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Home My WebLink About06-01-10 (2) 15056041046 REV-1500 EX (05-04) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Dept. 280601 INHERITANCE TAX RETURN ~ r ~ Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~ ~ / ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~-o~ 16 7 ~9a 030 ) ~~~ ~ iz~~ ~41~ Decedents Last Name Suffix Decedent's Firs t Name MI ~~ANs ~a~c ~~~ ~ (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) >~ 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 T0: Name Daytime Telephone Number s~a~~- ~V~ NS ~ 1~ 9~ 9 ~a5~ Firm Name (If Applicable i First line of address as ~-~..L~~s ~~~ ~.~ Second line of address City or Post Office State ~NaL~ ~fl ZIP Code REGISTER~6f WILLS USE LY ~ c~ C_ c j ~Ty G.. ~}~y ~ F G` ~ ~ J J ~ ti~~~ _ C' J r`-1 `s`1 ~~., , µ fV r E~ILED ) ~ ~ a ~ Correspondent's a-mail address: ~~ OTT ~ ~ S / @ Ce~!' \ C'AS'T' N r~-r ~~ a .,_) .~ _;i CJ ,a 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 PERSON RESPONSIBLE FOR FILING RETURN ~ DATE `~ ID ~ d ADDRESS ~ ~ L r/ f~p S IV1 i F' GAP ~~ `-~o~ ~ P~ 17 oaf SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056041046 15056041046 J J 15056042047 REV-1500 EX Decedent's Social Security Numb e r ' / ~ ~ I `' I 6 n ~ ~ ~ ~ cd- Decedent s Name: ~ RECAPITULATION 1. Real estate (Schedule A) . .......................................... .. 1. ~. ;~ ; , ,~ . ~ ,, . ,, .: 2. Stocks and Bonds (Schedule B) 2. ~ } ~ ; ~ a I C b x ~' . _ :: e ~ .. 3. Closely Held Corporation, Partnership or,Sole-P€oPrietorship (Schedule C) ... .. 3. '~ ~'; Lt '.td. i;i::r~i.F ~c~ ~ 4. Mortgages & Notes Receivable (Schedule D) ........................... .. 4. ~ yi ,. .. ,__r _ ,.,t a ~ ~ ~ ~ ,; ~ 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. I ~ ~;~ 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. ,. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. _ ~ 3: • - 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. _ ~ ~ ~ ~ ._ _ ~ ~ ~~ d ;~ 9. Funeral Expenses & Administrative Costs (Schedule H).......... ......... .. 9. ~ 4 ~ ~ , 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10, 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. ~ 0 0 9 ,• ~ I 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. ~ ~ U `~ ,, 1 ~ ~," 3 =~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... .. 13. i 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. ~ ~ ~ y ! ~ ~ d 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 ~ ~ ~ ~ ~ ~ ~ 3 ~' ~ ) ~ ~ a "~ (° ~ ~ '~ 6 at lineal rate X .0 . 16. a . 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. # p ~ ~ U 0 ~ y / b 19. TAX DUE ....................................................... .. 19. .~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 15056042047 15056042047 J REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME M~~~c:c~ ~ ~y~tJs STREET ADDRESS p „ nA' ~~ ~ p ~ ~~ CITY ~~/\ ~~ STATE /~ n ZIP ~ ~ ~ d S Tax Payments and Credits: 1 ~~ ~ 1 ~ 1. Tax Due (Page 2 Line 19) (1) 2. CreditslPayments A. Spousal Poverty Credit -- _ _ B. Prior Payments C. Discount ,s % - _ - _- ^ `l e) `J V ~~ 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. f d 2 Li 20 t t Fill i l P (4) ~ Cl ~ -7 1 ~ (~ a re un . , ne o reques n ova on age ) . 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. (56) ~ ~ ~ ~ S' ~ ZI Make Check Payable fo: 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. Ditl 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 exemot 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) SCNEDVLE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Ni ~A3E(,i.