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Home My WebLink About12-03-101505610143 REV-1500 Ex(ll,_10, PA De artment of Revenue OFFICIAL USE ONLY p pennsylvania county code Year File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE PO 80X.280601 INHERITANCE TAX RETURN 21 10 0 933 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 197 03 0642 09 04 2010 10 14 1916 Decedent's Last Name Suffix Decedent's First Name MI HENDERSON WILLIAM I, (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 Re uired (date of death after 12-12-82) ^ q g Decedent Died Testate (Attach Copy of Will) ^ 9. Litigation Proceeds Received ~ Deceden0t Maintained a Living Trust (Attach Copy of Trust) ^ 10. Spousal Povert Credit (date of death between 12-31 X31 and T-1-95) ~ 8. Total Number of Safe Deposit Boxes ^ 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 TO: Name Daytime Telephone Number FOREST N MYERS' 717 532 9046 First line of address 137 PARK PLACE WEST Second line of address City or Post Office SHIPPENSBURG State ZIP Code PA REGISTER Ql~WILLS USB:ONLY ~O o - ~ c7 r°rt c7 ~ Cn ~ I GJ r: O ~ ~ ~ J C~,7 ~ - DA~'~-RLED ~ r 0 ~~, -;~ --t- i ^i ~~ Correspondent's a-mail address: fnmyers@IawofFiceforestmyers.com Under penalties of perjury, I d~ I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, ,iy~e-true-ce~Ct and comp) eclara I reparer other than the personal representative Is based on all information of which preparer has any knowledge. SIGNATURE OF P cnNK7F nIJCIQI C CIl Orrstown Bank, by Daniel Baer, Trust 77 E King Street P O Box 250 Shippensburg PA 17257 awnHi urct ur rt(tPARER OTHER THAN REPRESENTATIVE ~"""~ DATE ~= ~ Forest N Myers 1 ~_ z -Za to ADDRESS 137 Park Place West, Shippensburg, PA Side 1 L 1505610143 1505610143 J 1505610243 REV-1500 EX Decedent's Social Security Number oecedenYsName: HENDERSON, William L. 197 03 0642 RECAPITULATION 1. Real Estate (Schedule A) ....................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................. 2. 2 81 , 0 2 7 . 8 7 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3. 4. Mortgages ~ Notes Receivable (Schedule D) ....................:................................... 4. 13 , 4 7 $ . 7 $ 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 42 , 4 72.14 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous t~q Probate Property (Schedule G) S U eparate Billing Requested............ 7, 9, 944.78 8. Total Gross Assets (total Lines 1-7) ..................................................................... g. 34 6, 923.57 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 4 O , 67 O . 33 10. Debts of Decedent, Mortgage Liabilities, t;< Liens (Schedule I) .............................. 10. 1 , 3 64.7 3 11. Total Deductions (total Lines g & 10) ........................................... ........................ 11. 42 , 035.0 6 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12, 304 , 88 $ . 51 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• 3 O 4 , $ $ $ . 51 TAX COMPUTATION -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 .00 15. 0 . 0 0 16. Amount of Line 14 taxable at lineal rate x .045 83 , 68 0.71 1 s. 3 , 7 65.63 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. O. O O 18. Amount of Line 14 taxable at collateral rate X .15 2 21 , 2 0 7.$ 0 1 s. 3 3 ,181.17 1 s. Tax Due .................................................................................................................. 1 g. 3 6, 94 6. 8 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 1505610243 1505610243 J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME HENDERSON, William L. STREET ADDRESS 210 Big Spring Road CITY Nevwille Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 35,099.46 1,847.34 3. Interest File Number 21-10-0933 STATE ZIP PA (1) Total Credits (A + g) (2) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2 Line 20 to request a refund 5. ff Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 17241 36,946.80 36,946.80 ~.00 Make Check Pa able to: REGISTER OF WILLS, AGENT. ,r ~~ 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 ............................................................................................................... 0 d. receive the promise for life of either payments, benefifs or care?............ .................................. . ............. eath 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?....... 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation?............ .... ............. ............................................................. E ANSWER TO ANY OF THE ABOVE QUES TIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ~:~~_~~ ~ _~~W ,. ._, a :.`~`~ J. _ ~'.."~. _ :. ~ '~ r.. :~ r n~: , For dates of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net alue of transfers to or for the use of the surviving .^ spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)j. 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)]. . 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-1503 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS ~ BONDS ESTATE OF RENDERS! L. All property jointly-owned with right of survivorship must be disclosed on Schedule F. FILE NUMBER 21-10-0933 ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE 1 31428Q101 2,567.901 shares of Federated Total Return Series -Mutual 11.2999995 fund 2 922031810 1,744.117 shares of Vanguard Fixed Income Securities Fund 10.2500004 INTRM -Mutual fund 3 922031836 2,841.112 shares of Vanguard Fixed Income Securities Fund 10.829999 STRM -Mutual fund 4 921938106 517.599 shares of Vanguard Wellesley Income Fund -Mutual 21.3800065 fund 5 14912L4A6 $25,000 Caterpillar Financial Svcs -Corp. bond 110.053 Accrued interest on Item 5 through date of death 6 237051 NX1 $50,000 Darby Bank -Corp. bond 106.98656 Accrued interest on Item 6 through date of death 7 36966RXS4 $50,000 GE Capital Internotes -Corp. bond 106.38026 Accrued interest on Item 7 through date of death 8 369604606 $50,000 General Electric Co -Corp. bond 111.87356 Accrued interest on Item 8 through date of death TOTAL (Also enter on Line 2, Recapitulation) VALUE AT DATE OF DEATH 29,017.28 17,877.20 30,769.24 11,068.27 27,513.25 64.65 53,493.28 686.04 53,190.13 772.08 55,936.78 641.67 .,s.....