HomeMy WebLinkAbout06-24-1015056051047
REV-1500 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes '` INHERITANCE TAX RETURN
PO BOX 280601
Harrisburg PA 17128-0601 -°° ~ RESIDENT DECEDENT 2 1 1 0 0 3 9 7
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
`1 `7 9 1 2 3 1 0 4 0 3 2 5 2 0 1 0 1 1 0 7 1 9 1 8
Decedent's Last Name Suffix Decedents First Name MI
F r i s e t D o r o t h y J.
(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 0 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
A n t h o n y L. `D e `L u c a E s q. 7 1 7 2 5 8 6 '8 4 4
Firm Name (If Applicable)
First line of address
1 1 3 F r u n t S t r e`e t
Second line of address
P.O. B'o x 3 5 8
City or Post Office State ZIP Code
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B o i 1 i n g S p r i n g s P A 1 7 0 0 7 ~ ~ ~~ ~~ °;
Correspondent's e-mail address: anth
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.
S GN URE OF PCRSON SP SIBLE FOR_FILING RETURN DATE
Side 1
15056051047 15056051047
ADDRB$S ~.i A ; ~
J
15056052048
REV-1500 EX
Decedent's Social Securit y Nu mber
oecedent'sName: Dorothy J. Pr1Set 1 7 9 1 2 3 1 0 4
RECAPITULATION
1. Real estate (Schedule A) . .......................................... .. 1. O , O O
2. Stocks and Bonds (Schedule B) ..................................... .. 2. O • O O
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. O 0 0
4. Mortgages & Notes Receivable (Schedule D) ........................... .. 4. 0 .' 0 0
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. 2, 4 8 O 2 8
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. 4 4 ~ 7 8 4 , 7 4
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
1
(Schedule G) O Separate Billing Requested...... .. 7. 1 3, 3 6 9 ,, 5 4
8. Total Gross Assets (total Lines 1-7) .................................. .. 8. 1 , O O, 6 3 4 • 5 6
9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. 4 ~ 5 2 $ 1 5
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10, 1 , 0 0 6 • $ ' 6
11. Total Deductions (total Lines 9 & 10) ................................. .. 11. 5 ~ 5 3 5 0 1
12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 1 5 5 ~ 0 9 9 5 5
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ...................... .. 13. 0 O O
14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. 1 5 5 , 0 9 9 5 5
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 4 5 1 5 5, 0 9 9. 5 5 16. 6, 9 7 9 4 8
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.
20. F-LL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
6,9 7 9 .4 8
Side 2
15056052048 15056052048 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21 -1 0-0397
DECEDENT'S NAME
Dorothy J. Priset
STREET ADDRESS
274 Mooreland Avenue
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19) (1) $ 6 , 9 7 9 . 4 8
2. CreditslPayments
A. Spousal Poverty Credit - 0
B. Prior Payments - 0 -
C. Discount $ 3 4 3. 3 9
Total Credits (A + B + C) (2) 3 4 $ . g 7
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E) (3) -0-
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) $ 6 , ~ 3 0.51
A. Enter the interest on the tax due. (5A) - 0
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) $ 6 , 6 3 0.51
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 :.................................................................................... ...... ^ ^X
b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ 0
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 "intrust for" or payable upon death bank account or security at his or her death? ....... ....... ^
4. Ditl 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-1502 EX+ (6-98)
SCHEDULE A
COMMONWEALTH OF PENNSYLVANIA REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Dorothy J. Priset 21-10-0397
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be
exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property which is 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-1503 EX+ (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Dorothy J. Priset
FILE NUMBER
21-10-0397
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
---
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
NONE ~ -0-
TOTAL (Also enter on line 2, Recapitulation) I $ -0-
(If more space is needed, insert additional sheets of the same size)
REV-1504 EX+ (1-97) ,
..Y ~ .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE OF FILE NUMBER
Dorothy J. Priset 21-10-0397
Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a
sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
(If more space is needed, insert additional sheets of the same size)
REV-107 EX+ (1-97)
~~ ;~ SCHEDULE D
COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES
INHERITANCE TAX RETURN RECEIVABLE
RESIDENT DECEDENT
ESTATE OF F1LE NUMBER
Dorothy J. Priset 21-10-0397
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-1508 EX ~ (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, 8~ MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Dorothy J. Priset 21-10-0397
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
~~ Refund from Frontier (telephone) 6.28
2. Refund from security deposit
3. Miscellaneous household goods
474.00
2,000.00
TOTAL (Also enter on line 5, Recapitulation) I $ 2 - 4 8 0 . 2 8
(If more space is needed, insert additional sheets of the same size)
REV-1509 EX ~(1-971.
