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HomeMy WebLinkAbout11-15-101 `~ 1505610101 REV-1500 Ex ~O1.1°' ''~ PA Department of Revenue pennsylvania DEPARTMENT OF REVENUE Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 Harrisburg, PA 1128-0601 RESIDENT DECEDENT Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY ~~ _ i. ,. ` ~ ~: -. ,... iu.V~B~7.7. "~ -.' - ,.d'n"_lw 1.."FnIt~F 1+. rig. Decedent's Last Name Suffix Decedent's First Name MI .-~ ~ .,~ .rY~. '°~.%w ,E 4 (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI ~:_a< - ~ wig' T1R y'~`. F .' ~~. ; ~ ~ t ~' { J ` ~ { f ( ~ '~~ t f~NlWtl: ~ . _ (~ f .. Wi r ~~. _ _ ~' , t , ' .*~e1M't .... .. .~.: - ~. ]tl'; ~.., , .3. ~.a:r:1f-~,.,.. T+`N"~!' Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF 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) OFFICIAL USE ONLY Code Year File Number L , a;;, .., .. ~ - ~. ~ .:, ENTER DECEDENT INFORMATION BELOW CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number • i 4 ~J First line of address .:;..z ~ ? ~ a.. . Second line of address ..Z ~ ~ ,~.~. 1 GL} D ` U ..~ r City or Post Office State .. ZIP Code 1 ~~ ~ REGISTER OF WILLS USE ONLY C~ C ~Q ~ ..; r ~ ~ r . -~~~ ~ ~ :' ~: ~"" '"',~ f: fir: h CJ't r. , .. ._ :~ t":a ~ r r UAT$FILED ,; , .. --- .; Correspondent's a-mail address: _ DA' /L2. r!° ~ ~ Q ADDRESS ;' SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE _ DATE SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN 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 and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. ADDRESS PLEASE USE ORIGINAL FORM ONLY M 1505610101 Side 1 1505610101 J 1505610105 REV-1500 EX Decedent's Social Security Number ' ~ ~~ ~ ` "~ s Name: Decedent 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. 'l ~ ~ ~ ~- d ~ 6. Jointly Owned Property (Schedule F) p Separate Billing Requested ....... 6. l „~ ~ ,~.? ~ ~ • ~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ®Separate Billing Requested........ 7. • 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ~ ~' ~ ~, ,; f: ~ • G' "j 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 9 ~ ~? ~ + 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 11. Total Deductions (total Lines 9 and 10) ................................. 11. ~ ~" L~ ~ . 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. ~ ,[ f ~ ~ 3 y ~"" 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. ~ ~ 1 ~ ,;~ ~~ 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_ . 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ . 16. 17. Amount of Line 14 taxable / at sibling rate X .12 l / f ~ f ,~ ~ •~~ lp 17. 18. Amount of Line 14 taxable at collateral rate X .15 • 18. 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1 7 ~ ~ ~ • -l .5` • } ~~ Side 2 1505610105 1505610],05 REV-19utl~X + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY _ ESTATE OF FILE NUMBER ~~~ ~ler ~ as a ~ Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1, ~~ n y ~~~ /Yo ~~ ~a~~~ ~~~e~s~~ L /' , f ~~o r ~n ~ s~ ~~ -~'~i c~ n ~ rw ~ ~ ~ r ~h,u r Y •~ y ~~-S~Tr y _~ ~ S ~~ ~° / l,- c~- S 7 r ~~ s' ~ ~~ C~u r~(' P.. ~l 1-7 ' y fti ~. ~rn a U n / ~ f "Thy. TOTAL (Also enter on line 