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Home My WebLink About11-05-101505610101 REV-1500 Ex ~o~_~o, OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes °".~."E.'r"`~E~F~`.` County Code Year Po Box Z8o6oi INHERITANCE TAX RETURN , Harrisburg, PA 1128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 203-54-2852 02/13/2010 09/11 /1966 Decedent's Last Name Suffix Decedent's First Name Gingrich Todd (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 4. Limited Estate O 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS O 2. Supplemental Return O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) File//Number 4.d ~,`. O 11. Election to tax under Sec. 9113(A) (Attach Sch. O) MI M MI CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number John C Oszustowicz (717) 243-7437 First line of address 104 S Hanover St Second line of address City or Post Office State ZIP Code Carlisle PA 17013 REGISTER OF WILLS USE ONLY t'~ rv c::a , C~ ~ =a- ~~ ~ t " ~ ; ? L7 _ C= ~ ~ ~ r-- i _" _~- rn I ~~~ DAT~~TN:_:ED =-a .. :v ..._ .~ _} -~ ~, r ti_ `a t:: s ~!;* J 1 i Correspondent's a-mail address: iohno@carlislepalaw.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 and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGr'' RE OFD PERSON RESPONSIBLE FOR FILING RETURN DATE / /~ ADDRESS 188$ ry 'a , Carlisle, PA 17013 SIGNATURf~ O THER THAN REPRESENTATIVE DATE ADDRE~6S~' ~ 104~,r5 Hanover St., Carlisle, PA 17013 ~~' PLEASE USE ORIGINAL FORM ONLY L 1505610101 Side 1 O 3. Remainder Return (date of death prior to 12-13-82) O 5. Federal Estate Tax Return Required ~ 8. Total Number of Safe Deposit Boxes 1505610101 J J 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: 203-54-2852 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. 5,854.17 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. 8. Total Gross Assets (total Lines 1 through 7) ........................ ..... 8. 5,854.17 9. Funeral Expenses and Administrative Costs (Schedule H) .............. ..... 9. 3,528.28 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .......... .... 10. 11,593.34 11. Total Deductions (total Lines 9 and 10) ............................ ..... 11. 15,121.62 12. Net Value of Estate (Line 8 minus Line 11) .......................... .... 12. -9,267.45 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. 0.00 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 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 O Side 2 1505610105 1505610105 J REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME Todd M Gingrich STREET ADDRESS 214 Stonehouse Rd CITY Carlisle STATE ?IP PA 17015 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. 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 :.......................................................................................... ^ ^K 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. 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. 0.00 Total Credits (A + B) (2) (3) (4) (5) REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Gingrich, Todd M 21-10-0347 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. (It more space is needed, insert additional sheets of the same size) I\:~. ~J _ 1 3.1 ~ ~J 1.. ~'~' 117 ~~ ~7{~ ,i ~ pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Gingrich, Todd M 21-10-0347 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is ~~es. ITEM NUMBER DESCRIPTION OF PROPERTY IrvauDE -fir- NAME or rfiE TRArvsFEREE, THEIR RELArIONSHiP 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 ~Ir APPLICABLE) TAXABLE VAGUE 1• 401 K with no rights to possess transferred to Jennifer Rossiter, girlfriend 25,000.00 100 0.0~ TOTAL (Also enter on Line 7, Recapitulation) $ ~ 0.00 If more space is needed, use additional sheets of paper of the same size. -~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Gingrich, Todd M 21-10-0347 Decedent's debts must be reported on Schedule I. If more space is needed, use additional sheets of paper of the same size. 5 ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS -- ESTATE OF FILE NUMBER Gingrich, Todd M 21-10-0347 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1~ Members 1st Loan Account 149880-14 (Hyundai Tiburon auto loan) 583.75 2 Members 1st Visa Account 4672090000187294 1,166.28 3 Next Day Cash Loan 270.00 4 Columbia House Record Club 82.50 5 PPL Account 19380-82128 2,133.74 6 Kinetic Imaging Acct 16275 -medical expense 28.00 7 Alexander Springs Emergency Physicians Acct CLL94569415 -medical expense 65.20 8 Moffitt Heart & Vascular Acct 180970 -medical expense 160.00 9 Quest Diagnostics Acct 6351241452 -medical expense 287.13 10 Cumberland Goodwill EMS Acct7613 -medical expense 434.50 11 Health Management Associates Acct 858-4999494 -medical expense 2,474.04 12 MSHMC Physicians Group Acct 1887609 -medical expense 102.70 13 Walnut Bottom Radiology Acct WBR-15377L3138 -medical expense 488.00 14 Carlisle Regional Medical Center Acct 9456941 -medical expense 1,440.31 15 Nationwide Auto Insurance Acct 8768292 -medical expense 265.18 16 Internal Revenue Service 2008 taxes due 473.00 17 MBM Marketing -medical expense 397.50 18 Carlisle Propane 741.51 TnTAL (Also PntPr nn I ine 1(l. Recanitulafinnl I $ 11,593.34 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ~ BENEFICIARIES ESTATE OF: FILE NUMBER: Gingrich, Todd M 21-10-0347 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. Ryan Rossiter 18881 Mary Lane, Carlisle, PA 17013 Son 100% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. 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: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, use additional sheets of paper of the same size.