HomeMy WebLinkAbout08-18-101505610101
REV-1500 t:x `01.1°'
Enn Lvania OFFICIAL USE ONLY
PA Department of Revenue P sY
Bureau of Individual Taxes °°"'"~"`"~°`"`.E"~` County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA >_~>28-0601 RESIDENT DECEDENT Z ~ / C 4 ~' /p
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
192-14-5705 ' 06/09/2010 ' i 12/23/1918
Decedent's Last Name Suffix Decedent's First Name MI
Sheaffer ' 'Mary E
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Return
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
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
James W. KOllas ' ', (717) 731-1600
First line of address
1104 Fernwood Avenue
Second line of address
Suite 104
City or Post Office State ZIP Code
Camp Hill ' PA ' 17011
REGISTER OF WILLS USE ONLY
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Correspondent's a-mail address: jameS kollasandkennedy.com
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 a complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATU F R~+;~E SIBLE FOR FILING RETURN DATE
15 Cedarhurst Lane, Camp Hill, PA 17011
SIGNATURE~r)b PREPARER OTHER THAN REPRESENTATIVE DATE ~
1104 Fernwood Ave, Ste 104, Camp Hill, PA 17011
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610101 1505610101 J
1505610105
REV-1500 EX
Decedent's Social Security Number
192-14-5705
Decedent's Name:
RECAPITULATION
1. Real Estate (Schedule A) ........................................... .. 1. ' 0.00
2. Stocks and Bonds {Schedule B) .......................... . .......... .. 2. ' 0.00
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. ' 0.00
4.
9 9 ( ) .........................
Mort a es and Notes Receivable Schedule D 4.
.. 0.00
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. ' 90,193.66
6. Jointly Owned Property (Schedule F} C7 Separate Billing Requested ..... .. 6. ' 4,913.04
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested...... .. 7. 0.00
8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. ', 95,106.70
9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. ; 15,583.87
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ .. 10. ', 0.00
11. Total Deductions (total Lines 9 and 10) ............................... .. 11. ' 15,583.87
12. Net Value of Estate (Line 8 minus Line 11) ................ . ........... .. 12. ', 79,522.83
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ...................... .. 13. 0.00
14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. ', 79,522.83
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
16. Amount of Line 14 taxable
at lineal rate X .0 45 79,522.83
16.
3,578.53
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. ', $,578.53
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
1505610105 1505610105 J
REV-1500 EX Page 3 File Number
1'lw w...J ~. r.ifc. f"~wrwwlw~~ AeJ rl re~cc~• ~'S ~ ,~
Tax Payments and Credits:
1. Tax Due {Page 2, Line 19) (1) 3,578.53
2. CreditslPayments
A. Prior Payments
B. Discount 178.93
_.......____..._._.....- - - - --.........._...._ ................._._.__.... 178.93
Total Credits (A + g) {2)
3. Interest
(3) 0.00
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) 0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 3,399.60
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 :.................................................................................... ...... ^ Q
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 Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ........................................................................................................ ...... ^
3. Did decedent own an "intrust for" orpayable-upon-death bank account or security at his or her death? ........ ...... ^ x^
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? .................................................................................................................. ...... >r^ ^
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)J. 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 the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)J.
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 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 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-7508 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Mary E. Sheaffer 21-10-0610
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.
(If more space is needed, insert additional sheets of the same size)
REV->,5o9 EX+ (oi-io)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCI~IEDt~LE F
70INTLY-OWNED PROPERTY
ESTATE OF: FILE NUMBER:
Mary E. Sheaffer 21-10-0610
If an asset became jointly owned within one year of the decedents date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A• Barbara S. Bourdette
15 Cedarhurst Lane
Camp Hill, PA 17011
Daughter
B.
C.
JOINTLY OWNED PROPERTY:
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
]DINT DESCRIPTION OF PROPERLY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR]OINTLY HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET Mo OF
DECEDENT'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
1. A. 11/10108 PNC Bank, Acwuntant Number 5006307399 9,826.07 50 4,913.04
TOTAL (Also enter on Line 6, Recapitulation) I ~ 4,913.04
If more space is needed, use additional sheets of paper of the same size.
