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HomeMy WebLinkAbout04-13-10 (2) Q 15056051058 pA " ~ O EX (°8-°5) OFFICIAL USE ONLY a 1 - I o - 6 o b Bureau of Individual Taxes INHERITANCE TAX RETURN Count' Code Year '~ Number PO BOX 28(1601 _ lianisburg, PA tt128-0601 RESIDENT DECEDENT 21 ~ 10-'-"~`~' (~~~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 163-14-9260 01 /20/2010 03/13/1922 Decedent's Last Name Suffix Decedent's First Name MI Rotz Jr Calvin g (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Rotz Dorothy K Spouse's Socal Severity Number 204-01-3909 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW t>D 1. Original Retum O 2. Supplemental Retum O 3. Remainder Retum (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death after l2-12-82) C_~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust (Attach Co of Will) ___ _ _ 8. Total Number of Safe Deposit Boxes py (Attach Copy of Trust) (e'er 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 SEI;TpII YUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Linda Weldon (717) 231-8494 Firm Name (IfApplipble) - ___- _...---.__ -__ REGISTER OF WILLS USE ONLY '~ First line of address rV Q ~ 10 Goliview Road o ~- -moo ` ~ r~ Second line of address ~ ~ ~ =~ G ~ K: ~1 t~ City w Post Office State ZIP Code ~ ,,, ___- F""-'~'~`F°_._._.__~ - ~ k ~ ~ `T t .._ ,~ Camp Hill PA 17011 ~ = :z- ,~ • n ~ ~.~ Correspordenes e-mail address: linda'+veidon~hotmail.com under penalties ~ per)ray,1 declare that I nave examined ttws realm, indWYg aownparrying schedules and !rest ~ rrV k9e and belief, it is true coned and oorryrlete. Declaration of proparer odwsr than lire personal represer~tive t d N i f s x~se on a n ormation of wlwfi preparer has arty krawledge. SIGMA PER30N RESPONS~LE FOR FILING RETURN i9 . i n i DATE SIGNATURE OF PREF;1~(2ER OTHER TFiIW ADDRESS l ~Q~~ DATE PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051058 15056051058 J REV-1500 EX Decedent's Name: C81VIn RECAPITULATION B Rotz Decedent's Social Security Number 163-14-9260 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. Mortgages 8 Nofes Receivable (Schedule D) ......................... .... 4. 0.00 5. Cash, Bank Deposits & Mis~ltar~us Personal Property (Schedule E) .... .... 5. 92,315.20 6. Jointly thvned Property (Schedule F) ~ Separate Billing Requested ... .... 8. 0.00 7. Inter-Vrvos Transfers & Miscellaneous Non-Probate Properly _ (Schedule G) C~ Separate Baling Requested. - .. .... 7. 0.00 8. Total Gross Assets (total Lines 1-7) ................................ .... 8. 92,315.20 9. Funeral Expenses & Administrative Costs (Schedule H) ................. .... 9. 7,791.1..1 10. Debts of Decedent, Mortgage LiabilNes, 8 Liens (Schedule I) ............ .... 10. 288.70 11. Total Dsduetbrrs (total Lines 9 & 10) ............................... .... 11. 8,079.81 12. Net Value of Estate (Line 8 minus Line 11) .......................... .... 12. 84,235.39 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has rat been made (Schedule J) ..................... ... 13. 