forming a part of my estate, for cash or upon credit, in such a way and on such terms as my Executrix may deem best; (c) To manage, operate, repair, improve, mortgage, and lease for any term any real estate at any time held; (d) To make distribution in cash or in kind upon any division of my estate; and (e) In general, to exercise all powers in the management of my estate which any individual could exercise in the management of similar property in his own right, and to do all acts which my Executrix deems necessary or proper to carry out the purposes of this Will. IN WITNESS WHEREOF, I hereunto set my hand this / ~~~ da of Y ~"~ ~-- , 2004. MARY R MELVIN COMMOrf WEALTH OF PENNSYLVANIA COUNTY OF SS: We, ~-1 S f~ '~oC.~~- and ~~~e ~3A Rey S, the wi ~ o u /2t,~£ ~rf tresses whose names are signed to the attached instrument, being duly qualified according to law, do depose and say that we were present and saw the Testatrix, MARY R. MELVIN, sign and execute the instrument of her Last Will and Testament; that she signed it willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn to and subscribed to before me by ~ S~ I~ U~,,IL and / ~ ~~n ~p ~-~ ,/~ ~ ~ .~ ~/sy~ S witnesses, this fJ~- day of -gyp b.~„r 2004. fitness . ~~ Notary Public J~ ,~ u~ Witness NO ARIAL SE L CAROLE A ROSE Notary Public TWSP OF LOWER ALLEN CUMBERLAND COUNTY Commission E Tres Ocr Z1, 2007 SIGNED, PUBLISHED and DECLARED by the above, MARY R MELVIN, as and for her Last Will and Testament, in the presence of us, who, at her request, in her presence, and in the presence of each other, have hereunto subscribed our names as witnesses: ~-R- c~ „~ COMMONWEALTH OF PENNSYLVANIA COUNTY OF i~~ / ~D // SS: I, MARY R. MELVIN, Testatrix, whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I have signed and executed the instrument of my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. -~h Sworn to and acknowledged before me by MARY R. MELVIN, the Testatrix, this ~_~ - day of 2004. ~f^~ /~ %~~m~~ MARY R. MELVIN ~~ otary Public N ARIAL CAROLE A ROSE Notary PubI1C TWSP OF LOWER ALLEN CUMBERWNO COUNTY Comrr~aion E s Oct 21.2007 S~ ,fix qo crc '~ 4c~. r~~