REV-1510 EX+ {08-09)
~. SCHEDULE G
Pennsylvania
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Mary E. Sheaffer 21-10-0610
This schedule must be completed and tiled if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR REIATIONSNIP 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
(IFAPPUCABLEJ TAXABLE
VALUE
1• Allstate Life Ins. Co., Annuity Contract No. GA 19348775, Named Beneficiary
147,103.00 100 100.00 O.OC
was Barbara S. Bourdette, Daughter of decedent, exclusion claimed under
72 P.S. 9111(r); See attached fax/letter from Allstate dated 07/15/2010.
TOTAL (Also enter on Line 7, Recapitulation) ; ~ 0.00
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Mary E. Sheaffer 21-10-0610
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' Musselman Funeral Home, Inc. 7,847.22
2. Rolling Green Cemetery 1,620.00
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City
Year(s) Commission Paid:
State ZIP
0.00
2,000.00
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) 3,500.00
Claimant Barbara S. Bourdette
street Address 15 Cedarhurst Lane
City Camp Hill State PA ZIp 17011
Relationship of Claimant to Decedent Daughter
4. Probate Fees: 616.65
5. Accountant Fees: 0.00
6. Tax Return Preparer Fees: 0.00
7.
TOTAL (Also enter on Line 9, Recapitulation) I # 15,583.87
If more space is needed, use additional sheets of paper of the same size.
REV-1513 EX+ (01-10)
i Pennsylvania SCHEDULE ~
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
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• Barbara S. Bourdette, 15 Cedarhurst Lane, Camp Hill PA 17011 Daughter 100%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE,
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.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $
If more space is needed, use additional sheets of paper of the same size.
ii S 0 ~I.~"~ f ~ ~~ I~~ 3 $
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~~~`~~~` ''^ , `'~~ ',`~ JJ' LAST WILL AND TESTAMENT
OF
MARY ("BETTY") ELIZABETH SHEAFFER
I, MARY ELIZABETH SHEAFFER, of 15 Cedarhurst Lane, Camp Hill, Cumberland
County, Pennsylvania, do make and declare this to be my last Will and Testament, hereby
revoking all prior Wills and Codicils.
FIRST: I direct that all my debts and funeral expenses be paid as soon after my
death as may be practicable. I further direct that all estate, inheritance, transfer, legacy or
succession taxes which may be assessed to my estate or any part of my estate as an expense of
administration and without appointment.
SECOND: I give the rest, residue, and remainder of my estate to my daughter,
BARBARA S. BOURDETTE of Camp Hill, Pennsylvania.
THIRD: If my daughter fails to survive me, her portion of my estate shall be
distributed equally (50%/50%) to my granddaughters, LISA B. BOCK ,Camp Hill,
Pennsylvania and LESLIE SANSONE ,Tucson, Arizona.
FOURTH: If my granddaughters fail to survive me, then I give the rest, residue, and
remainder of my estate to their children, my great grandchildren, to be divided equally among
them.
FIFTH: Without limiting the powers conferred by statute by general rules of law,
my Executrix is specifically authorized and empowered:
(a) To invest any funds of my estate in any corporate shares, bonds, notes, or
other securities or property, real or personal, including any common or commingled funds
maintained by my Executrix. This is to reflect my intention to give the broadest powers and
discretion to my Executrix;
(b) To sell or otherwise dispose of any property, real or personal, at any time
forming a part of my estate, for cash or upon credit, in such a way and on such terms as my
Executrix may deem best;
(c) To manage, operate, repair, improve, mortgage, and lease for any term any
real estate at any time held;
(d) To make distribution in cash or in kind upon any division of my estate;
and
(e) In general, to exercise all powers in the management of my estate which
any individual could exercise in the management of similar property in her own right, and to do
all acts which my Executor or Executrix may deem necessary or proper to carry out the purposes
of this Will.
