The URL can be used to link to this page

Home My WebLink About10-08-10 (2) 150561D101 REV-1500 ext°'-'°' ~' PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau ofIndivtdualTaxes PO BOX z8o6o> ~.,.~.~d,~~ County Code Year File Number INHERITANCE TAX RETURN ~ `~ !~'~~ Harrisburg, PA 17128-o6oi RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMODYYYY Date of Birth MMDDYYYY 194-28-8141 07 /13/2010 ' 08/16/1938 Decedent's Last Name Suffix Decedent's First Name MI Keller ~ E. Robert (if Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name __ _ _. Suffix Spouse's First Name MI Keller _ . !Michele R 'i _. Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH TNi~ 171-54-0596 REGISTER OF WILLS FILL IN APPROPRIATE OYALS BELOW t3D 1. Original Return O 2. Supplemental Return O 3. Remainder Returrt (date of death prior to 12-13-8x) 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 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 dE bIRECTED TO: Name Daytime Telephone Number Jerome J. McDonald (717) 566-2127 ~ ~ cam, ,-,- .... ..~ __~ ~, ; REGISTER OF USE ON r,_,F.~ ~; _7 ~ S { r First line of address _ t'1 r ~ .~. ~ ~S7 ~ c- + r i t :~ , ,~-~ 439 Walton Avenue - ___ ,~ ~ '--~ ~ -cy ~~ r^ ;'- Second line of address ~ ~ c~ ~ __ _ ;- - - - ~. ~ _. _ _ _ _ .._ ---i r ~,. City or Post Office State ZIP Code DATE FILffD ~ Hummelstown PA 17036 Correspondent's a-mail address: Under penalties of perjury, I deGare that I have examined this return, inGUding accompanying schedules and statements, and to the best of m k~AOwledge and ballet, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all Information of which preparer heel an/~y/knowledge. SR1~gFyjtq O~~RE~PO IB R FILING RETURN ~Q pp~/!~+ ADDRESS ~ ~ I-~ 'T- 1059 Country Club Road, Camp Hill, PA 17011 SIGN OF PREPAR M REP NTATIVE DA E O'- - d ADDR 43 Iton Aven e, Hummelstown, PA 17036 PLEASE USE ORIGINAL FORM ONLY Side 1 L 15D561D101 1505610101' 15D561D1D5 REV-1500 EX oecedenYs Name: E. Robert Keller Decedents Social Security Number 194-28-8141 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 Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5.: 88,318.21 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. 130,785.00 8. Total Gross Aasets (total Lines 1 through 7) ........................... .. 6. 219,103.21 9. Funeral Expenses and Administrative Costs (Schedule H} ...... ............ 9. 19,007.86 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 11. Total Deductions (total Lines 9 and 10) ................................. 11. ', 19,007.88 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. ' 200,095.35 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ~" "~ ~~"~~~-"-`"+~~ ~" ~ -~" an election to tax has not been made (Schedule J) ........................ 13. 14. Net Yalue Subject to Tax (Line 12 minus Line 13) ...................... .. 14. ; 200,095.35 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 0 152,868.26 15. 0.00 16. Amount of Line 14 taxable at lineal rate X .0 45 47,227.09 18. 2,125.22 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 ................................. . ...................... . 1s. ` 2,125.22 20. FILL IN THE OYAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 15D5610105 150561D1D5 I~ J REV-1500 EX Pape 3 Decedent's Complete Address: DECEDENTS NAME E. Robert Keller 21-10-0757 STREET ADDRESS 1059 Country Club Road CITY ~ STATE 1 Camp Hill ' PA 21P 17011 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditsfPayments A. Prior Payments _ B. Discount 3. Interest 106.26 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. FIII in oval on Page 2, Line 20 to request a refund, 5. If line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. Flle Number (1) 2,125.22 Total Credits (A + B) (2) 106.26 i (3) (4) (5) 2,018.96 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROP!RI~4TE BLOCKS 1. Did decedent make a transfer and: Yelt ' 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 :............................................ ^ Q 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 consideration7 .............................................................................................................. ^~i x^ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at h(s or her death? .............. ^ Q 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 ITAS P1ART 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 tUse of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)J. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of Vansfers 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 requirem~nt~ for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only benefic(ary. ~, 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 benefidaries is 4.~ p~rcent, 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)(1.3~)j. A sibling 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-1509 EX+ (6-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN OCCIfICAIT r1Ff:G~1CWT SCHEDULE E CASH, BANK L?EPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF RILE NUMBER E. Robert Keller 21-10-0757 Indude the proceeds of IitigaGon and the date the proceeds were received by the estate. Ali orooarty iointly-owned with right of aurvivonhio must be dlecloeed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (08-09) Pennsylvania DEPARTMENT OF REVENUE INHERRANGE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUM~Et~ E. Robert Keller 21-10-0757 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-iSpO I$ yes, ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME of THE TRANSFEREE, THEIR REU1TIONSH[P TD DECEDENT AND THE DATE aF TRANSreI. ATTACH A coP~ aF THE DEED FoR REAL EsrATE. DATE OF DEATH VALUE OF ASSET % OF DECO'S INTEREST ~X USION IF TAXABLE VALUE L• Edward Jones IRA #896-96582-1-3 119,849.00 100 119,849.0( 2 -Mass Mutual IRA #VA08094605 10,936.00 100 10,936.0( TOTAL (Also enter on Line 7, Recapitulation) ; I ~' 130,785.00 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE [NNERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS B. ADMINISTRATIVE COSTS: ' 1. Personal Representative Commissions: Name(s) of Personal Representative{s) _ __ Street Address GtY _.. _,. _ State _ ZIP ....__....---..._.... Year(s) Commission Paid: Z• Attorney Fees: 3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) ', i claimant Michele R. Keller ~I ', Street Address 1059 Country. Club Road ', c;ty _Camp Hill State PA z[P 17011 Relationship of Claimant to Decedent Spouse 4• Probate Fees: 5• Accountant Fees: 6• Tax Return Preparer Fees: ~• Rockbass Griil-private dinner for family B An Olde Towne Florist &Greenery-Flowers s Colonial Golf & Tennis Club- celebration of life of E. Robert Keller attended by family and friends I ~~ ESTATE OF FILE NUMBEI>~ E. Robert Keller 21-10-Or~ST Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION ' AMOUNT A. FUNERAL EXPENSES: I' Myers-Hamer Funeral Home ', 3,519.00 i ', TOTAL (Also enter on Line 9, Recapitulation) #• If more space is needed, use additional sheets of paper of the same size. __ _ __ _ i_ 5,166.00 3,500.00 228.50 1,817.54 314.82 4,462.00 19,007.86 MYERS-HARNER FUAiERAL HOME, INC. ~~ Nuwc~T srReeT car tm.i., vAnnA i~~ t n~-rtp-psi F.OCAI.t:Y OW'\EA :1:YD nPERAT£D July 28, 2010 Mrs. Michele R. Keller 1059 Country Club Road Camp Hill PA 17011 Services for E. Robert "Woody" Keller July 17, 2010 Cremation with Service Cremation Container Cash Advanced Newspaper Notice/LACal Certified Copies Coroner Fee Total: $ 284.00 120.00 25.00 xosrrern. B,+Rxee suvFxv~sat DUS7Ui R IAKLA FU:~ML DIRECI+OR ~ x,950.00 $ 140.00 '' 429.00 ~,3ig:aII' I I 0005 Server: SHARON 0 t#16} Rec: 5 07/17/10 14:14, Swiped T: 408 Term: 3 ROCKBASS GRILL 4fi1 S. FRONT ST~'EET (717}731-1160 MERCHANT #: CARD TYPE .. ~ .~ ~' ~ ~ :~~? VISA ~?'%;;,~:,..s:~.