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Home My WebLink About08-20-10~ LsoseLOla1 REV-1500 Ex `ol-lo, enns lvania OFFICIAL USE ONLY PA Department of Revenue P Y County Code Year File Number Bureau of Individual Taxes "`°"N'"~h' ~~ HF~_N~E PO BOX 28o6oi INHERITANCE TAX RETURN ~ 1 r Harrisburg, PA i~iz8-o6o1 RESIDENT DECEDENT ~-~ ~ t ~~ ~ ~~~,,~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 185-28-1862 01/17/2010 09/16/1922 5' Decedent's Last Name Suffix Decedent's First Name Van Brakle Ruth !, (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER 4F 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 T0: Name Daytime Telephone Number Daniel D. Worley (717) 854-591. First line of address 101 E. Philadelphia St. Second line of address City or Post Office York State ZIP Code PA 17401 REGISTER 01`N~~.f<.8 Ol~1G ~ -C7 C~' t - d l,_., . ,; ~, . ; c~..._ . _ ~,~ -T..~ -"I ~ .. '' t<'~„1 DATE FpLED _~ _i . _~ .7 _, -., ~. .: C~~) .:., Correspondent's a-mail address: dan worleyandworley.com Under penalties of per}ury, I declare that f 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 person~Lce~rysentative is~ed on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ATE ~ ~ / `~" 2G 1 U _ ADDRESS Karen R. Worley 178 Plank Road, York Springs, PA ohn D. Van Brakle 1731 Penns Crossing Allentown PA SIGNATU E OF PREPARE Tl-lER N REPRESENTATIVE DATE ADDRESS Daniel D. Worley 101 E. Philadelphia St. York, PA 17401 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 1505610105 REV-1500 EX Decedent's Name: Decedent's Social Security Number 185-28-1862 RECAPITULATION 1. ........................... Real Estate (Schedule A} ................. . 1. 0.00 2. Stocks and Bonds (Schedule B) ....... ... 2. ,~~ 4~4 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. 9 9 ( } ........................... Mort a es and Notes Receivable Schedule D 4. , `~~ 4'00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 183,862.66 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 0.00 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 0 00 (Schedule G) O Separate Billing Requested........ 7. . 8. Total Gross Assets (total Lines 1 through 7) . ............................ 8. 183,862.66 9. Funeral Expenses and Administrative Costs (Schedule H) ............ ....... 9. 784.87 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... ....... 10. 13,485.62 11. Total Deductions (total Lines 9 and 10) .......................... ....... 11. 14,270.49 12. Net Value of Estate (Line 8 minus Line 11) ....................... ....... 12. 169,592.17 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................. ....... 13. 4,590.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ................. ....... 14. 165,002.17 TAX CALCULATION -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.~ 0.00 15. 16. Amount of Line 14 taxable at lineal rate X .0 45 7,425.09 16. 17. Amount of Line 14 taxable 0 00 . at sibling rate X .12 17. 18. Amount of Line 14 taxable 00 0 . at collateral rate X .15 18 19. TAX DUE ...................................................... ... 19. 20. FILL tN THE OVAL tF YOU ARE RE4UESTING A REFUND OF AN OVERPAYMENT 7,425.09 ............:.............. . 7,425.09 O Side 2 1505610105 1505610105 REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Ruth E. Van Brakle STREET ADDRESS 100 Mt Allen Dr. __ - -- _ _ ___- i STATEPA _ _ -_ _ ,-. - _ - __ . CITY Mechanicsburg ! ZiP17055 i Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 7,425.09 2. CreditslPayments A. Prior Payments 6,174.00 B. Discount 308.70 Total Credits (A + B) (2) 6,482.07 3. Interest (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) 943.02 Make check payable to: REGISTER OF W1LLS, 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 ar income of the property transferred :.......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ 0 c. retain a reversionary interest; or .......................................................................................................................... ^ 0 d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 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 Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 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 21 years of age or younger at death to or for thEl use of a natural parent, an 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 beneficiaries is 4.5 f-ercent, 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 12 percent [72 P.S. §9116(a)(1.;i)J. 