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Home My WebLink About12-06-10~ 1505610101 REV-1500 Ex ~°'_,°' ~ OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Year File Nurnber DEVIIPTMM Of INUHERITANCE TAX RETURN Bureau of Individual Taxes :~~ PO BOX 280601 RESIDENT DECEDENT ~''~ / ~ v ~~--~' / Harrisburg, PA 1'7128-0601 _ ENTER DECEDENT INFORMATION BELOW L: ` "'~ Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 189-09-4653 02/22/2010 11 /11 /1920 Decedent's Last Name Suffix Decedent's First Name MI ADAMS ROBERT A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N/A Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW O 1. Original Return ~ 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) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JAMES D. FLOWER, JR (717) 243-5513 REGISTER OF WILLS USE ONLY r~,7~ n ~ c First line of address ~ C~ '° _T ~ ,~_~_~ FLOWER LAW, LLC ~-, ; -~ ~ n Second line of address ~,~. ~ ~l ~ ~ ~ + -, i 10 WEST HIGH STREET ~ ; ~~ ~--} ~~_ _ DATE-PiIC~"~'7 ~ City or Post Office State ZIP Code _ -~ CARLISLE PA 17013 '~+ •• .~ .. Correspondent's a-mail address: j1t71 flower-IaW.CAm 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 mplete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SI R ~N P SIBLE FOR F RETURN /' /DA l~ ` v / ADDRESS !' THOMAS W. ADAMS, EX., 20566 GUTHRIE ROAD, REHOBOTH BEACH, DE 19971 SIG TU E OF PR ER THAN REPRESENTATIVE DAT ADDRESS FLOWER LAW, LLC, 10 WEST HIGH STREET, CARLISLE, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: ROBERT A. ADAMS 189-09-4653 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. 9 9 ( ) ......................... Mort a es 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 8~ Miscellaneous Non-Probate Property 7 04 920 34 (Schedule G} O Separate Billing Requested...... . .. . , 8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. 34,920.04 9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ .. 10. 11. Total Deductions (total Lines 9 and 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. 34,920.04 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 04 34,920.04 1g. 1,571.40 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. 1,571.40 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME ROBERT A. ADAMS STREET ADDRESS 31 GREENFIELD DR CITY STATE ZIP CARLISLE PA 17A15 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 1,571.40 2. Credits/Payments 275 73 1 , . A. Prior Payments B. Discount Total Credits (A + B) (2) _ _ 1,275.73 3. Interest (3) __ _ 295.67 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) 295.67 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 Rio a. retain the use or income of the property transferred :.................................................................................... ...... ^ [x] b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ [x] c. retain a reversionary interest; or .................................................................................................................... ...... ^ [x] d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ [x] 2. If death occurred after Dec. 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? ........ ...... ~ [] 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? .................................................................................................................. ...... 