232.04 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. 84,003.35 TAX COMPUTATION • SEE INSTRUCTIONS FOR APPLICABLE RATES.-.___.___ .-.,_.__._~____ .__._.~._-_~________-___~„ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (ax1.2) X .0_ 15. 0.00 16. Amount of Line 14 taxable _ at lineal rate X.0_ 84,003-35 16. 3,780.15, 17. Amount of Line 14 taxable _ _ _ at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 t8, 19. TAX DUE ....................................................... .. 19. 3,780.50 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 ~7 15056052059 Side 2 I.. 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: File Nymber 21 ~~ 10 ~.~.... ..~ ,~.._.~ _-oecEOerirssocw,.~ DECED S NAME SECURITY NUMBER Calvin B Rotz 163-14-9260 STREETADDRESS -- 2100 Bent Creek Bbd CITY STATE ZIP Mechanicsburg Pa 71055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 3,780.50 2. Credits/Payments A. Spousal Poverty Credit _ B. Prior Payments C. Discount Total Credits (A+ B + C) (2) 0 00 3. Interesf/Penalty if applicable . D. Interest E. Penalty Total Interesf/Penalty (D + E) (3) 0 00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. . Flfl in oval on Page 2, Line 20 ~ request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 3, 780.50 A. Enter the interest on the tax due. (SA) 0.00 B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (56) 3,780.50 Make Chec k P ayab l e fo: REGIS TER OF WILL S, AG E N T ~YQ.'~j ..ryry~~~~ 44 ~t µ ~ ~d 'y 'g,~gp,M p~p]S y~~ Gyu y }( ~ JN {w~\,.;. bY~1J hyfih~k#.p'3*53 Yk~it ~~~~~~~'1~~K~°~i'}L&~y{Mi`K ~~iNa~l`iL'}~p V ~ ~.tlk.+l L~~~~FW..~.~r'aY~MT'' ~.2'!~°h~h$'/Plaq')i RSt.~~[. x~:. ~y q3~~'}'~?+Y'~[ 'a4 l~ryryj~yy~~~9 3 are ~-.. .Pr E~r 43;yYft~. r"'d~'i~V. 9'A . PLEASE ANSWER THE FOLLOWING QUESTIONS BY P~CING " " AN X IN THE APPR OPRIATE 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 "intrust 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? ........................................................................................................................ ^ 0 IF THE ANSWER TO ANY OF THE A80VE Qq~UESTIOy~NS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN, Y;.:.. ~ .;~'Y~'tS,'~, ~ Ft~t ~'~?„M~~'#: ~~,~i1".~, •-.., iFi.2Z~+*'{~"s~4~s',.~,.:..., z ."-~7.4.~, ,~.~ er. ~{-gam' ?~e,ec[r'.~mn,.";~u3 `"i' ~: ~; 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)J. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disdosure 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 benefiaaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)J. 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-1508 EX+ (6.98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNE01/LE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Clavin Blaine Rotz, Jr. 80-6150580 inaude the proceeds of litigation and the date the proceeds were received by the estate. AM propaAy lulrAlyownad with fight o4 aurvivorshio must bs dbdosed on schodul. F_ l~1 M&T Bank 1200 Market Street, Lemoyne, PA 17043 717 731 1730 Fix 717 761 6497 April 5, 2010 Estate of Calvin B Rotz Jr. 10 Golfview