HomeMy WebLinkAbout08-19-10 (2) 505610101
REV-1500 °` X01-1°' ~
PA Department of Revenue pe^~SYt~~
DEV~XTXEXT OF INHERITANCE TAX RETURN
Bureau of Individual Taxes
PO Box 28o6oi RESIDENT DECEDENT
Harrisburcr. PA t7i28-oE)01
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY
0 6 ~ ~~~~ rT a /~oT
Decedents Last Name Suffix
i n ra ne ~ ~ r.
(If Applkabls~ Enter Surviving Spouse's Information Below
OFFICIAL USE ONLY
County Code Year File Number
Date of Birth MMDDYYYY
~'
Decedent's First Name MI
p ®S~~
Spouse's Last Name Suffix Spouse's First Name
~~
i n ~ ~ ® A nn
FILL IN APPROPRIATE OVALS BELOW
i• 1. Original Retum O 2. Supplemental Return
O 4. Limited Estate
f• 6. Decedent Died Testate
(Affect, copy of wilr>
O 9. Litigation Proceeds Received
O 4a. Future Interest Compromise (date of
death after 12-12-82)
O 7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
O 10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
MI
O 3. Remainder ~tetum (date of death
prior to 121-1(i-82)
O 5. Federal E$t~te Tax Retum Required
8. Total Number of Safe Deposit Boxes
O 11. Election t0 tax under Sec. 9113(A)
(Attach S¢h~ O)
C~ -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION
N~ Daytime Tele
First line of address
Second line of address
City or Post CHfice State ZIP Code
` sv`11 ®~
correspondent's e-mau address: ~ Y"O q renal.. ~ (~ 0 mcdL-s-` . n G'4"
ttE DIRECTED TO:
Ntdmber
Et~ ~F WILLS USE ONLY
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Under penalties of perjury, I dedare that I have examined this return, induding accompanying schedules and statements, and to the tbe~t of my knowledge and belief,
it is true correct and complete. Dedaretion of preparer other than the personal representative is based on all information of which ~ arer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN SATE
ADDRESS U
/yo~9 Cla-f'-ferbu.E-1~C Loa~o, (xunes~l ~~e, ~/!4 7.0 l 55
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE U8E ORIGINAL FORM ONLY
150.5610101
Side 1
1 1-. .
1505610105
REV 1500 EX
Decedent's Social Security Number
Decedent's Name:
1. Real Estate (Schedule A) ............................................. 1. m i~mni in.oi^ i ~i a^o om^
2. Stocks and Bonds(Sc~redule B) ....................................... 2.
3. Closely Hekl Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages and Notes Rer~ivable (Schedule D) ........................... 4.
5. Cash. Bank Deposits and Miscellaneous Personal Properly (Schedule E)....... 5. 9 ~ '
6. Jointly Owned Properly (Sc~redule F) O Separate 8tiling Requested ....... 6.
i
7. Inter-Vivos Transfers & Misc~llanears Non-Probate Property
{Sr~edule G) O Separate Billing Requested........ 7.
S. Total Gross Assorts (total Lines 1 thrrxigh 7) .......... ...... 8. 3 5 ~ 7
9. Funeral Expenses and Adm~istrative Costs (S^. hedule H) ................... 9. Q 0 d O
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10.
11. Total DeducMons (total Lines 9 and 10) ................:................ 11. / O O / U O
12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 3 ~ 6 8
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. ~ ~ 6
~r~n a.r~~.va.ru nm - xc ma ~ nw ~ ~vna rvn Rrr~.n,r-ale KAr C,
15. Amount of line 14 taxable
at the spousal tax rate, or
transfers under Sec. 911fi
(a~1.2) X .0_ Q
16. Amount of Line 14 taxable
at lineal rate X .0 _
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
15.
16.
17.
18.
19. TAX DUE ......................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
O
Slde 2
L 1505610105 1505610105
REV 1500 EX Page 3
Decedent's Complete Address:
Flle Number 2 0 0 '~ O D O ~ 7
sTR>=ET AoDRESs
yQ~~ ~
clTV meth an i c5b u,rq STATE
Tax Payments and Clredits:
1. Tax Due (Page 2, L'Ine 19)
2. CreditslPay-nenis
A. Prior Payments
B. Discount
3. Interest
4. ff Line 2 is greatelr tltarl Line 1 + Line 3, solar the difference. Tt>is is the OVERPAYMENT.
FiN in oval orl Page 2, Lila 20 to requt+st a refund.