0 ^ 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. ~ pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER ROBERT A. ADAMS 21-10-0179 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 yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, 7HE1R RELATIONSHIP 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 (IF APPLICABLE) TAXABLE VALUE 1. WESTERN NATIONAL LIFE ANNUITY PAYABLE TO THE ESTATE 15,977.32 100 15,977.3; 2 WESTERN NATIONAL LIFE IRA PAYABLE TO THE ESTATE 18,943.72 100 I i i i 18,942.7; TOTAL (Also enter on Line i, Recapitulation) $ I 34,920.04 If more space is needed, use additional sheets of paper of the same size. r • r r s '~ Western Nationa~ L fe knsurance Company vEN~oR Nt). ~oi_IC~r NO. CHECK Nl? E '` '=' ' - - I i 106 1486909(1 - OAS OVV2 3tl P.O. Box 871, Amarillo. ?{ 79105-0871 BNY Mellon ' nas,[ of Delaware NFWARK,DELA n'ARE PAY THIS A,N10t1NT *** EIGHTEEN THOUSAND NINE HUNDRED FORTY-TWO and '72/100 DOLLARS **~'~ S' ~ * ~' ""~' " 18,942.72 ********NOT VALID BEFORE CHECK DATE CHECK DATE 04/15/10 Two signatures required if over $250,000.00 VOID ..AFTER 1$0 DAYS PAY ROBERT A ADAMS ESTATE T TO THE THOMAS ADAMS EXECUTOR ~ f ~~~ ORDER 20566 GUTHRIE RD -1~ OE 'REHOBOTH BEACH DE 19971 n' ~ 486909011• ~.D 3 L L00 3 5 ~~: 0 3009 500 3 711• Western National Life Insurance Company P.O. Box 871, Amarillo, TX 79105-0871 CHECK# 14869152: INTERNAL REFERENCE# 2200309568 TRANSACTION STATEMENT NAME: ROBERT ADAMS April 15, 2010 POLICY: XV215780 TRANSACTION: DEATH CLAIM PROCEEDS OWNER: ROBERT ADAMS AMOUNT OF CHECK $ 15,977.32 TAXABLE INCOME $ 3,808.15 PLEASE DETACH AND KEEP THIS STUB FOR YOUR RECORDS II• L4869 L5 2t1' x:03 L L0035 ~~: 0 3009 500 3?II' _ _ Western Nationa{ Life, Insurance Company P.O. Box 871 , Amarillo, TX 79105-0871 CHECK# 14869090 INTERNAL REFERENCE# 2200309501 TRANSACTION STATEMENT NAME: ROBERT ADAMS April 15, 2010 POLICY: VV217106 TRANSACTION: DEATH CLAIM PROCEEDS OWNER: ROBERT ADAMS AMOUNT OF CHECK TAXABLE INCOME S 18,942.72 1r1/estern National Life Insurance Company VENDOR NO. POLICY" NO. CI-tECIC NU OAS OX`J215180 14869151 .~%-35_ P.O. Box 871, Amarillo, TX 79105-0871 ~1' BfYY Mello3i Trust of Delaware NEWARK,DELAWARE PAY THIS AMOUNT *** FIFTEEN THOIISAND NINE HUNDRED SEVENTY-SEVEN and 32/100 DOLLARS *** S*"`'""*' 15.9 ~r7.32' ********NOT VALID BEFORE CMECK DATE CHECK DATE 04J15J10 Two signatures required if over 5250,000.00 VOID AFTER 180 DAYS PAY ROBERT ADAMS ESTATE TO THE THOMAS W ADAMS EXECUTOR ~ ! ~~~ , Q ORDER 20566 GUTHRIE RD '1/l 't.000.~.~ OF REHOBOTH BEACH DE 19971 S 18,942.72 PLEASE DETACH AND KEEP THIS STUB FOR YOUR RECORDS PAYER'S Warne. street irddress, city, state. and Z!P r_ode WESTERN NATIONAL LIFE INSURANCE COMPANY PO BOX 871 AMARILLO, TX 79105 800-987- i 173 I PAYERS tederal identrticatron number RECiP4Et~°T'S identrfication number 75 0770838 37-6455961 RECIPIENT'S name, street address, city. state, any ZAP code ROBERT A ADAMS ESTATE THOMAS ADAMS EXECUTOR 20566 GUTHRIE RD REHOBOTH BEACH, DE 19971 t st year of dasig Roth contrib. 1099-R PAYER'S name. street address, city, state. and Z1F code WESTERN NATIONAL LIFE INSURANCE COMPANY PO BOX 871 AMARILLO, TX 79105 800-987-1173 PAYERS federal identification number RECIPIENT'S identification number 75-0770838 _.__..._.._..._._ ................_. ~ 37-6455961 RECIPIENTS name, street address. cmy. state.. and Z!P code - ~~~ ROBERT A ADAMS ESTATE THOMAS ADAMS EXECU iOR 20566 GUTHRIE RD REHOBOTI-i BEACH, DE 19971 t st year of dasig. Roth contrib. VV217106 Form 1099-R PAYER'S name, street address, city, state. and ZIP rode WESTE. RN NATIONAE.. f..l(=E INSURANCE COMPANY PO BOX 871 AMARILLO, TX 79105 800-987-1173 PAYERS laderal idantifirstion numlaer ~ RECIP=ENT's Hiantitication number 75-07708.38 i 37-6455961 RECIPIENT'S name. street .addrrss, city: state. and 2}P Cade ROBERT A ADAMS ESTATE THOMAS ADAMS EXECUTOR 20566 GUTFIRIE RD REHOBOTH BEACH, DE 19971 1 st year of dasrg Roth contra CORRECTED (if checked} 1 Gross distrti~utan OMB NO. 1:}4~ 0119 318 942 72 2tJ1 ~ Distributions From Pensions, Annuities, Retirement or 2a Taxable amount Profit-Sharing Plans,IRAs, 318,942.72 Form 1099-R Insurance Contracts, etc. 2b Taxable amount not Total distribution ~ C aP-y ~-_ date+mined ~. _~ _ E~.V.......