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HomeMy WebLinkAbout05-03-10 (3)15056041046 REV-1500 EX (05-04) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year Fiie Number Dept. 280601 INHERITANCE TAX RETURN ~ ~ , ~ 0 ~ ~ ~ 4 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth Decedents Last Name Suffix Decedent's First Name MI ~~ r~ EL ~G ~ L ~ !~ (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 SA r~.~+~~ ~ ~~~~~ ~ I ~ ~~~ ~ ~ ~'g Firm Name (If Applicable) First line of address ~'C ~~X ~~ Second line of address ~ ~ ~ :~ ~ o ~ ~ ~ ~. ~ ,~ City or Post Office State ~o~c~~~.y P~ Correspondent's a-mail address: ZIP Code r REGISTE ,.»(ILLS USE~ILY . ~ 7 rk~ V t I' l !~"'~ (;~ ~...... may"' ...~ ~ ~ ~ 4., d y `.`'1 ~7 f ~ ~Q f~ ,, r--~ ~ --y..r ' ~ _~ L..._.. ' . . ~ WT~k ~, ~ Y w I_ M+ IE FILED L3 - y .1 i `7 ~ ~ f ~'t 1 t T~ ~_.:.~ _~.:; E 'f°i ~--~ m ~~ 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. SIGNATURE OF PER ON RESPONSIB E FO I ING ETURN DA ~- ~ ~ ~ ADDRESS PD.13~~ ~S %Q,~b ~ ~~ , ~.4 / 7aS/ ~/3 ~ l c~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY 15056041046 Side 1 15056041046 J `~ '~ 15056042047 . REV-1500 EX Decedent's Social Security Number Decedent's Name: (~ ~ _ RECAPITUL ~ O ~ / ,i ~ / ~ u ,~ ATION / 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 8 Notes Receivable (Schedule D) ..... . ,. • .................. ..... . 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ... ..... 5. ~ / 300 . y ~ 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .. 7. Inter-Vivos Transfers ~ Miscellaneous Non-Probate Property (Schedule G) O Separate Billin Re t ..... 6. • g ques ed... ..... 7. 8. Total Gross Assets (total Lines 1-7) .... . .................. . ............. 8. ~ f 300.3 9. Funeral Expenses & Administrative Costs (Schedule H)....... ......... ..... 9. ~~ ~ ~~5. ~~ 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ........... ..... 10. 11. Total Deductions (total Lines 9 & 10) .................. . ........... ..... 11. ~ ~ ~ ~ / . (~ 12. Net Value of Estate (Line 8 minus Line 11) ..... . .................... 13. Charitable and Governmental Be uests/S 9 .... 12. 1 ~/ ~ !yL . 9 ~3 q ec 113 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) .................... TAX ....14. ~ / ~ ~'~~ 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 16. Amount of Line 14 taxable • 15. at lineal rate X .0 4S / r7r ~ ~ ~~ / 17. Amount of Line 14 taxable 16. rl ~ • / at sibling rate X .12 ~ 18. Amount of Line 14 taxable 17. • at collateral rate X .15 • 18. 19. TAX DUE ...................................................... ... 