Total Credits (A + 13 )
ZIP
1-7a 5~
(1)
(2) _ -C~
(3) ~ _ --
(a) U
5. ff Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) (~
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRUITE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain ills use Or income Of the property lrarlsierred :.......................................................................................... ^ ~.
b. retain the rift in designate who shall use the properly transferred ~ its income : ............................................ ^ .
c. retain a reversionary interest; or .......................................................................................................................... ^ ~
d. receive the promise for life of either payments, benefits or care? .......................~.............................................. ^
2. ff death occurred af61x Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate oonlsideratiorl? .............................................................................................................. ^ ~.
3. Did decedent own an "In trust for" ~ payable-upon~eaih bank account or security at his or her death? .............. ^
4. Did decedent own an individual retirement accamt, annuity or other non-probate property, which
contains a beneficiary designation? ........................................................................................................................ ^
~ THE ANSYVER TO ANY OF THE ABOVE AUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE R AS PART OF THE RETUR
For dates of death on or after Juty 1,1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spou=
3 percent p2 P.S. §9116 (a) (1.1) (i)].
For dales of death on or after Jan. 1, 1995, the tax rate imposed on the net walue of transfers to or for the use of the surviving spouse is 0 pe<
(72 P.S. §9116 (a) (1.1) (il)l. The statue does not exem~ a trartsfer to a surviving spouse from tax, and the statutory requirerrlerrts for disr~osure of assets
ring a tax retturt are still applicable even iF the survivirg 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 21 years of a~ or younger at death to or for the use of a natural parern
adoptive parent or a stepparent of the child is 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 4.5 percent, except as noM
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 tt>e decedent's sittings is 12 percer~ [72 P.S. §9116(a)(1.3)]. A'sibling is defined, u
Sectial 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
..~v-~saoc.~~an
COMMONNIEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE E
CASH, BANK DEPOSITS, ~ MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
John ~~ngra.ne.< <i Sr. 2O to -- DQ ~'d7
' Indude the proceeds of litigation and the date the proceeds were received by the estate. AN properly johrtly~onmsd with the right of eurvivorsh~p must be discbeed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
~. ~P~r;ty Li -Fc.. T-ns+.~-r'a..,c.~ Cor,.,.~nY ~`inpncio~1
P. ~JO - ~jm'X 5 7 Z o i n5~i 1~n
~ i ,~ c:;, n r~ a..t-i , o l-4 (-15 7~ (- 5 7 Z o
S~ ~ e trre~ ~ u n• U e~.r~ ~ 1}n n u.+~-Y
-Maw ~ 2 1 0 6 o q -7 0 l Z. P rd ~.ta.r~-
Ow~nu' ~• Jvhn Ctngrun~-~~1
' S t t ~ Pre.rr-i u.rn
^9 P ~-
Co n hra-e~ #~ 2. / O O O q -Z o/! N
~~ n 1-Y Lt ~- ~Cn s uLrat.~c~ Co r.~an y
.~.o . $o~ 5~ ao
~i ncrnna-ti , ok~' ~152o t -vr'? Za
~j,,,a,~,o-~l
• i ns~ dun
J~//~f, 6 9 3 .~o
~Z~S, og~~ 37
TOTAL (Also enter on line 5, Recapitulatioln)li S ~ rJ 9
(If more space is needed, insert additional sheets of the same size)
__
.~ • ~
REV-1511 EX+ (10-06)
scN~ou~E N
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES Sc
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
~dhln C~ n~ ra.•ne~~ ~ i L S r let o -- Q Q ~Q 7
Debts of decedent must be reported on Schedule L
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1, q/z;/SOr- Gu.~ +erA-l ~vm e ~j~ G 6 7.: / G1
Tr"c~..-, s p e r #~ 0>7 ~ p ~.ra! S es LOO .
A F~ ~ t.~ni/~(_ ~ a-.-~h~ert n q ~ i 3 - l 'S
M15c. 'P-~c~enses f=or Vle-W~J~ t O 1 -'f8
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
7.
cJ ~I • .5,6
TOTAL (Also enter on line 9, Recapitulation) I' $ /O ~ V Q /-
(If more space is needed, insert additional sheets of the same size)
` 'Integrity Life
Insurance Company
A member of V~esbern i Soutlbm Financial Group
Owner
JOHN CINGRANELLI
4833 EAST TRINDLE RD
BLDG 5 APT 503
MECHANICSBURG, PA 17050
_ Atcoun~ Change
- - - Projected value assuming no withdrawals, loans or transfers,
if permitted.