SIXTH: I direct that my daughter, Barbara S. Bourdette of 15 Cedarhurst Lane,
Camp Hill, Pennsylvania, shall be Executrix of this Will. If my daughter, Barbara Bourdette,
predeceases me or otherwise cannot act as Executrix, then I direct my granddaughter, Lisa Bock
of 38 Essex Road, Camp Hill, Pennsylvania, shall be Executrix of this Will, If my
granddaughter, Lisa Bock, predeceases me or other wise cannot act as Executrix, then I direct my
granddaughter, Leslie Sansone, 3310 W. Bright Terrace, Tucson, Arizona, shall be Executrix of
this Will. No Executor or Executrix acting hereunder shall be required to post bond or enter
surety in any jurisdiction.
IN WITNESS WHEREOF, I hereunto set my hand this J •=-- aay U1 J Uly, ~~.. ~ .
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MARY ELIZABETH SHEAFFER
SIGNED, PUBLISIIEll, and DECLARED by the above, MARY ELIZABETH
SHEAFFER, as and for her Last Will and Testament, in the presence of us, who, at her request,
in her presence, and in the presence of each other, have hereunto subscribed our names as
witnesses:
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COMIVIC7IVW~~IL"I~H C)F t'~`IVNS~LVANI"A
SS:
COUNTY OF CUMBERLAND
I, MARY ELIZABETH SHEAFFER, Testator, whose name is signed to the foregoing
instrument, having been duly qualified according to law, do hereby acknowledge that I have
signed and executed the instrument of my Last Will and Testament; that I signed it willingly;
and that I signed it as my free and voluntary act for the purposes therein expressed.
Sworn to and acknowledged before me by MARY ELIZABETH SHEAFFER, the
Testator, this Jr ~ day of July, 2007.
(~fiAn1 (~ l~aX~
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MARY LIB BETH SHEA FER
Notary Public NOTARIAL SEAL '
CAROLE A ROSE
Notary Public
TWSP OF LOWER ALLEN
CUMBERLAND COUNN
My Commission Expires Oct 21, 2007
COUNTY OF CUMBERLAND
SS:
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the witnesses
We, ; ._~- .,~ ; ~- ~ .d ~~~~ ; ~ ~ y s -and ~ ~:- ~,,~~ < ~ i_. ,.. ~ 1; r ~ ~~ ~t~ . ,
~ ~ .~
whose names are signed to the attached instrument, being duly qualified according to law, do
depose and say that we were present and saw the Testator, MARY ELIZABETH SHEAFFER,
sign and execute the instrument of her Last Will and Testament; that she signed it willingly and
that she executed it as her free and voluntary act for the purposes therein expressed; that each of
us in the hearing and sight of the Testator signed the Will as witnesses; and that to the best of our
knowledge the Testator was at that time 18 or more years of age, of sound mind and under no
constraint or undue influence.
,I j
Sworn to and subscribed to before me by , .. + ' _ ~ + . 1 `, ~ ~ _ and
-~~ - ~ ~~, _, witnesses, this ,~ '' day of July, 2007.
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. ~ NOTARIAL SEAL .`
CAROLE A ROSE
otary Public Notary Public
TWSP OF LOWER ALLEN
CUMBERLAND COUNTY
My Commission Expires Oct 21, 2007 ~
Fax from
Allstate Life Insurance Company
P.U. Box 94212
palatine, XL. G0094-4212
Telephone: (877) 499-6418
Facsimile: ($66) 635-452:3
Duly 1S, 2Qlt)
Holly O'Hara
PNC Investments
4242 Carlisle Pike
- Camp Hill, PA 17011
12e: Mary ~. Sheal'feY
Contract Nu: GA1934$775
pear Ms. O'Tdara:
87-16-18 12:21 Pg: 2
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You're in good hatt:ds.
We received a request to complete IRS Form 712 for the. above referenced con~ix^ect. The purpose of dorm
712 is to provide an estate or donor with the value of a life insurance contractor its proceeds as of a certain
date (usually the owner's date of death or date of transfer of the contract).
Because this contract is an annuity, it is not reportable on IRS Form 712. I can, however, provide the
fallowing information for estate purposes:
Date of Death: Tune ~, 2010
Annuity Value as of Qate of Death: $147,103.02'
Cost Basis: $ 106,000.IIQ
1~Tamed Beneficiary: Barbara S. Bourdette
*The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender
Charges.
If you have any questions, please contact me at 1-$77-499641$ E;ct. 24.520.
Sincerely,
~.~
Sr. Claim Examiner