~~~ For Rociplont's 3 Capital gain (included m box lay _ ~4 Federal income tax wrthhe?d ~ -^~ Records Thos Information is c being furnished to 5 Empbyee contributons/Despnatod 6 Net unrealized appreciation in employer's the Internal Roth contributions or rnsuranco ~ securtties premiums i Reaenua Service. 7 D)strtbution coda(s) IRA t SEP ! e Other 4 SIMPLE X % _ 9a Your percentage of total disvibution Sb Total employee contributions 00°I4 10 Slate trix withheld 11 Stater?ayes s state no 12 State distrbution i S0.00 ~ DE11-750770&38-001 31$,942.72 t3 Local tax withheld ~ t4 Name of locality ~ ~ t S t.ocsl distr~ution for your records] Department of the Treasury-Internal Revenue Service CORRECTED {if checked} t Gross distribution OMB No. 1546-0119 518,942.72 ~~~ n Distributions From Pensions, (j Annuities, Retirementar 2a Taxable amount Profit-Sharing Plans,IRAs, S18,942.72 Farm 1099-R Insurance Contracts, etc. -- 2b Taxable amount not ^ Total distribution (-~ oPY ~ determined 1. Report this incotna 3 Capital gain (included m twx 20} 4 Federal income tax withheld on your foderaf tax rotum. tt thls form _.- shows federal hicome 5 Empbyea conhibutions'pesignated 6 Nat unrealized appreciation in ett~loyer", tax wtthhotd in Roth conhbutions or rnsuranco securities box 4, attach this premiums r cap} to your rotum. 7 Distr~rution code(s) IFtA! 5EP / a 8 Other ° ~ -- - This intorn~tion fa being ---.___.-4 . SIMPLE __. ,,. ..... _~0........_... ......_... _.._.....__ ...............___.__... tarnished to the 9s Your percentage of total distribuuon 9b Total employee contributions Intamal ROVenue Sorvico. 10 State tax withhek! t t StatslPayer's state no t2 State distrt~utian 50.00 ~ DEl1-750770838-001 ~ 318,942..72 19 Laca1 tax wrthhaid J_- 14 Narne of IacalRy f!i Local distribution Department of the Treasury-Internal Revenue Service CORRECTED (if checked] 1 Gross n~vbuhor. S 18,942.72 2a Taxabb amount 518,942.72 _.. _ 2tr Taxable amount not ^ determined 5 Capita! gain (included ut box 2a) rrq~ ayes cantr utwns'6esrg-` natea~-~- Roth coninbutions or insurance premiums 7 Distribution code(s) 4 !RA! SEP SIMPLE i a our percentage o rota rstr utian 00°I° 30.OU ~~~ ~ Distributions From Pensions, Annuities, Retirement ar Profit-Sharing Plans,IRAs, Form 1099-R Insurance Contracts, etc. Tote! distribution ~ oPY __ Ftie this copy 4 Federal income tax withheld wtth your state. ctty, or bcat income tax 6 et unrea rze appreaaLOn m emp er's ;ecurtlirs rntum, when raqulred. syet s stela no ~ t [scare arsutuurwn DEI1-750710838-001 ~ 318,942.72 VV217106 i ~___j_ Form 1099-R ____ - - ----_~___.____.~ Cepartment of the Treasury-Internal Revenue Se:rviee Page t of 2 P.4YER5 name, street address, erfy state. and ZiP coda WESTERN NATIONAL. UFF INSURANCE COMPANY PO B(:>X 871 AMARILLO, TX 79105 800-987-1173 PAYER"'a federal identficanor. numbor RECIPIENT'S ldentrfwatwn number 75-0770838 37-6455961 RECIPIENT'S Herne: stroet address, city. saete, and 21P code ROBERT ADAMS ESTATE THOMAS W ADAMS EXECUTOR 20566 GUTHRIE RD REHOBOTH BEACH, DE 19971 1 st year of desig. Roth contra XV215780 Form 1099-R PAYER'S name, street address, cM, state. and 2EP code WESTERN NATIONAL LIFE INSURANCE COMPANY PO BOX 871 AMARILLO, TX 79105 800-987-1173 CORRECTED (if rherkt~d) I Gross distribution - OMB N0. 