SCHEDULE F
COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Dorothy J. Priset 21-10-0397
If an asset was made joint wkhin one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
A. Joan Jones
ADDRESS
274 Mooreland Avenue
Carlisle, PA 17013
RELATIONSHIP TO DECEDENT
Daughter
B,
C.
JOINTLY-OWNED PROPERTY:
ITEM LETTER
FOR JOINT DATE
MADE DESCRIPTION OF PROPERTY
Include name of financial institution and bank account number or similar identifying number. Attach % OF
INTEREST DATE OF DEATH
DECEDENT'S NTEREST
NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSE7
1. A. 2/31 Checking Account, #112344, at $ 3,043.30 50$ $ 1,521.65
83 Citizens & Northern Bank,
Wellsboro, PA
2. A /18/ Savings Account #142906, at 25,273.77 50$ 12,636.88
00 Citizens & Northern Bank,
Wellsboro, PA
3. A 0/16 Certificate of Deposit, 61,252.43 50~ 30,626.21
07 #85770975, at Citizens &
Northern Bank, Wellsboro, PA
TOTAL (Also enter on line 6, Recapitulation) I $ 4 4 , 7 8 4 . 7 4
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX t(1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE G
INTER-VIVOS TRANSFERS 8~
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
Dorothy J. Priset 21-10-0397
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET 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
iFAPPUCneLE
TAXABLE VALUE
1. Annuity, #706168866, at 28,982.97 100 $28,982.97
Genworth Financial
2. Annuity, #706166646, at 37,663.38 100$ 37,663.38
Genworth Financial
3. Taxdeferred Annuity #0000696362, at 46,723.19 100 46,723.19
Genworth Financial
TOTAL (Also enter on line 7, Recapitulation) I$ 1 1 3, 3 6 9. 5 4
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (10-06)
SCHEDULE N
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Dorothy J. Priset 21-10-0397
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
~~ Tioga County Memorial Gardens $515.00
Wellsboro, PA. - Internment
2. Jacquelyn A. Buckheit Funeral Chapel 371.87
Crematory & Monuments - Funeral
3. Pastor Ken Smith - Funeral Service 100.00
B.
1
2.
3.
4
5
6.
7.
~.
8.
9.
10.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City
Year(s) Commission Paid:
Attorney Fees Anthony L. DeLuca, Esquire
Zip
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
Probate Fees
Accountant's Fees
Tax Return Preparer's Fees
Filing Fee for Inheritance Tax
Legal Advertising - Cumberland Law Journal
Legal Advertising - The Sentinel
Cherry Flats Baptist Church - Funeral Luncheon
2,500.00
342.50
300.00
15.00
75.00
208.78
100.00
TOTAL (Also enter on line 9, Recapitulation) $ 4 , 5 2 8 . 1 5
State
(It more space is needed, insert additional sheets of the same size)
REV-1512 EX+ (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCNEDt~LE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF
FILE NUMBER
Dorothy J. Priset 21-10-0397
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE A` DATE
NUMBER _~ DESCRIPTION OF DEATH
~. ~ Spirit Physician Services - Medical 19.10
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Camp Hill Emergency Physicians - Medical
Cumberland Goodwill EMS - Medical
Heritage Medical Group, LLP - Medical
In Your Home Care - Homemaker Services
Quantum Imaging and Therapeutic Associates - Medical
Soldiers & Sailors Memorial Hospital - Medical
Heritage Diagnostic Center - Medical
Pine Creek Internal Medicine - Medical
West Shore EMS-BLS-Medical
Cardmember Services - Credit Card
12.49
23.05
63.87
70.00
8.62
164.64
3.35
60.77
187.29
393.68
i
TOTAL (Also enter on line 10, Recapitulation) $ 1 , 006.86
ilf more space is needed, Insert addl?ior~a! sheets of the same size)
REV-1513 EX+ (9-00)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Dorothy J. Priset
FILE NUMBER
21-10-0397
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)J
1 Joan West Jones Daughter 100
274 Mooreland Avenue
Carlisle, PA 17013
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. NONE
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS NONE
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ _ 0 _
(If more space is needed, insert additional sheets of the same size)
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LAST WILL AND TESTAMENT _ ,_,nz~ w
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I, Dorothy J. Priset, of 21 Grant Street, Apartment D-202, Wellsboro, County o~'Tioga, ~
State of Pennsylvania, being of sound mind, and not acting under duress, menace, fraud,
or undue influence of any person do hereby make, publish and declare this instrument my
Last Will and Testament and do hereby revoke any and all other Wills and Codicils
heretofore made by me.