Road Camp Hill, PA 17011 Re: Date of Death Balance Request To Whom R May Concern, In response to your request regarding the date of death balance for CaMin Rotz, please find below the following information. if you require additional assistance please contact me. Date of Death -January 20, 2010 Checking Account - 9847138337 Account Balance - $17,607.82 + accrued interest $.17 = 517,607.99 Tota Checking Account - 359866 Account Balance - $232.04 + aarued interest $.00 = $232.04 Certificate of Deposit - 31003919238088 A4coynt Balance - $70,000.00 + accrued interest $4,475.17 = $74,475.17 SincArefy, `.~,~" ~ Leigh Sfieaffer /«sistant Branch Manager West ShQrRr PIat4 i, _, ,;' ,.;,.: ~' ~,,; .; ,at`+~ :eN YF,, ~,~p, .~ F.' <i° .. .. . ,.. .... ~ ,!'1 © One MBufhlo. ort 1A~0 West Shore Plaza March 5, 2010 ~~a CALVIN B ROTZ JR 10 tiOLFVIEW RD CAMP HILL PA 17011 Re: CD Account Closing Notice -- - - - __ _ Acc_ount~ 31.0039192380 _ __.______ ____ Dear Calvin B Rotz Jr, We are writing to confirm that on 03/05/10, your CD account was closed or transferred. At that time, the balance was $74,867.33. We'd like to remind you that M&T Bank is committed to providing you with solutions to all your financial needs. To find out more about the many ways we can help you with those needs, simply stop by any MBcT Bank office or call the M&T Telephone Banking Center at 716-626-1900 or 1-800-724-3222. Or if you'd like, visit the M&T website at www.mandtbank.com. Thank you for banking with MBtT Bank. Sincerely, M.~cheEe Cope-Hec~on Michele Cole-Hector Customer Service Manager .... ev-e s2RlSl REV-1511 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX REfI1RN RE51DENi DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Calvin Blaine Rotz, Jr. 80-6150580 Decedent's datdx must be roported on Schedule I. ITEM NUMBER DESCRIPRON AMOUNT A. FUNERAL EXPENSES: I' Burial -Thomas L. Giese) Funeral Home, Inc 6,243.92 ~~~"~~ Cemetery 900.00 First United Metllodis Church -Food 291.69 Organist -Linda Peppemick 100.00 ~ Flonst 53.00 B. 1. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commissron Paid: State ZIP 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as daimaM's, attach explanation.) Claimant Street Address 4. 5. 6. 7. City State Relatlonship of gaimant to Decedent Probate Fees: Accountant Fees: Tax Return Preparer Fees: ZIP 202.50 TOTAL (Also enter on Line 9, Recapitulation) I ~ 7,791.11 If more space is needed, use additional sheets of paper of the same size. REY-1512 EX+ (12-08) pennsylvarria SCHEDULE I DEPARTMENT OP REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES 8t LIENS RESIDENT DECEDENT I eslwle ur FItE NUMBER Calin Blaine Rotz, Jr. 80150580 Report debts inaured by the decedent prior to death tlut remained unoahl at the date of death- ind..Nn^ ..n..unhu..~J ....u..