~:'~,. , ir~~ 00 TRAt;SAC1'ION APPRI';~, ~ ` AUTHORIZATION #: 09515E Ref erer.!:e : 071'010000005 TRANS TYPE: Credi~i Card SALt CHEEK: 1527.24 TIP: 290.30 ADD t_.., T I Fs • __._. _ _._. _._._ T IJT A t_ : ___~_,R___t_._ . X PHONE: ~ ) - ***Duplicate Copy*** CARDHOLDER WILL PAY CARD ISSUER ABOVE AMOUNT PURSUANT TO CARDHOLDER AGREEMENT Sign One Copy & Keep a Copy for Your Records _~ , __ __ _ ~~ ~ OAT ~ ~ Br~9e , pp 17070 b 12F0 ~ ~-tom ~ on ~ ~"s ate btvok° p'° -ra M~cN~ ~ c~~B ROAD ,~.,_,_._-'.--' ~~ ~ ~ #, PA ~~~ ~ dew' ~ ~, v~+Y~ p~^1°~' °~' T~ D~ ~7 K~A , X 11 /18IZQ10 ~ #D, 4607 ~`~~ KE-~-~` ,ti ae1t~: ~ 46a7 --r `: ,~~-t P~ ? S ANGLE WH~E F TOTS- p~,sE. ~ ~~, ~a+eipt #o~ard ~° ~Y BR AND ~~AGE ~ ftX y~u-r b~~se ~ A#~E~CCRA N ~ W~~ T --. _ •e. ~~~ z L ,~p7,40 0$ ~.~ COLONIAL ~~~ -~"""-~ asol Linglestown ~-a COLONIAL Harrisb~,rg, Ptanrtsy~vania 17112 ~, ~,~ ca~a Phone 717/fi57~212 • fax 717/657-1692 00034843 {Jul 31/1 Robert Keller 1059 Country Club Road 4,377.51 Camp Hill, PA 17811 .... ~ .:. Balance Forward -119.49 u118/10 000115 Keller Celebration of Life 4,054.00 300.Op ', 108.00 4,462.00 u131/10 08 Facility Fee 35.00 0.0~ 0.00 35.00 Checks need to be made out to Colonial C3olf & T a Club i1e can no longer accept checks made out to Colo al Count Club] AN sfale~ne~Ns e~ due and paya6b ~ receipt and h no evaM ~ than 20 days atler the date of the sfatamerM. Inleeaet 1.5X rtKxidily wMl be added to all aileg 6etanaes. cu'r orrl~t ~ t o~tt ~ tsars -` oust ae uA~rs 377.51 0.00 0.00 0.00 4,089.00 ~ 300.00 ~~I, 108.00 4,377.51 ;Balatrtcal~ Dr~- 4 , 3 7 7.51 REV-1513 EX+ (O1-10) pennsylvania X17 DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE BENEFICIARIES _- ESTATE OF: FI E NUMBER: E. Robert Keller 21-10-0757 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 dlsMbugons and transfers under Sec. 9116 (a) (1.2).] 1• Michele R. Keller Spouse 152,868.26 2 Tracy Harner Daughter 23,613.55 3 Suzanne Hebeliig Daughter 23,613.54 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 19 OF REV-1500 COVER SHEET, AS 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; L 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. ~_ , 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name; E. Robert Keller :194-28-814fi RECAPITIft.ATION ....._ _ _......_ 1. Real Estate (Schedule A) ............................................. 1. ' .._......_....._,.._..w..~._.._..._._ ~..--..,~._._,.-._ _.._..~._..._..,. 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. ' w rw.. .m_. ~..~...._~_ 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. ........_,.. „~, ~~ 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers r;< Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 6. Total Gross Assets (total Lines 1 through 7) ............................. 6. 219,103.21 9. Funeral Expenses and Administrative Costs (Schedule H) ...... .......... .. 9. ', 19,007.86 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ...... . ..... .. 10. 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. 19,007.86 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 200,095.35 13. Charitable and Governmental Bequestsl5ec 9113 Trusts For which ~'~ an election to tax has not been made (Schedule J) ..................... ... 13. 14. Nat Value SubJect to Tax (Line 12 minus Line 13) ..................... ... 14. ; 200,095.35 TAX CALCULATION - 5EE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (ai(1.2) x .0 0 152,868.26 15. 0.00 16. __...~._...._._....,_~.._....._._._..... .. ,....__..,..1 Amount of Line 14 taxable i at lineal rate x .0 45 47,227.09: _._.. t6 .....___...._..._..__.....__.~ T ~.....~.._....._._.~ 2,125.22 . _... _v... . . 17. _._ _..... .. _.._ _.._..~ Amount of Line 14 taxable w.._ ; .. _ ._ . .......~.~__...._.. ~_.__..w _..... at sibling rate X .12 ~ 17. , , 18. _.,. __,..~..__._.....M... _..~.w~..__ ___ __.__... ___.._.......~ Amount of Line 14 taxable F-w --.- ._.,~..~._...,......__..._...F.,~, at collateral rate X .15 18. 19. TAX DUE ...................................................... ... 19. ' 2,125.22 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610105 88, 318.21 130,785.00 O 1505610105 I J