Death Benefit Value $235,659.01
Ca[endaz YTD Contributions (See page 2) $0.00
Integrity Life insurance Company •400 Broadway • Cincinnati, OH 45202
M U dv n a
n ua to m t o co
8/0 08 - /2
Representative Information Phone: (703) 810-1072
RUSSEL A. CESARI
200 SPRING STREET
SUITE 120
HERNDON, VA 20170
.~
Beginning Account Value $226,595;20 $200,000.00
lsa.aa Contributions $0:00 $0.00
~ Withdrawals $0.00 $0.00
Chazges and Adjustments $0:00 $0.00
Interest Credited $9,063;81 .$35,659.01
Total Change $9,063.81 $35,659.01
2005 2009 2012
If you have any questions concerning your annuity, refer to your contract, or consult with your financial represenRative. Please contact us
immediately if you feel this statement is in error. If we are not notified within 30 days of the date of this statement, we will not be
responsible for any errors. Our Customer Service Team can be contacted at 1.800.325.8583. Our mailing address is Integrity Life
Insurance Company, P.O. Box 5720, Cincinnati, OH 45201-5720. Express mail should be sent to Integrity Life Tnnsurance Company,
400 Broadway, Cincinnati, OH 45202. Faxes should be sent to 1.888.220.2677.
Visit our website at www.integritycompanies.com or email us at service~integritycompanies.com
JOHN CTNGRANFLT I CONTRACT# 2100097011
MOMENTUM Advantage ~ Page 2
Your Annuity Activity reflects values as of the Statement Date.
Ending Account Value does not include surrender chazges or mazket value adjustments (MVA) that may apply if you surrender your
contract.
Death Benefit Value, will be calculated as of the date we receive proof of the annuitant's death. This is the value your beneficiazy(ies)
will receive in the event of the annuitant's death. The amount shown in this statement is an estimated value as of the statement date.
Interest Rates are declared by the insurance company at annual effective rates, taking into account daily compounding of interest.
Any withdrawals or transfers (if permitted) during the guazantee period will dilute the benefit of daily compounding and thus lower
the effective annual interest rate.
IRS 10% Petialty may apply to eazly withdrawals from your annuity contract made prior to age 59 1/2. You should check with your
tax advisor before making withdrawals from your annuity contract.
Transactions since 8/01
integrity life Insurance `ompany •400 Broadway • tic-enati; OH 4 02
'Integrity Life
Insurance Company
A member of Western b Southern Fimncial Group
M U dv n a
n ua to pm t o co
8/0 08 - /2
Owner Representative Information Phone: (703)810-1072
JOHN CINGRANELLI RUSSEL A. CESARI
4833 EAST TRII~IDLE RD 200 SPRING STREET
BLDG 5 APT 503 SUITE 120
MECHANICSBURG, PA 17050 HERNDON, VA 20170
~
Account Change
Beginning Account Value $111,03 .61 $100,000.00
s
Contributions $0.00 $0.00
2s.n Withdrawals $0.00 $0.04
Charges and Adjustments $0.00 $0.00
$ Interest Credited $3,663,.19 $14,693.80
Total Change $3,663.19 $14,693.80
Death Benefit Value $114,693.80
Calendar YTD Contributions (See page a) $0.00
If you have any questions concerning your annuity, refer to your contract, or consult with your financial representative. Please contact us
immediately if you feel this statement is in error. If we aze not notified within 30 days of the date of this statement, we will not be
responsible for any errors. Our Customer Service Team can be contacted at 1.800.325.8583. Our mailing address is Integrity Life
Insurance Company, P.O. Box 5720, Cincinnati, OH 45201-5720. Express mail should be sent to Integrity Life Insurance Company,
400 Broadway, Cincinnati, OH 45202. Faxes should be sent to 1.888.220.2677.
Visit our website at www.integritycompanies.com or email us at service@integritycompanies.com
Integrity Life Insurance Company •400 Broadway • Cincinnati, OH 45202
2005 2009 2010
- - - Projected value assuming no withdrawals, loans or transfers,
if permitted.
.IUH.N C;1NCJiZANr1..1~1 CONTRACT# 21000970;.2
MOMENTUM Advantage . Rags 2
Your Annuity Activity reflects values as of the Statement Date.
Ending Account Value does not include surrender charges or nuirltet value adjustments (MVA) that may apply if you surrender your
contract.
Death Benefk Vahee will be caieulated as of the date we receive proof of the annuitant's death. This is the value your beneficiary(ies)
will receive in the event of the annuitant's death. The amount shown in this statement is an estimated value as of the statement date.
Interest Rates are declared by the insurance company at annual effective rates, taking into account daily compounding of interest.
Any withdrawals or transfers (if permitted) during the guarantee period will dilute the benefit of daily compounding and thus lower
the effective annual interest rate.
IRS 10% Penalty may apply to early withdrawals from your annuity contract made prior to age 59 1/2. You should check with your
tax advisor before making withdrawals from your annuity contract.
'Tnteg~ity` e V ,s'urance mpany •400 $roadway • Cinclnnati, bH 43202