~~ .r____~ ' ALERT PHARMACY S$RV. INC. A FINANCE CAARGE OF 1.50 t PER MATH ' 219 NORTH BALTIMOR$ AVB. (AN ANNDAL PERCENTAGE RATE OF 18.0$) OR A MT. HOLLY SPRINGS, PA 17065 IAINIMOt+t SERVICE CHARGE OF $ 1.00 HILL SE CHARGED OB ALL AMOUNTS 30 DAYS OR MORE PAST DUS PHONE: 800-266-9954 IF YOU RECEIVE A NSN INSURANCE CARD FOR YOUR PRESCRIPTIONS SS SURE TO SUPPLY US WI14i A COPY. 02/19/2010 PMT DIIB..03/15/10 ROTZ JR, CALVIN B ROTZC LINDA WSLDON G}RP-58 10 GOLFVIBFI DR PAC3'S 1 CAMP HILL PA 17011 ALERT PHARMACY SSRV. INC.219 NORTH SALTII~4DRS AVE. MT.HOLLY SPRII3~Ci8,PA 1065. ** ACTIVITY FOR ROTZ JR, CALVIN B 01/06/10 7511214 9 DIObXIN 125 MCG 01/06/10 7372124 9 ASPIRIN 81MG SC 01/06/10 7507024 9 POTASSIUM CL 20 M 01/06/10 7521725 9 CEROVITE $ILVSR 01/06/10 7507025 9 LISINOPRIL 2.5 MG 01/06/10 7507027 9 METOPROLOL *%L* 5 01/06/10 7566141 9 SERTRALINE 100MG 01/06/10 7629645 6 iPARFARIN 6MC+ 01/06/10 7558065 17 FLORASTOR 250 MG 01/06/10 4106574 12 IARAZSPAM 0.5 MG 01/12/10 7633323 4 NARFARIN 4MG O1/18/10 7627157 9 FOROSSMIDS 20MG 01/27/10 Payment-Thank You -ROTZC - -58 O1 3.~1 .00 3.lic O1 * 2. 3 .00 2.73 O1 3.48 .00 3.48c 01 * 2.96 .00 2.96 of a.pa .o0 2.ozc O1 i 9.32 .00 9.32c O1 10. 8 6 .00 10.68c I~ 1 O1 4.16 .00 4.16c O1 * 14.89 .00 14.89 O1 3.51 .00 3.51c O1 2.76 .00 2.760 O1 1.75 .00 1.75c 227.33- ' .00 227.33- .00 40.79 120.58 LBGSND NON r.rzru*m FOR MONTH FOR MONTH 227.33 61.37 .00 288.70 227.33 61.37 ~r«i..tt.6 ~ s ~~~l~fd~9~~t. 4~~34€ota..l~R ;.R'i~i?.. ~~~ ALERT PHARMACY SSRV. INC. 219 NORTH BALTIMORE AVE. MT.HOLLY SPRINGS,PA 17065 A PIIiANCB CHARGB OF 1.50 3 PHR MONTH (AN ANNOAL PBRCBNTAGB RATE OF 18.03) OR A Mn7IMOM SSRVICB CEIARGB OF $ 1.00 Wrr.r. BS CHARGED ON ALL AMOONTS 30 DAYS OR MORE PAST DOS PHONE: 800-266-9954 IF YOU RECEIVE A NSW INSORANCS CARD FOR YOOR pRBSCRIPTI~iS BS SORB TO SUPPLY US WITH A COPY. 01/20/2010 ROTZ JR, CALVIN B ROTZC PMT DUS..02/15/10 LINDA WELDON GRP-58 10 GOLFVIEN DR PAGE 1 CAMP HILL PA 17011 ALERT PHARMACY SBRV. IIQC.219 NORTH BALTIMORE AVE. MT.HOLLY SPRINGS,PA 17065 ** ACTIVITY FOR ROTZ JR, CALVIN B -ROTZC - -58 12/09/09 7511214 28 DI(30%IN 125 MOC3 O1 1.96 .00 1.960 12/09/09 7372124 28 ASPIRIN 81llG 8C O1 * 3.01 .00 3.01 12/09/09 7507024 28 POTASSIUM CL 20 M O1 2.36 .00 2.36c 12/09/09 7521725 28 CEROVITS SILVER O1 * 3.74 .00 3.74 12/09/09 7507025 28 LISIIiOPRIL 2.5 MG O1 .95 .00 .95c 12/09/09 7507027 28 MSTOPROLOL *%L* 5 O1 7.80 .00 7.BOc 12/09/09 7566141 28 SSRTRALINE 100MG O1 9.29 .00 9.29c 12./09/09 7563945 14 WARFARIN 5 MG O1 1.81 .00 1.Bic 12/09/09 7563946 14 WARFARIN 4M(3 O1 1.81 .00 1.81c 12/09/09 7558065 56 FLORASTOR 250 MG O1 * 43.11 .00 43.11 12/09/09 4106574 42 LORAZEPAM 0.5 MG O1 2.63 .00 2.63c 12/23/09 7526249 5 GSL TIMOLOL .253 O1 12.78 .00 12.78c 12/26/09 8113426 7 FORMS lIATIl~'P O1 3.50 .00 3.50 12/28/09 7479960 28 FOROSEMIDB 20MG O1 .69 .00 .69C 12/29/09 7627398 8 WARFARIN 4MG 01 1.23 .00 1.23c 01/04/10 8113426 7 FORMS MANAGEMENT O1 3.50 .00 3.50 01/04/10 7629645 2 WARFARIN 6MG Ol 2.39 .00 2.390 01/07/10 Payment-R71ank You 160.8- .00 160.78- 01/08/10 8113426 7 FORMS MANAGEt~ffi~1'P O1 3.50 .00 3.50 01/12/10 7526249 5 GBL TIMOLOL .253 O1 42.34 .00 42.34c 01/13/10 7526248 2.50 RALATAN 0.0053 BY O1 78.93 .00 78.93c .00 177.47 49.86' I ,$GBriD NON-LHGBI~ID FOR MONTH FOR MONTf~ 160.78 227. 33 .00 388.11 16.78 227.33 ;' ..