~ ~ ~~ A,~S All property jointly-owned with right of survivorship must be disclosed on Schedule F. pf more space is needed, insert addfional sheets of the same size) Page 2 Estate of Mabelle B. Evans Account No. 3041-0100 WY38 Date of Death: March 1, 2010 SS# 201-16-7392 Amount Security Price Value Common S tocks: 4,762 A T & T Incorporated 24.950 118,811.90 25.07 / 24.83 3,062 Bank of America Corporation 16.715 51,181.33 16.86 / 16.57 1,903 Comcast Corporation New Class A 16.695 31,770.59 16.89 / 16.50 742 Consolidated Edison Incorporated 43.125 31,998.75 43.44 / 42.81 1,151 Covidien Plc Shares 49.490 56,962.99 49.79 / 49.19 639 Daimler AG 42.135 26,924.27 42.47 / 41.80 1,000 Deere (The John) & Company 57.955 57,955.00 58.46 / 57.45 2,123 MeadWestvaco Corporation 23.480 49,848.04 23.94 / 23.02 700 PNC Financial Services Corporation 53.640 37,548.00 54.00 / 53.28 2,115 Park Electrochemical Corporation 27.855 58,913.33 28.48 / 27.23 756 Tyco Electronics Ltd 26.065 19,705.14 26.54 / 25.59 1,151 Tyco International Ltd 36.615 42,143.87 37.05 / 36.18 707 Wells Fargo Company 27.370 19,350.59 27.59 / 27.15 Exchange Traded Funds: 2,650 Blackrock MuniYield PA Ins'd Fund 13.450 35,642.50 13.51 / 13.39 3,000 Dreyfus Municipal Income Fund 8.980 26,940.00 9.01 / 8.95 Page 3 Estate of Mabelle B. Evans Account No. 3041-0100 WY38 Date of Death: March 1, 2010 SS# 201-16-7392 Amount Security Price Value 1,315 Nuveen PA Premium Muni Fund #2 12.575 12.61 / 12.54 1,241 Western Asset Emerging Mkt Income Fd 12.655 12.70 / 12.61 Mutual Funds (Open-End): 7530.755 Dreyfus PA Muni Bond Fund Class A 15.990 Closed-End Funds (Unit Investment Trusts): 10 PA Insured Muni Income Trust 118M 211.900 Accrued Interest Municipal Bonds: 25,000 Montgomery County PA Hgr Ed Rev 96.851 Abington Mem Hosp 5.000% acc int Due 06/01 /2028 Cash (Money Market Fund): 72,760 Bank Deposit Sweep (FDIC Insured) 1.000 Total: 16,536.13 15,704.86 120,416.77 2,119.00 1.08 24,212.75 339.04 72,760.28 $917,786.21 "This evaluation has been prepared solely for informational purposes and does not supersede the proper use of your Wells Fargo Advisors client statement which is considered to be the only official and accurate record of your account. If there are any discrepancies between this and your client statement, please call your local branch manager." REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEpULE E CASH, BANK DEPOSITS, 8r MISC. PERSONAL PROPERTY ESTATE OF M ~6~/ ~ ~ ~~ n -\~ FILE NUMBER Indude the proceeds of litigation and the date the proceeds were received by the estate. AN properly jointly-owned with right of wrvivorship must be disclosed on Schedule F. REV-1511 EX+ (10-06) SCFIEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER m~ ~C` Ll,~. ~ ~~Aa~ Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. ~-~.~~~ ~u~~ RPrL H-aME ~~l~ ~ !1 3 y ~ r IUd~ ~ -~-~ 5-s- C ~M P 1-rt ~ t, ~ ! ~~ t l ~ ~ c..L 14 A r,'-S R-~..s ~ Ata ~~1~-~' B. 1 2 3 4. 5. 6. 7 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: State Zip Attorney Fees 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 Probate Fees Accountant's Fees Tax Return Preparer's Fees TOTAL (Also enter on line 9, Recapitulation) I $ ~ V ~ ~. I (It more space is needed, insert additional sheets of the same size) Zip REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF ., n n .. ,~ ~. e FILE NUMBER NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under 1. Sec. 9116 (a) (1.2)] ~ V ~ a SC p l~ C. ~ S°i~ 3 d ~• $o nn l~l.E. ~c.S 4$f ~ ~ aL~ p}~ s'~ aa5 b °/ comas IcY~ ~ ~2~ao sor ~ ro S o M t ~L`~S GAP r~ ~av~6~ Pp ~~a~ k~)S' E "' ~a~I~S ~ 30 3 a, ~,~ aNI..I,~ ~,,~ ()flfl~~ o~uc"' , o %Y A~;3 wt~~,a4,ya ~, f98c~ 7 y ~psa~ aR v~flr~Y ~o~ G ~~ ~~ ~~ ~ s MQ ali Y~ c~]au 4!-i~(L 3 b °/~ f ~c~N IS~ 4Q ~~1a~0 aS3 N ~''=S~ RP-r3~ ~ G~ao ~~u4~t~TE.~ , ~ °~~ . Pit[ t_ A~ CA ] 9 f I, ~ R~~2~- Ct2A~1~N° ~~~ O~ ~p ~a~ yy G e.~~~ ~~4~f~Ec. I o c/ c SEV ~ ~~ ~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 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)