~ .._ (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inca Form PA-1500 Schedule B (Rev. 6-98) Rev-1507 EX+(6-98) COMMONWEALTHOFPENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF HENDERSON, William L. FILE NUMBER 21-10-0933 All property Jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1 James and Audrey Sherman -mortgage interest due 2 James and Audrey Sherman -mortgage; principal balance outstanding on date of death VALUE AT DATE OF DEATH 77.65 13,401.13 TOTAL (Also enter on Line 4, Recapitulation) I 13,478.78 (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 D (Rev. 6-98) Rev-1508 FaC+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER HENDERSON, William L. 21-10-0933 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with the right of survivorship must be disclosed on schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Federated Money Market -Principal -Date of Death balance in account 24,827.93 2 Orrstown Bank Burial Fund Certificate of Deposit -accrued interest to date of death 3.47 3 Orrstown Bank Checking -Date of Death balance 17,590.48 Accrued interest on Item 3 through date of death 0.04 4 Green Ridge Village -refund 50.22 TOTAL (Also enter on Line 5, Recapitulation) I 42,472.14 (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 E (Rev. 6-98) Rev-1510 EX+(6-98) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT - ESTATE OF FILE NUMBER HENDERSON, William L. 21-10-0933 This schedule must be completed and filedrf 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 DATE OF TR4NSFER.SATTACN A COPY OF THE DEED FOOREREAL ESTATE. DATE OF DEATH VALUE OF ASSET °~ OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 Orrstown Bank Burial Fund Certificate of Deposit - 9,944.78 9,944.78 No. 4000015288 TOTAL (Also enter on Line 7, Recapitulation) I 9,944.78 (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-1151 EX+(10-06) COMMONWEALTCC~~{{ QF,,gqP~~ENEEN YLVANIA R~ID~NTEDECEDEN RN SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE. COSTS ESTATE OF FILE NUMBER HENDERSON, William L.. 21-10-0933 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT N MB R A, FUNERAL EXPENSES: Fogelsonger-Bricker Funeral Home, funeral bill 9,492.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Orrstown Bank street Address 77 E King Street P O Box 250 City Shippensbur~ ~ State PA zip 17257 Year(s1 Commission Daid 2. Attorney's Fees Law Office Forest N Myers 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees See continuation schedule(s) attached 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs See continuation schedule(s) attached 16,900.00 13,668.43 442.50 167.40 TOTAL (Also enter on line 9, Recapitulation) I 40,670.33 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER HENDERSON, William L. 21-10-0933 ITEM NUMBER DESCRIPTION AMOUNT Probate Fees 1 Cumberland County Register of Wills -Fees/Costs for probate: cost for Petition 310.00 2 Cumberland County Register of Wills -Fees/Costs for probate: Short Certificates 24.00 3 Cumberland County Register of Wills -Fees/Costs for probate: filing Will 15.00 4 Cumberland County Register of Wills -Fees/Costs for probate: County JCS fee and 28.50 Automation fee 5 Cumberland County Register of Wills -Additional probate based on gross assets 50.00 6 Cumberland County Register of Wills -Filing Inheritance Tax Return 15.00 H-B4 442.50 7 Cumberland Law Journal -advertising estate 75.00 8 EVP Systems Inc -valuation of estate assets 12.40 9 News-Chronicle -advertising estate 80.00 H-B7 167.40 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 EX+(12.08) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OFPENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER HENDERSON, William L. 21-10-0933 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 Alexander Springs Emergency Physicians -medical bill 43.98 2 Appalachian Orthopedic Center -medical bill 266.67 3 Blue Mountain Anesthesia Assoc -medical bill 23.34 4 Carlisle HMA Physician Management -medical bill 22.91 5 Millennium Phcy Systems -prescriptions 830.55 6 Millennium Phcy Systems -prescriptions 177.28 TOTAL (Also enter on Line 10, Recapitulation) I 1,364.73 (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) REV-1513 EX+ (11-08) COMINHERI RENT ECEpN~N~RNANIA ESTATE OF HENDER50N, William L. NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I~ TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116(a1~1 X11 FILE NUMBER 21-10-0933 ATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE DECEDENT ~ L rus e s (Words) ($~$) Betty HANCOCK 1045 Greenspring Rd Sister-in-Law Three-fourths 228,666.38 Newville, PA 17241 (3/4) of the net distributable James SHERMAN Jr estate . 22532 Maple Ln Grandson One-fourth (1/4) 76,222 13 P O Box 46 . of the net Amberson, PA 17210 distributable estate Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 ovOeasheet, as a ro riate. 304,888.51 NON-TAXABLE DISTRIBUTIONS II• : A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9 113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS SCHEDULE J BENEFICIARIES i UrAL 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)