19. ,r-~ 7 . 1 `~' 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 15056042047 ],5056042047 REV-1500 EX Page 3 File Number Decedent's Complete Address: -1 ~ ~ ~~ ~,~., ~ ~ a ~. DECEDENT'S NAME -_ _ -- STREETADDRESS _ _ _ __ __ __ CITY '_ST~1~ _ i ZI ~ _ __ Shk e~s~~ ~ 7~:s~ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments .Discount (1) ~ ~, ! 7 Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest __ E. Penalty __. __ _ __ Total InterestlPenalty (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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~ ~ , ` 7 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 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 + (1-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, O~ MASC. IN RESIDENT DECEDENT RN PERSONAL PROPERTY ESTATE OF FILE NUMBER ~ Eu. L a M Ir-• Q ~2 ID E L ~ l t o c~ C7 t Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointty-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~ . ~ + M `rt'12.u~t -~- ~-hcc~, i n9 1~ e~cic~nrt ~ X34 - ~7 ~ t .3 ~ t-~. ~C, 4©. 5' ~ p, C . Sex ~O 1 t~ ~ ~~ 17 ~t~ 1 a~ m h ~~-S b ~~ ~ ~ "~ u5~ _ ~~E.c~ ah ~, f~ ` i ~ ~ ~ur i a~.. ~t~ n ~ lp t (~ ~ g.. ~. F -~ IM R #Diw -':a.~- $341 C. ~x both ~ $, ~Ytct ~ n ~-~ . cLr~r+ b ~5 b U;r~ , ~ ~ ~ T r~© ~ TOTAL (Also enter on line 5, Recapitulation) I $ f r, 3 Imo. ~~ (If more space Is needed, Insert additional sheets of the same size) ~~ ~~ ~ o'~ 1 ~ d ~ toc~ DDDHIST Demand Deposit Display History 0022 02/02/10 Acct 34-98131 Request ALLTRANS Alpha key BEIDEBF.O1 Last stmt 01/08/10 S --Date-- ----Description----- -Serial Nbr- -Reference- ------Amount------ * 12/29/09 DAILY BALANCE 4,542.31 * 12/31/09 #FORCE PAY CHECK 183 90073800004 (75.00) (Eff date: 12/30/09) * 12/31/09 DAILY BAI.~ANCB 4,467.31 * 01/08/10 #FORCE PAY CHECK 184 90073800008 (400.00) (Eff date: 01/07/10) * 01/08/10 INT'SREST CREDIT 00000000000 0.40 * Ol/OS/10 DAILY BALANCE 4,067.71 01/26/10 #FORCS PAY CHECK 00300101859 (2,500.60) 01/26/10 DAILY BALANCE 1,567.11 02/01/10 FORCE PAY DEPOSIT 90073800031 147.62 (Eff date: 01/29/10) 02/OI/10 DAILY BALANCE 1,714.73 _ DDDHISTREQ _ DDDHISTBAL DDDNIl~IN DDDACCT DDDINT Last page of information. _ _ _ GN20000I02 COrIl~iND -__> F2=Retrieve F3=Exi.t F4=CRFwindow F7=Backward ~. ,~ .~~ -~~ ~~ ~- s fi ~~ _~ ~ ~ ~ ~ ~' . _~ urn ~~ --~.~C ~ ~`~ ` `'~- r ~~~~•~ r ~ ~~ ~ ~} ...• Cd ~ Sca roc G ~-~ Tr G~C~ar ~' _,- t' ~' r ~~._ ~ J~ ~' --- ~~L ~ ~-- ~~ ~' i `~ 14'- `~~ 1 ~ ~ ~ ~ ~~~ REV-1511 EX+ (10-06) SCNEDIJLE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER ~~ E~ L~ ~ F ~E~.fl~ l.._ ~ ~ ~ O no ~, o ca Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~ 1. r ' 3~1 i 4+o-..y ~0 1C.Isc~r~c-r--- ~-icl~ie. ~t~.ner~-. 