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+ (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Ruth E. Van Brakle 21-10-0169 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. PNC Bank CD # 31700306445 15,288.37 2. PNC Bank CD # 31700316451 15,313.38 3. PNC Bank Checking Account # 5004883317 11,361.94 4. Embassy Bank CD # 1478044 12,142.20 5. Embassy Bank CD # 1494512 49,956.99 6. Embassy Bank CD # 1490260 38,183.00 7. Burial Plots in Mount Rose Cemetery, York PA (see valuation letter) 2 plots @ $2295 each 4,590.00 8. PNC Money Market Account 36,217.68 9. Pension Plan Payment 555.10 10. Health Insurance Reimbursement 254.00 TOTAL (Also enter on line 5, Recapitulation) $ I 183,862.66 (If more space is needed, insert additional sheets of the same size) Ms. Karen Worley 178 Plank RD. York Springs,PA 17322 Dear Karen, Your property transfer to the Salvation Army has been completed. The estimated value of each space is 2295.OOIf you have any questions, please call. Thank you. Marty Reeve ~~.~ ~ Family Service Counselor ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Ruth E. Van Brakle 21-10-01Ei9 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Parthemore Funeral Home -remainder due for prepaid funeral expenses 169.87 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Karen R. World and- John Van Brakle Street Address 178 Plank Road city York Springs state PA ZIP 17372 Year(s) Commission Paid: N/A Z• 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 Fees: 6. Tax Return Preparer Fees: ~. TOTAL (Also enter on Line 9, Recapitulation) I $. If more space is needed, use additional sheets of paper of the same size. 0.00 0.00 0.00 315.50 300.00 784.87 Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Ruth E. Van Brakle 21-10-0169 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. REV-7.s13 ~x-+ ,o7.-i.aa ~ pennsylvania SCHEDULE ~ DEPARTMENT Df REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF. FILE NUMBER: Ruth E. Van Brakle 21-10-0169 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).) 1• Karen R. Worley 178 Plank Road, York Springs, PA Daughter one third 2. John D. Van Brakle 1731 Penns Crossing Allentown PA Son one third 3. James D. VanBrakle 1131 Scout Road; Hershey, PA Son one third ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. Salvation Army - (2) burial plots at Mount Rose Cemetery York PA (see attached letter) 4590.00 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ 4590.00 If more space is needed, use additional sheets of paper of the same size. SHAW CLIFTON GENERAL 1 ~~~ ?y 8'~IVAT~~~ THE SALVATION ARMY FOUNDED 1865 by WILLIAM AND CATHERINE BOOTH 50 EAST KING ST., P.O. BOX 127 YORK, PA 17405 PHONE:717-848-2364 FAX:717-854-9357 ADVISORY BOARD Charles B. Calkins, Esq. Chair Mr. Frank R. Baker Vice Chair Mr. Stanton L. Miller Treasurer Mr. James D. Adelsperger Mr. Rodney J. Barnett Mayor John S. Brenner Dr. Dean Cheesebrough Ms. Elizabeth Dellinger Mr. Thomas E. Donley Mr. Robert M. Etzweiler Mr. William H. Everhart Mr. Stephen F. Feldmann Mrs. Susan M. Gordon Rees Griffiths, Esq. Judge Ronald J. Haskell, Jr. Dr. Julia Hines-Harris Mr. B. Vann Johnson Mr. Thomas Norris Mr. Lawrence R. Pike Mrs. Ray Rife Mrs. Rayda Rivera Mr. Kenneth Scalet Mr. Thomas Senft Mr. Gary Sutton Mrs. Edward M. Wiest, Sr. Mr. William R. Wendel Mr. Samuel Willman Mr. Charles Zarfos LIFE MEMBERS Mrs. William R. Baker Mr. Lester W. Bentz, Jr. Mr. Charles E. Lehman J. Ross McGinnis, Esq. MEMBER EMERITUS Mr. Walter Henry WOMEN'S AUXILIARY Mrs. Carol Marks Preside~at . ~ . ~ rY) , • _~:~' ~`: United Way of York County Community Partner July 12, 2010 Ms. Karen Worley 178 Plank Rd York Springs, PA 17372 Dear Ms. Worley, LAWRENCE R. MORETZ TERRITORIAL COMMANDER We are in receipt of the deed for Spaces 3 & 4 of Lot 50 , Unit A in the Parkway Section of Mount Rose Cemetery in York. Thank you for your kind contribution of these cemetery plots for use by needy families. I understand that these burial plots were a part of your mother's, Mrs. Ruth Wan Brakle, estate. We do not re-sell donated plots, but rather donate them to families who are under financial stress in paying for the burial of a loved one. Your plots will be used in this fashion. On behalf of the families who will benefit from your gift, we thank you. You may use this letter in claiming any donation amount for tax purposes. No goods or services were received by you in exchange for this donation. Thank you again and God bless you. Sincerely, ...,_. Dennis E. Camuti, Major Citadel Corps Officer