Loading...
HomeMy WebLinkAbout04-19-1015056051047 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Coun Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN tY ~ ~ PO BOX 280601 /~ ~ ~ ~ ~ ~~ Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~ (~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~ ~Z ~v ~~ 1 $ U3~ZZ~t~oS' d7 ~yl~iy~ Decedent's Last Name Suffix Decedent's First Name MI ~oaS E ~~.~ ~ ~wT~ M.tN ~" (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 O 2. Supplemental Return O 3. Remainder Return (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 TO: Name Daytime Telephone Number 3~NJ~~~r~ ~' ~©osE Firm Name (If A licabl pp e) First line of address So J ~ R o rv T' Second line of address City or Post Office ~A-~ys ~z~~.E Correspondent's a-mail address: REGISTER OF WILLS USE ONLY N C7 `'°' ~- ~ c r -~~ t _ ~ ~r-~n~ -- r.e~ ~-. ~ ~, ~ f pAf ~~fILED --° ' ^--I W ~t .......... _.,7 ~: "> .W.' i~.... 4~ ,+ .., ~,} :, . `~r=1 State ZIP Code ~ P ~- 1 ~ ©s 3 __ .,.,I ~" 1 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 preparer other than the personal representative is based on all information of which preparer has any knowledge. SI JVATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE AUUFZESS PLEASE USE ORIGINAL FORM ONLY Side 1 L,~, 15056051047 15056051047 J 15056052048 REV-1500 EX Decedent's Soccial Security Number Decedent's Name: ~ ~ Z ~r D 9 ,( ~ g RECAPITULATION 1. Real estate (Schedule A) . ........................................ .... 1. • 2. Stocks and Bonds (Schedule B) .................................... ... 2. • 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. ~ b ~ ~ . 3 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. • 7. Inter-Vivos Transfers & Miscellaneous Non-Pro pate Prope 9 (Schedule G) O S Billi e crate n Re uested..... q ... 7. ~ ~ ~ ~ • 8. Total Gross Assets (total Lines 1-7) .................................... 8. g ~ ~ `~ , ~ 9. Funeral Expenses 8 Administrative Costs (Schedule H) .................. ... 9. g ~ 7 S • b Q 10. Debts of Decedent, Mortgage Liabilities, 8~ Liens (Schedule I) ............. ... 10. 11. Total Deductions (total Lines 9 8~ 10) ................................ ... 11. $ ~ ~ S ~, o 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. ~ ~ ~ ~ ~ l 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. S ~ ~ ~ ~ l 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 ~ • 16. 17. Amount of Line 14 taxable at sibling rate X .12 , 17 18. Amount of Line 14 taxable at collateral rate X .15 • 1 g 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT $ a~`t .~ 1 • 3 ~.D ~ Side 2 15056052048 15056052048 REV-1500 EX Page 3 File Number Decedent's Complete Address: 2 t C~7 S - C .~ ~ DECEDE T'S NAME ,~' ~'~]~''f''~ v v ~ t~ I .- ,$ e- .~_.L_.. STREET ADDRESS Z l l ~ C.ec,(a ~' K ~ ~ ~- ~ I ~ ~ CITY C. ~-yvt f-f - ~ c_1__ STATE ~4- ZIP ~ ~~oc r - ~ y~8 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments ~ a~, y { C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits (A + B + C) (2) ~ ~,~~ , Total Interest/Penalty (D + E) (3) _ 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) ~ ~ 1~ 3~ 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 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? .................................................................................................................. ...... ~ ^ 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 exemdt 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 SCNEDt~LE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER ~~~~ Aw.~~. ~_ Fdo s ~ Z..1 ~ 5~-U3 gS~ 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. fir more space is needed, insert additional sheets of the same size) REV-1510 EX+ (08-09) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IF APPLICABLE TAXABLE VALUE 1. j-1Z- Cs ~- ZZ- L s C+~n~r~- t t ~~n-F r.'~ ~ k-~ ~16 ~C~re.~~-t ,P~,~ t ~ L1- 0 ~' ~ 3~' . ~2 ~ ~ 3S, 3,~ TOTAL (Also enter on Line 7, Recapitulation) $ I y~~~. bs If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ~ e~ ; a ~ ~ -~ ~ ~s e. ~ ~-l oS~ 0 3 8S Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~/~ ~ C 1 f~_ ~ ,, (~'/''~ 1. 