FIRST: I order and direct that my just debts and funeral expenses, expenses for
administration of my estate and any inheritance, State or Federal taxes upon said estate,
except those, if any, which are secured by mortgage or deed of trust, shall be paid as soon
after my death as may be practical.
SECOND: I am a widowed person. My spouses, Claude M. West and Oscar Priset, are
deceased and Joan West Jones and Dora West Logan are all my natural children.
THIRD: I hereby make the following specific bequests to my grandchildren:
Kevin Patterson $6,000
Linda Kent $6,000
Todd Patterson $6,000
Jamie Logan $6,000
Susan Logan $3,470 ($6,000 less $2,530 loan balance not repaid)
Penny Fassett $2,205.23 ($6,000 less $3,749.791oan balance not
repaid)
Patty Chilson $10 ($6,000 less $5,9901oan balance not repaid)
FOURTH: I hereby give, devise and bequeath all of the rest and residue of my estate, all
property over which I have power to dispose to Joan West Patterson Jones, her heirs and
assigns and Dora West Logan, her heirs and assigns.
FIFTH: I nominate and appoint Joan West Jones as Executor of this Will. In the event
that the Executor named above shall predecease me or fail to serve as such Executor of
this Will, I nominate and appoint Dr. Kevin L. Patterson as Executor. I further direct that
no appointee hereunder shall be required to give any bond for the faithful performance of
their duties.
SIXTH: I hereby authorize my Executor to exercise all power, rights, discretion and
duties deemed necessary for the proper administration and disposition of my estate.
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I subscribe m~ name to this ~~ ill this ~ ~: da}~ of ~harch ?U08.
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Signatczre: D~ ~ }• J. Priset
On the day ~~~ritten below, Dorothy Jelliff West. Priset, declared to us, the undersigned
that tlzis instrument, consisting of t~~~o (2) pages tiuas her Wi11 and she requested us to act
as witzlesses to it. Doroth}- Jelliff Va'est Priset thereupon signed this Fill in our Presence.
~hr'e ncr~+ in her presence s~zbsc~rihe o~zr narnes as z~ritnesses.
;<t is ~aezr belief that I~earothy ~eYliff`~'est Priset is ®f sound mind and under no constxairzt
or undue influence whatsoever.
We declare under penalty of perjury that the foregoing is true and correct. and that this
declaration ~~-as e~:eeu~ed on tl~e .r (a day of ?1~arch, 208.
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~.ddress
CODICIL
I, DOROTHY J. PRISET, of 21 Grant Street, Apartment D-202, Wellsboro, County of
Tioga, State of Pennsylvania, being of sound mind, and not acting under duress, menace,
fraud, or undue influence of any person do hereby make, publish and declare this addition
to my Last Will and Testament.
Since my daughter, Dora West Logan, predeceased me I hereby direct as follows:
Any expenses I have paid on behalf of my deceased daughter connected with her
burial will be deducted from her one-half portion of the remainder of my estate. A pre-
paid funeral plan for Charles Logan will also be deducted from her one-half portion of
the remainder of my estate. No distribution will be made to the heirs of my deceased
daughter until they present the executor of my estate with proof of obtaining this pre-paid
funeral plan.
If my deceased daughter's spouse, Charles Logan, is living and has not remarried,
then I direct the remainder of my deceased daughter's one-half share of my estate be
distributed in six equal shares to her spouse and children, their heirs and assigns. If my
deceased daughter's spouse has remarried then I direct my Executor to divide my
deceased daughter's one half share of the remainder of my estate in five equal shares to
her children, their heirs and assigns.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~ ,7 ~i day of
~~" ~~ , 2010
~~~
Dorothy J. Prise
Witness - _ ~,,
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