5, Recapitulation) j $ ~ 3 ~, ~` t~th (If more space Is needed, Insert add(t(onal sheets of the same s-ze) ,. _* PRENEED FUNERAL AGREEMENT AND ASSIGNMENT EXHIBIT 1 -STATEMENT OF FUNERAL MERCHANDISE AND FUNERAL SERVICES '~ NOTE: THIS AGREEMENT IS T,O BE FUNDED BY THE ASSIGNMENT OF INSURANCE BENEFITS ~• ? / f FC)R THE BENEFIT OF T;~ - ~ ~'.'1 L. ~~ ~i~'/1;~ .dll1/ ~~li ~ l`~ ' (Funeral Recipient/Insured) (Address) (Phone) IN AGREEMENT WITH AND ASSIGNMENT TO - (Funeral Provider Name) GUARANTEED PROFESSIONAL SERVICES Services of Funeral Director and Staff Embalming (See Agreement and Below*) Other Preparation Visitation Days at $ /Day Funeral Ceremony/Memorial Service GUARANTEED MERCHANDISE Casket ~ $.~.?~~S' '~ Manufacturer S", c,cX,~t ~'.~ .G':..~r•~"' Model Name Model Number Other Use of Facilities and Staff (Specify) Exterior Descnphon - - • ~ ~ -~ ~ $ Interior Description ~.- „~ ~,~r' (, v- ~L ~ >~ : _ ~r.~,-r~ 'Transfer of Remains to Funeral Home $ ..~- Outer Burial Container $ ~yl~ If beyond a mile radius, wh ich is our service Model Name area, there will be a charge of $__ per mile one way. Model Number ~ . ~ . ,~f Family Car(s) at $ each $ -•--- Limousine Hearse $ '~ Manufacturer Cremation $ -~-- Constructed of ~'~ t' Forwarding/Receiving Remains $ _---- Other Guaranteed Merchandise (Specify) Other Services/Facilities/Equipment (Specify) $ $ $ TOTAL GUARANTEED SERVICES $ c,7 --r TOTAL GUARANTEED MERCHANDISE ~-~ ~~---- NON-GUARANTEED CASH ADVANCES Death Certificates _T ~~ at $ 0 "' Escort $ Flowers $ Grave Opening and Closing $ .S`~ E~ Music $ /'7S'r -•' Memorial Cards/Book $ Honorariums $ ~~U " Clothing (Specify) $ Obituaries $~ .o ,,~~ ~' Monument/Marker $ Ha~dresser $ -""'• Engraving $ /c..l(,~ ''" ~ Shipping Container $ Other (Specify) f ~ ,,~ ~ d~u f ~ $ Other (Specify) $ $ $ $ We charge you for our services in obtainin g: ~' ~ U ~~'' TOTAL NON-GUARANTE ED CASH ADVANCES s ~ ~ "" TOTAL GUARANTEED AND NON-GUARANTF,E D fUNERA4;PRtCE ~; """' -- 'REQUIRED PURCHASES--Charges are only for those items that you selected or that are required. If we are required by law or by a cemete or crematory to use any items, we will explain the reasons in writing below. v ~- ~- ; ,c i+ ~ < ~ o--7.' EXHIBIT 1 ABOVE AND THE PRENEED FUNERAL AGREEMENT AND ASSIGNMENT ON THE REVERSE SIDE SHALL CONSTITUTE THE TERMS AND CONDTT'IONS OF THIS AGREEMENT. AGREEMENT AND ASS/GNMENT BY: ~( ,Z / (Signature of Purchaser) (Date) (Address) ,Q T (Phone) (City, State) (Zip) AGREEMENT A D ACCEPTANCE BY: ~ ~ (Signs o eider' uthorized Representative) (Date) (Location) (Phone) (City, State) (Zip) HOME SALES ONLY: You, the Buyer, may cancel this transaction at any time prior to the third business day after the date of this transaction. See the attached Notice of Cancellation form for an explanation of this right. P001 ©HLC,1995, All rights reserved. No use or reproduction without express permission. Rev. 03/10/95 Copies: Original -Homesteaders Life Company; Pink -Provider; Canary -Purchaser X-G• .• ~+~f. t~f . cr4 E* ~~~~ ..~. •~ ~~ l ~ ~ C~ ~ ~ ~ ....,~ y r-- ~~ •c '" ~ '~ a a~ _ ,~ µ/ ~ ~ ~ ~ (.