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Home My WebLink About09-17-10 (3)1505610101 REV-1 S00 EX (01-10) ,~' PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau of lndividualTaxes DfvuDMMlDixfvlMW ~' Year File Number un e / / Po Box 280601 INHERITANCE TAX RETURN "" "----^ U ~ "~ ~ l ~-7.. Harristwrg, PA 17128-0601 RESIDENT DECEDENT ~ 1 ! 1 , ENTER DECEDENT INFORMATION BELOW Soaal Security Number Date of Death MMDDYYYY --.-- - -~ -_........______ .__--r - - __._ 441-20-3005 06/18/2010 ._.__. Decedent's Last Name Suffix ,--- -~.__.~__..________.__._._..__.._.____..._._._._ r.,_.___ Roseberry `--_-~_ _._____ ___ ___._ __--_-__-- ~------.__._J (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last ame Suffix N Spouse's Social Security Number Date of Birth MMDDYYYY _. - - - ~ 01/20/1922 _.__._~ Decedent's First Name ~ MI _ r ora ~...__. . __,_., ._~.^_ L....... - ._~___. ~A _I First Name ! MI -. ~ ~ ~~ ------------ --- -------- ------~ THIS RETURN MUST BE FILED IN DUPLICATE WITH REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW (>~ 1. Original Return O 2. Supplemental Return O 3. Remainder Retur n (dgte of death prior to 12-13-82 O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate T Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of ~afe 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 un der 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 B DI((ECTED T0: Name Daytime Telephone N mbar Ronald D Roseberry ! (717) 564 3734 REGISTER O -_._.~„r~ ......... SE ON~ First line of address (~ - V _ __ 6121 Sawgrass Court l ~ ~ ~ c _- __ _ _ ._ _._. _ _ ._ _ .. Second Ime of address -p A I ~ II ~ .~ _ Ci or Post OffiCe ___..-...~__...----_....__.----__.__..- ~ ----.----_.°--..____._State.....__._ZIP I a DATE ILEm ~°f Harnsburg -__._..___._~__ .,.._._.._.,________._._y~,.._.... ~ J _ PA_ II 17111 ____ ___.___.__~ ~ _..._._.1 ._...___ . II _..._..._ .___.__. J._. _-- _ Correspondent's e-mali address: net G~ C Under penalties of perjury, I declare that 1 have examined this return, inGuding accompanying schedules and statements, and to the bestUnder of perjury, I that I have examined this return, schedules and statements, and to the best of~y knbwledge and beliefknpwledgeancl belief, it is true, correct and complete. Declaratlon of preparer other than the personal representative is based on all information of which preparer has pny knowledge. SIGNATUBQOF PERSON RES-ONSIB R FILING RETURN D TEi. / w ADDRESS OF PREPARil12 OTHER THAN REPRESENTATIVE ,'~^ ADDRESS PLEABE U8E ORIGINAL FORM ONLY Side 1 1505610101 150561010 J I I J 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: Nora A Roseberry 441-20-3005 RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. ~ ~. ~ .~. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. '~ 5. Cash, Bank De sits and Miscellaneous Personal Pro rt Schedule E ....... 5. ~TY~ ~T _^__,' 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. II ', 54,751.00 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property I ~~~~ '~~ ~~'~~-~ ~i (Schedule G) O Separate Billing Requested........ 7. ', 8. Total Gross Asaets (total Lines 1 through 7) ............................. 8. 54,751.00 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. ~ 9,931.97 _ ____~_ -~--- 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. ', 4,246.93 ""'"1 11. Total Deductions (total Lines 9 and 10) ................................. 11. ', 14,178.90 12. Net Value of Estate (line 8 minus Line 11) .............................. 12. ~ ~ 40,573.00 j 13. Charitable and Governmental BequestslSec 9113 Trusts for which I ----"~ an election to tax has not been made (Schedule J) ........................ 13. ~, 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. ~ 40,573.00 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATE8 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 ~~ ~ i at lineal rate X .0 ~` 18. 1,825.00 17. Amount of Line 14 taxable ~~-~ _ ~ ~~-~ at sibling rate X .12 17. .M 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE .............................~-----.................... 19. ' 1,825A0~ __. _.______.-----._-_ a_._.._ _...._ _.....__.~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 150561010.E J I REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENTS NAME Nora A Roseberry STREETADDRESS 824 Lisburn Road, THE WOODS CITE Camp Hill STATE PA ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 0.00 (1) 1,825.00 Total Credits (A + B) (2) ~ 0.00 (3) I 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, LMe 20 to request a refund. (4) 5, ff Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 1,825.00 Make check payable to: REGISTER OF WILLS, AGENT. i PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRNATE 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? .............................................................................................................. ^ '', x^ 3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or othernon-probate property, which ', contains a benefcary designation? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT A~ 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 th~ 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 ~urviving 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 requiremen s 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 tt~e 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'per¢ent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)J. • 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)(11.3)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. ', 0.00 REV-1509 EX+ (oi-1o) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENTDECEDENi SCMEpuLE F JOINTLY-OWNED PROPERTY -- -- ESTATE OF: FILE .UMBER: Nora A Roseberry If an asset became jointly owned within one year of the decedent's date of death, it must be roporbt+d on hodule G. SURVMNG JOINT TENANT(S) NAME(S) ADDRESS RELA ONSHIP TO DECEDENT A•,JefFrey Lee Roseberry ;2656 Broadway Evanston Illinois 60201 !Son B. rty I ;Ronald D Rosebe x,6121 Sawgrass Court Harrisburg PA 17111 ..Son C. - JOINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY ~ OF DATE of DEATH ITEM FDR JOWT MADE INCLUDE NAME OF FMIWCULL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH Nr'S VALUE OF NUMBEit T9~IUfT MINT IDENTIFYING NUMBER. ATTACH DEED FOR IOINTLY HHD REAL ESTATE. VALUE OF ASSET I REST DECEDENTS INTEREST 1. A. "044105 ~UBS Finanaai Services Inc Investment Account #LV95878-RS 164,417.00 3~3~0 !~ _, '~~~~ I 54,751.00 TOTAL (Also enter on Line 6, Recapitulation) ; 54,751.00 If more space is needed, use additional sheets of paper of the same size. •REV-1512 EX+ (12-08) ~pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INNERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT Nora A Roseber Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM WALUE AT DATE NUMBER DESCRIPTION ' OF DEATH I • ~ Moving 310.00 2 Alert Pharmacy 315.18 3 'Colonial Park Rehab ~ 550.00 4, Colonial Park Rehab I i' 30.00 5' Compassionate Senior Care 321.75 6` 'South Central EMS '~ 120.00 7'i The Woods at Cedar Run 2,600.00 TOTAL (Also enter on Line 10, Recapitulation) I ; ~~ 4,246.93 If more space is needed, insert additional sheets of the same size. ~