1545-01 19 $i5 977 32 ^O~ O Distributions From Pensions, 2a Taxable amount G AnnUltle3, Retirement or Profit-Sharing Plans,IRAs, 53,908.15 Form 1099-R Insurance Contracts, etc. 2b T.xabie amount not ~ T°tal disUibuhon C~l f ~'OPY ~ determined ~~ ~ _ ~ For Raoipisnt's 3 CapAai yarn {included ,n box 2a} 4 ±=ederal income tax withhakl RocotMs This information is -- being furnished to 5 Ernployea contrd~uUOnsiDasignated 6 Not unroatizad appreciation in amptoyor's Roth contritrutions or insuratnco socurii~os the Internal premiums Revenue Service. )Distribution coda{s} IRA! SEP % 8 Other 4 SIMPLE ~ °7n _ 9a Your percentage of total distribution 9b Total empbyee contrt~utions UOalo 10 State tax withheld 11 StatelF'ayer's state no 12 Sti<~tte drsiribubon $0.00 DE/1-750770838-001 53,808.15 13 Local tax withheld 14 Namo of locabty i S l.ocai dtstribution (keep for your of the Treasury-i CORRECTED {if checked) 1 Grass distribution Oi~1 f~0 1545-0119 515,977.32 2~1 O Distributions From Pensions, Retirement or uities A . . . . . . . . . . . . . . . . . . . . . ------.__.....__.._...._._ ................._._..._._.....__._...._._._._. , nn 2a Taxable amount Profit-Sharing Plans,iRAs, $3,808.15 Form 1099-R Insurance Contracts, etc. 2b 7axabie amount not ^ Total distribution ~ oPY datarmirted Rsporl this income 3 Capital gain {included in box 2a} 4 Federal income tax withhaid on your fitdarol tax rotum. tt this torn shows federal income 5 Empbyee contributions/Designated 8 Net unrealized apprectation in entpioysr's tax wfthheW in Roth contributions ar insurance premums securities , box 4, attach this copy to your return. 7 Distributon coda{~} E P r ^ 5 MP t3 Other °1u ~ This Information is being L ---{ turnishod to the 9a Your percentage of total distr~uUon 96 Total empiayea contributions t Internet Rsvanue Service. 00% ._ ................. ~-....__....__..............._. 10 State tax withheld 11 StataJPayer's states no i i t 2 Stets distribution 50.00 DE/1-750770838-001 - I~ $3,808.15 13 Local tax withheld t4 Name of beatify 115 Loca! distribuUOn PAYER'S federal idantdicatton number ~ RECIPIENT'S idenitficatron number 75-0770838 } 97-6455961 RECIPIENT'S name. street address city, state. and ZIP code ROBERT ADAMS ESTATE THOMAS W ADAMS EXECUTOR 20566 GUTFiRiE RD REI-tOBOTFi BEACI I, DE 19971 t st year of tleslg Roth cornrib XV21578U Form 1099-R PAYER'S Hama. street address. city, s~ata. and ZIP code WESTERN NATIONAL LIFE INSURANCE COMPANY PO BOX 871 AMARILLO, TX 79105 800-987-1173 FAYER'S fedoras identification number RECIPIENT'S identificati°n number 75-0770838 37-6455961 RECIPIENT'S name, street address, c<ty, state. and ZIP code ROBERT ADAMS ESTATE THOMAS W ADAMS EXECUTOR 20566 GUTHRIE RD REHOBOTH BEACH, DE 19971 1st year of dasig, Roth cantrib. CORRECTED (if checked} 1 Gross distribution S 15, 977.32 2a Tsxabte amount $3, 808.15 2D Taxable amount not ^ determined 3 Capital gain (included in box 2a) Rath conir3>uhons ar insurance premiums Distribtton code{s} IRA! SEP' 4 SIMPLE a our percontage o rota d+stn~+rin 00% 50.00 Department of the i reasury-Internal Revenue Servit:e 201 O Qistributians From Pensions, Annuities, Retirement or Profit-Sharing Plans,IRAs, Form 1099-R insurance Contracts, etc. Total distribution U oPY _ File this copy 4 Federal income tax withheld wtth your state, ctty,ortocal _ .____. .__.- ,......._..._ fi AId(unreaTizsd appreaatwn in securities ,~._ amT pT-7a ey s income tax roturn, when naquirod. aver s state no tz State dr~mounon DE! t -750770838-001 53,808.15 Form 1099-R C)epartmeni of the Treasury-Internal Revenue Service Pays t of 2