't'~rne , .~nC ~ •-- ~ur~ a~.F'und Coco ~ ~. ~d .~• ..! c~,~,lp h ~.ee,~~ -- c..f2 i~ !84 - ~P~.r•~n~ a~ Gre~~~,. ~Od. c~c~ ~~I RO)C~Ue y ~~e~erc/ ftSSr('_t~ion ....Fee - ~ ~t /dt3 I `r.'~. dG B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: 2• ~ Attorney Fees State 3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Relationship of Claimant to Decedent 4. ~ Probate Fees 5• ~ Accountant's Fees 6• ~ Tax Return Preparer's Fees 7 Zip Zip TOTAL (Also enter on line 9, Recapitulation) I $ ~ Jr- °' ~.F~ J!"a i (It more space is needed, insert additional sheets of the same size) .. _ -~ i ~~ Via= ~:~, i l Q ~v 1 D _ _ -- ____ ~ THlS DOCUMENT HAS AN AA7IFlCIAL WA7EAMAgK PF~IiEO ON THE Bi1CK THE PROt+TF OF THE ppT HAS A ~MCRO.pii1NT SILiNATUF~ LprE. ABSENCE OF THESE FEA711RES HALL U~DICATE A COPY. m N ~~~ 20 South Main Street ~ ~,T Chambersburg, PA 17201 3 218 0 5 m N ~ REMiTtER 014-29-83441 Beulah F. Beidel -Irrevocable Burial Att. PAY To TFiE Fogelsanger-Bricker Funeral Home ORDER OF ~~ »o 6,609.90 _ DOLLARS OFFICIAL CHECK URAWER:F3MTRUST ISSUED BY: MONEYGRAM PAYMENT SYSTEMS, INC. ~ ~ P.O. BOX 9476, MINNEAPOI.iS, MN 55480 1~7~A,.~. ~s - `~~- `r ~.~.. DRAWEE: THE BANK OF NEW YORK MELLON EVERETT. MA ~ ~ ~~' 3 2 1 8 0 5 a' ~: O i ~ 0 0 7 0 9 2 ~: O L 6 O O L 0 4 4 6 9 0 0 ~~ AUTHORIZED slc~wTURE . ORIGINAL 4I 10 -- ~ ~^'~ ~ ~. ~ _ ~ ~ ACCT. NO. c ~~ .d~~ ~- ~G ~ ~ _---- ~uneral Services Name d Deoe~ased ~ECK 11 3 ~- I S~a.~ F~GELSANGER BRICKER CREDIT ; ~ ~~~ ~ T ~ ~+ 77.7 CARD ~' V 1~I t'.itC~L HO1r1G, iiy C. I-I r-rucc ~ - s-~~ ~, P~d~ oATE January 4, 2010 LAST BALANCE $ ~ ~ ~~ ~~ a ~~~ ~ L.ATE ~YV~ SUB TOTAL ~~ CREDITS LESS PAYMERff 6 NEW BALANCE $ ~ ~v'`-' ,~j O R ~a7~4a ~~ m ~; ~ 20 South Main Street ~ ~~- Chambersburg, PA 17201 ;~ 3218.16 ~m N REMITTER Beulah F. Beidel balance of funeral expenses DATE January 26, 2010 ~~ PAY To THE Fogelsanger-Bricker Funeral Home, Inc. ~ 2, 500.60 { ORDEta OF - s r 9 .~ ,~,~1~, DOLLARS i DRAWER: F8M TAUS7 {SSUED BY: MONEYGRAi~f PAYI S~""~S- 14G_ P.O. BOX 9478, Mi~AS..1~ ~ ~_ ~ ~-' 1~~,r.-_ Ap DRAWEE: THE BANK OF i~iE-Y v EVERETT, MA AUTHORIZED SIGNATURE ~' 3 ~ i8 i6r ~=0 ~ iQ0?09 2~.0 i60010446900a' ORIGINAL 4110 ,- - ~ ~- ~ ~~~, ...,-~' l~ fl ~~ ah~ re h~ti~~ ~ s :~~ ~ h ~ i.~ ~- ~(o G ~~~~ ~1U .~--- F. I~e~ Q Name ~ I3eoeased HECK # ~~ ~ ~1'~ FOGELSANGER BRICKER [] CREDIT j; ~E1~tiL HQ1YlU~ ~C~ CARD ^ OTHER ~~ ~ - /~ ~. ~., LAST BALANCE $ ~ ~~Q a uTE w-YaEHr SUBTOTAL CREDITS LESS PAYMENT ~~ NEW BALANCE $ ~. `-~ -07370 ACCT. NO.