1~ l eV'"~ t In ~C.r'G. ~ CTV~~'~ ~ ~ 6 (1 B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: State Zip 2• Attorney Fees 3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4• Probate Fees 5• Accountant's Fees 6• Tax Return Preparer's Fees TOTAL (Also enter on line 9, Recapitulation) I $ $ ~ '1 (If more space is needed, insert additional sheets of the same size) _..~ .. .. ~ .. .~ 4 ~ • S overel n g Bank Agent for Travelers Express TO THE ORDER OF ~~ ~"O~x~ ISSUED BY: TRAVELERS EXPRESS COMPANY, INC. P.O. BOX 9476, MINNEAPOLIS, MN 55480 DRAWEE: US BANK, ST. PAUL, MN Sovereign Bank Mellmo 04/27j2005 pcctwlr~t Ho 1 de r iRCC01JIrtt ~.111~l8Ir B r~ell'~ch Nura~be r : 1 tS8 OFFICIAL CHECK `~ ~ "~ 22-1676 960 Drawer: Sovereign Bank NON NEGOTIABLE _ CUSTa%1111ER COPY AUTHORIZED SIG,. ~-._._.. ~ ~ -- _....,. NATURE ~Ic~k~Ic~c~Ic~c**~4 ,604.36 DETACH AND RETAIN FOR YOUR RECORDS X381801 c---~ 7 r'QS:S Clr t~s L rs~2!?1Q "~ ~ F~. C/, ~Q k W I t T~~ I~ ING. Life Insurance and Annuity Company . Death Claim , 51 Farmington Avenue 401(a)/403(b) ERiSA ~~ 73 • ~ artford, cT 0615&1277 ING. 401/403 b Non-FRIBA Teie one: , oo- ~ ~ ~ Deferred Compensation ~~~a , ~~.-- I Ufa insurance and Annuity Company will be defined as "the Company'; "ILIAC", "tme'; "ua'; or /~ rr" !n this document. Please refer M attached instructlona. yT0 jl L~~~~~y~ t~ith claims must be accompanied by an original or certified copy of the Death Certificate esa the Trustee or Named Fiduciary fora 401 Corporate Market Plan certifies the Participant's ~m~~a~~~ Co n-~r," b~~~~ a P~n~- - please make the appropriate charges, and IMNa/ and date each change. Beneficiary Information Please print. ff you have a Pd Box, U.S. Tax laws requlrv a sheet address to be Indicated. ff provided, d/stributkHt checks will be mailed to PO Box Indicated ~R.,1;4 dllferent Instructions are provided in the Payment b Marling section. Complete one Ibrrn for each benelicrary to be paid from the Indicated account numbers. xx,nt Number(s) (15-digit Aocbunt n Name Name Date of Death (mm/ddyyyy) 03- as - ~c ~, .. Benefidary Name (Last. First. Midd-e 1 Fo 05 E". ~ FlV ~/~ Beneficiary Re atianship So ~/ MANDATORY - 6enefici Resident ~ a5 s-f~~ City/Town y ~ Email Address as shown on Aooess Report) I ~e-n arh, n ,~ Deceased Sodal Sep de of Birth (mm/dd/yyyy) o~-i~-~l9~1~ agg as - ~o - ~ 7 l ~f~/YI ~S ~G.~ rt ~ve Work Telephope No. Extension Home ( ) (~~ . ,r- Percent of Benefit Payment you ere entitled to: ~ x`"33 -~~_~-o~~/ O Box (optional) ~@te Zip Code ' c ~~f~ ~~ -~~.~a _ ~~ ~- ~ '% J Non-Resident Tax Information - This Infon~etion must be completed ~ resident address /s outskie the United States and distribution Is being made from a 403(6), 401 or governmental 457 Plan. Type of 457 Plan (This section must ba completed If claim /s being made from a delfemed compensation plan.) CHECK ONE BOX ONLY and complete information, ff applicable. ^ 1 am a citizen of the United States living in a Foreign Country If you are a U. S. Citizen, your withdrawal is subject to withhdding rules Tor U. S. Citizens (see the Non-Resident Tax Intbrmatlon section In the instructions for this form) with this exception: You are not able to elect 'out' of withhdding. ^ 1 am not s United States Citizen. My country of legal residence is If you art, oat a U. S. Citizen, your withdrawal is subject to withholding provisions for Non-Resident Aliens. You must complete, sign, date, and return to us the IRS Substitute Forr- W-BBEN, 'tCertilicate of Foreign Status of Beneficial Owner for United States Tax Withhdding." If you do not have a U. S. Soda) Security Number, you must apply (IRS Form W-7) for and receive an Individual Taxpayer Identification Number (ITIN) from the IRS. ^ governmental 457(6) -Distributions-processed from governmental 457 Plans wl! be taxed In accordance with the information provided In the attached Special Tax Notke and instructions found In the Tax Withholding Substitute W- 4P Section. of this form. ^ non profit - All dlstribuflons processed from non profrl Plans will be taxed uslrg the lnformatlon provided /n the "For Payments to Employees Federal income Tax Wifhhdd/ng Notice" Section of this form. ^ corporate non-qualified deferred compensation -All distributions processed from corporate non-qua/fled defem~d compensation Plans w1N be taxed using the Infomiatlon provided in the 'For Payments to Employees Fed~era/ lncame Tex Withholding Notke' Sect/on of this form. ^ nonprofit 457(f) -all distributions processed from non-profit 4570 plans will be made payable to employer. ILIAC wiN not complete any withholding calculat/ons or tax reportMg. Form No. 83077 (t3/a2) KEEP A COPY FOR YOUR RECORDS Page 1 of 11 - incomplete without all pages :~ _ "` -- ~ --~ ~ 7. ING Life Insurance and Annuity Company - ~. ~~~~ 151 Farmington Avenue April 28, 2005 Hartford, CT 06156-1268 000184/ 388 / Jclntrd ACTIVITY CONFIRMATION . ,- /~ ~'/77 f GL P ~' ~-" G ~r ~ W ~ .p ('~- ~ ~~~ I ~ Page 1 of 2 BENJAMIN F FOOSE III '~ Questions 2116 CEDAR RUN DR APT 107 24 hour touch-tone access CAMP HILL PA 1 701 1-7488 (800) 262-3862 Customer Service Mon-Fri. Sam - 10pm EST (800) 232-5422 web site: www.ingretirementp lans.com Your representative: MICHAEL BENEDICT 333 HILLCREST DR NEW CUMBERLND PA 17070 Transaction Detail- TRS OF CUMBERLAND-PERRY ASSN FOR RTRDD CTZ RP/PHQ922 Contract ,#: XXXXX8718Q922EC -Employer Contributions 1 ~,. S~~ ~ Gross Amount 79.40 Federal Withholding -177.94 Net Check Amount $1,601.46 Eff. Units Unit Date Activity Total Fund name and number Withdrawn Price Amount 04/28/05 Death Claim $1,779.40 ING VP Growth & Income Port(I)-001 -13.7850 $6.784163 $-93.52 Fidelity VIP Growth Portfolio-109 -105.5487 $5.840621 $-616.47 ING Oppenheimer Glob Pt-Init-432 -91.1112 $11.737414 $-1,069.41 Transaction Detail- TRS OF CUMBERLAND-PERRY ASSN FOR RTRDD CTZ RP/PHQ922 Contract #: XXXXX8718Q922EC -Employer Contributions key 1(~ ~t;<ia,- Gross Amount 1 779.39 `} Federal Withholding $-177.94 Net Check`~-mount $1,601.45 Eff. Units Unit Date Activity Total. Fund name and number Withdrawn Price Amount 04/28/05 Death Claim $1,779.39 ING VP Growth & Income Port(I)-001 -13.7837 $6.784163 $-93.51 Fidelity VIP Growth Portfolio-109 -105.5482 $5.840621 $-616.47 ING Oppenheimer Glob Pt-Init-432 -91.1114 $11.737414 $-1,069.41 This confirmation is provided on behalf of ING Financial Advisers, LLC (member SIPC). This confirmation contains time sensitive financial information. Please review the confirmation carefully and report any discrepancies by calling one of our customer service representatives at the.number shown above within 30 days of the date of this confirmation. Failure to report any discrepancy within 30 days will indicate that you are in agreement with the transactions in your account as reported in this confirmation. i~ RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 Receipt Date: Receipt Time: Receipt No.: ~M 4/26/2005 12:11:49 1040452 FOOSE III BENJAMIN FRANKLIN Estate File No.: 2005-00385 Paid By Remarks: BENJAMIN JAMES ELI FOOSE RSK ------------------- ----- Receipt Distrib ution ----- -------- ------- ---_ Fee/Tax Description Payment Amount Payee Name PETITION LTRS ADM 45.00 CUMBERLAND COUNTY GENERAL FUN RENUNCIATION SHORT CERTIFICATE 5.00 20.00 CUMBERLAND CUMBERLAND COUNTY COUNTY GENERAL GENERAL FUN FUN JCP FEE AUTOMATION FEE 10.00 5.00 -- BUREAU OF CUMBERLAND RECEIPTS COUNTY & CNTR GENERAL M.D FUN Check# CASH -------------- $85.00 Total Received..... .... $85.00 ' , Q 0' . BENJAIVIIN J. F44SE 25 AUSTEL DR. MARYSVILLE. P~4 17053 ~ti - :z ~~CJwntt~ .~: PAY.TO,TF~~ ~ , ~, ORDER OF t-7 r ' (j /1 e r• tlCh'' vj 0 i ~-~.-: ... - . ~ ,:' ' HARRISBURG. PA 1 7 1 1 0-2990 FOR '- ~:2313g1~L~~:O~?0 70 !~ ~ ~^ O ~ 60-6111(1313 7 DATE DOiLARS `..~"' Meg ~~ i.,r 0459904 2 56 ,~~p000799000~~' - - - _ _ ', ~ , -, .C~41 ~c1~;0~~~~7 Ud c gc'0~~.~" ~ .. _~~~=cross ~~r~~c=a~s~ - pY~=-~ ~ ~- ~ ~ - - -- . ~ - "`~ 8 ~ ~ _ _ _ j~ '~ ~ ' f 1l .~.... ~ ~ - ,, : ~ _ ._ ~~~ ~:~, coos Goa~oa~4 ~aco~ r ~oa7 ~ ~ o ~ z - ~~~...~ - - m Q ~ _ _ . . ~ ~ -~ n ^_ - S~ r