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Home My WebLink About11-09-101505610143 OFFICIAL USE ONLY -~ REV-1500 Ex`°'-'°' PA Department of Revenue pennsylvania cDUnty code Year File Number Bureau of Individual Taxes DEPARThENT OF REVENUE Po Box.2aoso~ INHERITANCE TAX RETURN 21 10 0372 Harrisburg, PA 17128-OS01 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 162 22 7369 03 08 2010 07 17 1926 Decedent's Last Name Suffix Decedent's First Name MI HENCH FAYE S (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI 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 ^ 2. Supplemental Return ^ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ^ qa, Future Interest Compromise ^ 5. Federal Estate Tax Return Required ^ (date ofrpldeath after 12-12-t32) a 8 Decedent Died Testate ~ ~• gatacdheGOpy Hof Trust)a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) ^ 9. Litigation Proceeds Received ^ 10. belweenl2v-3e1 ~J1 a dit,~dat~e5~f death ^ 11,Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number GARY L JAMES ESQ 717 533 3280 First line of address 134 SIPE AVENUE Second line of address City or Post Office State ZIP Code HUr~LSTOWN PA wv REGISTER WILLS USlS~NLY ;. 0 0 Y. -~+~ C.ti. -~ .C ~.. , ~ ^~ 3 - `_ _ `= ED ~' D fR `` . 7 CJ Correspondent's a-mail address: gI1~JSdC.COnI 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. Anita E. Lauck ~ (~ ~o? ~f~l Side 1 1505610143 1505610143 J REV-1500 EX Decedent's Name: Hench, Faye S. 3. RECAPITULATION 1. Real Estate (Schedule A) ....................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 4. Mortgages & Notes Receivable (Schedule D) ........................................................ 5. Cash, Bank Deposits 8~ Miscellaneous Personal Property (Schedule E) ............... 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 7. Inter-Vivos Transfers & Miscellaneous I~q Probate Property (Schedule G) u Separate Billing Requested............ 8, Total Gross Assets (total Lines 1-7) ..................................................................... 4. 5. Decedent's Social Security Number 162 22 7369 1,929.20 2,605.04 6. 7 433,065.00 $ 437,599.24 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 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. 22,370.67 1,970.04 24,340.71 413,258.53 413,258.53 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15 (a)(1.2) X .00 16. Amount of Line 14 taxable 413 , 2 5 8 . 5 3 16. at lineal rate X .045 17. Amount of Line 14 taxable 0 . 0 0 17. at sibling rate X .12 18. Amount of Line 14 taxable 0 , 0 0 18. at collateral rate X .15 19. Tax Due ................................................... ............................................................. .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 1505610243 0.00 18,596.63 0.00 0.00 18,596.63 Side 2 1505610243 1505610243 REV-1500 EX Page 3 npr_adRnt's Cemnlete Address: File Number 21-10-0372 DECEDENT'S NAME Hench, Faye S. STREET ADDRESS 5002 McDonald Drive CITY Mechanicsburg STATE PA ZIP 17050 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 18,596.63 2. Credits/Payments A. Prior Payments 18,000.00 B. Discount 929.83 Total Credits (A + B) (2) 18,929.83 3. Interest (3) 4, If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) 333.20 Check box 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. (5) 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 :............................................................................... 0 ^ b. retain the right to designate who shall use the property transferred or its income :.................................. ^x ^ c. retain a reversionary interest; or .............................................................................................................. d. receive the promise for life of either payments, benefits or care? ............................................................ 0 ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without ^ ^ receiving adequate consideration? .................................................................................................................... x 3. Did decedent own an "in trust for" or payable 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? .................................................................................................................. ^x ^ 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 January 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)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)]. 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-1505 EX+ (6-98) SCHEDULE B STOCKS & BONDS COMMONNEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Hench, Faye S. 21-10-0372 All property jointly-owned with right of survivorship must bedisclosed on Schedule F. ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 35 shares of Prudential Financial Inc. -valued per public 55.12 1,929.20 listing TOTAL (Also enter on Line 2, Recapitulation) 1,929.20 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Revtb08 FJC+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF (FILE NUMBER Hench. Fave S. 21-10-0372 Include the proceeds of litigation and the date the proceeds were received by the estate. All propeRy jointlyowned with the right of survivorship must be disclosed on schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Members 1st Regular Savings Account # 372500-00 -valued per letter dated March 31, 2010 25.00 2 1999 Ford Contour Sedan -valued per Kelley Blue Book 1,450.00 3 Personal Property -valued per personal representative 500.00 4 Delta Dental -refund for premium 46.84 5 Nationwide Insurance -refund 85.20 6 St. Francis Hospital -refund 50.00 7 U.S. Treasury - 2009 personal income tax refund 448.00 TOTAL (Also enter on Line 5, Recapitulation) (If more space is needed, additional pages of the same size) 2,605.04 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1510 EX+ (6.88) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TA% RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Hench, Faye S. 21-10-0372 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY THE DATENOF RANSFERSATTACFiTA COPY OF THE DEIED FOOREREAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST ( EXCLUSION IF APPLICABLE) TAXABLE VALUE 1 Bethlehem Steel -final pension 90.00 90.00 2 Midland National Life Insurance Company Annuity # 24,072.41 24,072.41 8500108872 -valued per letter dated June 9, 2010; beneficiary is the Faye S. Hench Living Trust dated January 30, 2003 3 Midland National Life Insurance Company IRA # 31,806.71 31,806.71 8500108872 -valued per letter dated June 9, 2010; beneficiary is the Faye S. Hench Living Trust dated January 30, 2003 4 North American Company Annuity # 8000026124 - 158,254.59 158,254.59 valued per letter dated June 9, 2010; beneficiary is the Faye S. Hench Living Trust dated January 30, 2003 5 1st National Bank of Marysville Savings Account # 432.60 432.60 18005330 • titled in the Faye S. Hench Living Trust dated January 30, 2003; valued per letter dated March 31, 2010 6 1st National Bank of Marysville Savings Account # 0.21 0.21 18005330 -accrued interest 7 4 $50.00 Series E Savings Bonds -titled in the Faye S. 880.62 880.62 Hench Living Trust dated January 30, 2003; valued pe savings bonds calculator 8 23,328.47 units of American Funds Money Market 23,328.47 23,328.47 Fund Class A • titled in the Faye S. Hench Living Trust dated January 30, 2003; held in the American Funds brokerage account # 82058465; valued per statement Total of Continuation Schedules See attached a es TOTAL (Also enter on Line 7, Recapitulation) I 433,065.00 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) Rev-1570 FJ(+ (8-98) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN continued RESIDENT DECEDENT ESTATE OF FILE NUMBER Hench, Faye S. 21-10-0372 ITEM NUMBER DESCRIPTION OF PROPERTY THE DATE OF TROAFNSFER.SATTACFI ACOPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST ( EXCLUSION IF APPLICABLE) TAXABLE VALUE 9 1,026.609 units of Capital World Growth and Income 34,360.60 34,360.60 Fund -titled in the Faye S. Hench Living Trust dated January 30, 2003; held in the American Funds brokerage account # 82058465; valued per public listing 10 516.707 units of Fundamental Investors Class A - 17,185.67 17,185.67 titled in the Faye S. Hench Living Trust dated January 30, 2003; held in the American Funds brokerage account # 82058465; valued per public listing 11 619.414 units of Growth Fund of America Class A - 17,244.49 17,244.49 titled in the Faye S. Hench Living Trust dated January 30, 2003; held in the American Funds brokerage account # 82058465; valued per public listing 12 Members 1st Certificate of Deposit Account # 261183 - 5,051.13 5,051.13 42 -titled in the Faye S. Hench Living Trust dated January 30, 2003; valued per fetter dated March 31, 2010 Accrued interest on Item 12 through date of death 1.39 1.39 13 Members 1st Certificate of Deposit Account # 261183 - 9,623.28 9,623.28 43 -titled in the Faye S. Hench Living Trust dated January 30, 2003; valued per letter dated March 31, 2010 Accrued interest on Item 13 through date of death 1.18 1.18 14 Members 1st Checking Account # 261183-11 -titled in 559.50 559.50 the Faye S. Hench Living Trust dated January 30, 2003; valued per letter dated March 31, 2010 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) SCHEDULE G INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY COMMONVYEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN continued RESIDENT DECEDENT ESTATE OF FILE NUMBER Hench, Faye S. 21-10-0372 ITEM NUMBER DESCRIPTION OF PROPERTY THE DATENOF ROANSFERSATTACiiTA COPY OF THE DEED FOOREREAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST ( EXCLUSION IF APPLICABLE) TAXABLE VALUE 15 Members 1st Money Management Account # 261183 2.04 2.04 -05 -titled in the Faye S. Hench Living Trust dated January 30, 2003; valued per letter dated March 31, 2010 16 Members 1st Regular Savings Account #281183-00 - 2,324.44 2,324.44 titled in the Faye S. Hench Living Trust dated January 30, 2003; valued per letter dated March 31, 2010 Accrued interest on Item 18 through date of death 0.33 0.33 17 6,128.724 units of The Bond Fund of America Class A 73,360.83 73,360.83 -titled in the Faye S. Hench Living Trust dated January 30, 2003; held in the American Funds brokerage account # 82058465; valued per public listing 18 2,202.076 units of The Income Fund of America Class 34,484.51 34,484.51 A -titled in the Faye S. Hench Living Trust dated January 30, 2003; held in the American Funds brokerage account # 82058485; valued per public listing TOTAL (Also enter on Line 7, Recapitulation) I 433,065.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) REV-1151 EX+(10.06) COM~N~~~~Y1.,1/ANIA SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Hench, Faye S. 21-10-0372 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT A, FUNERAL EXPENSES: See continuation schedule(s) attached B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zio Year(s1 Commission paid 2, Attorney's Fees James, Smith, Dietterick 8~ Connelly, LLP 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Cindy F. Chancellor Street Address 5002 McDonald Drive city Mechanicsburg state PA zio 17050 Relationshio of Claimant to Decedent Daughter 4. I Probate Fees 6,687.00 11,000.00 3,500.00 130.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1,053.17 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 22,370.87 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) Rev1512 EX+ (12-08) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Hench, Fa a S. 21-10-0372 Repoli debts Incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medlul expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Discover Card -credit card 160.38 2 Hampden Township -ambulance co-pay 75.00 3 Memphis RAD Group 3.87 4 Pinnacle Health Hospital -medical expense 100.00 5 Ron Hixon -preparation of 2009 personal income tax returns 131.00 6 Sutherland Cardiology -medical expense 276.48 7 Walgreen Specialty Pharmacy -eye injections 300.00 8 West Shore EMS -ambulance service 923.31 TOTAL (Also enter on Line 10, Recapitulation) I 1,970.04 (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Hench, Faye S _ 21-10-0372 ITEM DESCRIPTION AMOUNT NUMBER Funeral Expenses 1 Rice Memorial -engraving for headstone 135.00 2 Richardson's Funeral Home -funeral 6,552.00 H-A 6,687.00 3 Other Administrative Costs James Smith Dietterick & Connelly LLP -reserve for estate administration closing costs 500.00 4 Nationwide Insurance -car insurance 80.64 5 Nationwide Insurance -car insurance 80.63 6 Nationwide Insurance -car insurance 80.63 7 Nationwide Insurance -car insurance 80.63 8 Nationwide Insurance -car insurance 80.64 9 Ron Hixon -reserve for preparation of 2010 personal income tax returns 150.00 H-67 1,053.17 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) REV-151 EXt (11.08) COMM~~~DECED N YL\/ANIA ESTATE OF FILE NUMBER Hench, Fa a S. 21-10-0372 NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY (Words) ($$$) TAXABLE DISTRIBUTIONS [include outright spousal I~ distributions, and transfers under Sec. 9116 a 1.2 Cindy F. Chancellor Daughter 25% of residue 103,314.63 5002 McDonald Drive Mechanicsburg, PA 17050 Diana R. Griffiths Daughter 25% of residue 103,314.63 1042 Palmer Hill Road Waitsfield, VT 05673 Bernice L. LaPorte Daughter 25% of residue 103,314.63 7827 Jill Creek Cove Bartlett, TN 38133 Anita E. Lauck Daughter 25% of residue 103,314.63 421 7th Street New Cumberland, PA 17070 I ~ Total ~ Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet, as a ro r NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 413,258.52 _ TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) SCHEDULE J BENEFICIARIES '. ;~ RC~P[~~D (rF~'0~ 281ONOV -9 PM 4~ 44 CLERK C3F ORP~N'S CO';JRT CUMB~-R' ~~lD CC , PA. a J J T O O C ~ C ~ O p Uoc%~ Y p O U X ti r m Q O O ~ n rL-+ a L C ~ C ~ E _.. _ -L ~o~U jM ~ ~ ~ ~ o - ~ ~ ~ ~ = c° ~p o~ ~ ~ cu~o-Cai -~u,Y~~n _~•~~o~ ~ U U~Ur-U