~ '~, ~ J e ~ ~ ~~ ~ a CCS ~i ~, A~_ REV-1509 t~l(+ (1.97) V • COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE F JOINTLY-OWNED PROPERTY FILE NUMBER If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. ..--- ~-~ ~~. n ~ • ~~ Yt S r e. B C JOINTLY-OWNED PROPERTY: C'~.. ,~~ fl~~!/ f'~ / 7~="'/i Si s~~~ r ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar identifying number. Attach deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A, ~ ~\ ~ ~ nv ~3 e , a ~ ~ ~ :X ~v ~~ ,~~ ~ c~ X~' TOTAL (Also enter on line 6, Recapitulation) $ /,.j"'~ ~,2 ~r~ a ~ ~ (If more space is needed, insert additional sheets of the same size) ` V` t c'_ 2 .a S t~ C. ~ ~ , ant 1~7~ ~~ 'Is ~ ~~" ~ .~ s o ~, ~~~~`~~ ~ a~~ ~. f ,~. L.c ~ ,.,. ~3~k 1 ~. n ~ r t G ,- (C ~ ~°1~`~ ~7 ~ ~~~ ~~ ~~J z ~ ~~°~ Y ~ ~ aL ~' ~c' p~ l ~~ ~ ~, ~~~ ~~f~l ~~ jj~, ~ ~'!~' ~ ~, J c t_ l~ ~~x n ~> ~ j, ~ u ~ J ~z.c~'T 7 ~" 1 ~ r-z ~~ ' ~~~ ~ REV=`1511 EX+ (10-06) 4 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Debts of decedent must be repor ed on Schedule I. (If more space is needed, insert additional sheets of the same size) s~~ ff ~ ~~zs t- ~ ~~` P I ~' ~~" ~%~~ra /131 ~ ~ ~' - ,~ ~'1 ~ ~ ~.-~~~e ~u~~ f G c~ ~~` Q v l ~'~~ ~~' ~~~ pt7 ~ .3, a o 3~~~7. ~~ ~t 1~- CA. fl~~'G, ~~' 8 Market Plaza Way (717) 697-4696 Mechanicsburg, PA 17055 www.malpezzifuneralhome.com Jeremy J. Shartzer, FD October 19, 2010 Michael J. Malpezzi, Owner, FD Kyle C. Knipe, FD Ector J. Christie 212 Wood Street Camp Hill, PA 17011 The Funeral Service for Esther Canary We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED ST~.TEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES: Services of Funeral Director/Staff $4,625.00 FUNERAL HOME SERVICE CHARGES $4,625.00 SELECTED MERCHANDISE: Oak Casket $3,300.00 Guardian Burial Vault $1,125.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED $9,050.00 AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. CASH ADVANCES: Opening Grave $725.00 Cemetery Equipment $165.00 Certified Death Certificates $72.00 Newspaper Notices - Hazelton $58.00 Clergy/Mass Offering $1 SI1.Q0 (Organist $100.00 Clergy/Graveside $75.00 Flowers $80.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES $1,425.00 CONTRACT PRICE $10,475.00 HISTORY: 10/02/2010 Pre-Need Guarantee $1,735.51 10/04/2010 Homesteaders $8,465.84 TOTAL AMOUNT DUE $273.65 ~-~"~ i ,,~'11~ % ~LG. ~/~ , .~y' C."~re'~ -e ;, r r FtEV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME ~~ --- - -- STREETADDRESS CITY _ i ZIP Tax Payments and Credits: '1. Tax Due (Page 2, Line 19) (1) ~~ 7 ~~'~~ i 1 ~: ;?. Credits/Payments -T A. Prior Payments B. Discount ~~ --- -- -_ -- Total Credits (A + B) (2) ~ ~ ~~ 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) / .7 Qb r~ ~j' % 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 :.......................................................................................... ^ 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 "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. . d t K ,.v .<~ v>s_..,."1~ ..s - ~. _,~.~ ~ ,. •R.s =.: .n "'` .r.. t;'-, "J~^S~ ^"r - 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 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)]. • 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.