HomeMy WebLinkAbout12-13-10 (2)1505610140
REV-1500 ~` I°'-'°'
PA Department Of Revenue OFFICIAL U8EON~.Y
Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Ybar ', Fde Number
Po Box 280601 2 1 1 '; 0 1 1 2 8
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW ~
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
2 0 0 2 8 6 7 1 3 1 0 0 6 2 0 1 0 0 1 2 3 1 9 1 ?''
Decedent's Last Name Suffix Decedent's First Name ' MI
E R B H A Z E L
(H 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 ~MITH THE
REGISTER OF WILLS
r~~ ~n ArrRVrR1A1 c VYAW OCLV~I ',
® 1.Original Return ~ 2. Supplemental Return ~ 3. Remainder R~tum (date of death
pnorto h2- 3r82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal IEs tb Tax Return Required
death after 12-12-82)
® 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Nt}mb~ er of Safe Deposit Boxes
(Attach Copy of Wilq (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach c . )
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX NtfO TIO N ISHOULD~ DHtECTED T(
Name - Daytime Tele n e Number--
J A C Q U E L I N E A K E L L Y 7 1 7 ~ 1 ~i5 !~:Xk
c~ ~~..=
REtiIS US Y ~t"
First line of address C~ C__ ~ `_
, s
~ _
`
8 4 5 S I R T H O M A S C 0 U R T r ~~~~
Second line of address
I ~
S U I T E 1 2 !,
City or Poet Ofiioe State ZIP Code I D TS FILED
H A R R I S B U R G P A 1 7 1 0 9
Corrospondent's e-mail address: JACKIEJLB VERIZQN.NET '~
Under penaltles of penury, I declare that 1 have examined this return, including accompanying sc~eduoa and ~atemente, and to the o1 my k
and belief,
it is true, correct and compote. Declaration of preparer other than the personal repreaentathre is based on all Information of which ,has any kriowled
S NATURE OF P PONSBLE FOR FILING RETURN ~ ~ E
RESS
I
56 TRAVER ROAD LEWISBERRY i P A 17339
SIG RE OF P PARER REPRESENTATNE TE
-t
AD SS
84 S R THOMAS COUR STE 12 HARRISBURG 'P 171D9
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 150561~]1~ 4
J 1505610240
REV-1500 EX
Der:N~: HAZEL ERB
Decedents ~oc~al Security Number
2 0 0 ~ 8 6 7 1
3
RECAPITULATION '
1. Real Estate (Schedule A) ......................................... .. 1.
2. Stocks and Bonds (Schedule B) .................................... .. 2. •
3. Closely Hekl Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. ~,
4. Mortgages and Notes Receivable (Schedule D) ........................ .. 4. 1 2111 ~ 5 2 0 . D 2
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. ', 0 . 0 0
7. Inter-Vnros Transfers 8 Miscellaneous N~Probate Property
S
l
h
d
G _~,
1
~
(
c
e
u
e
) Separate Billing Requested ..... .. 7. I
6
~ 4 8 3. 4 2
8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 2 911!, (~ 0 0 3 . 4 4
9. Funeral Expenses and Administrative Costs (Schedule H) ................ .. 9. ~1 1 1 8. 6 5
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule q ........... .. 10. 1 ~ 6 6 4. 8 2
11. Total Deductlons (total Lines 9 and 10) ............................. .. 11. 1111 ~ 7 8 3 . 4 7
12. Net Value of Estate (Line 8 minus Line 11) .......................... .. 12. 2 7! ~ 2 1 9. 9 7
13. Charitable and Governmental BequestslSec 9113 Trusts for which ~ 1!
an election to tax has not been made (Schedule J) .................... .. 13.
14. Net Value SubJect to Tax (Line 12 minus Line 13) ...................... 14. 2 ~ ~I 2 1 9 . 9 7
TAX CALCULATION -SEE IN8TRUCTI0NS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or 1 II
transfers under Sec. 9116 I
(a>(1.2>x.o_ 0.0 0 15. D. 0 0
16. Amount of Line 14 taxable
at lineal rate x .oa5 2 7 8 2 1 9. 9 7 1 g, 1 I~ ~ 5 1 9. 9 0
17. Amount of Line 14 taxable
at sibling rate X .12 0 . 0 D 17. i 0. 0 0
18. Amount of Line 14 taxable t
' 11
at collateral rate X .15 0 . D 0 18. II 11 0 . D D
19. TAX DUE .................................................... .. 19. 1, 21
11 5 1 9 • 9 0
20.
FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1
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Side 2 it
II
1505610240 1505610/40
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REV-1500 EX Page 3
Decedents Complete Address:
File Number
21 10 1128
DECEDENT'S NAA~
HAZEL ERB
STREET ADDRESS
46 Erford Road ~
CDY STATE ZIP
Cam Hill PA 17011
Tax Payments and Credits:
1. tax Due (rage 2, Line 19)
2. CreditsJPayments
A. Prior Payments
B. Discount
3. Interest
s25.9s
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
FNI M oval on Page 2, Line 20 to request a refund.
5. ff Une 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(1) ~ 12 519.90
Total Credits (A + B) (2)
(3)
(4)
(5)
Make check a able to REGISTER OF WILLS, AGENT ',
:~~~ w, ~., ~~~~ ~ ~ r pit b ~ ~ ~;~ ~~;~,~~~: ¢ ~ :-r ~~~:. ~s .~
.. -
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APP~tO IATE BLOCKS
1. Did decedent make a transfer and: ' Y No
a. retain the use or income of the property transferred : ......................................................................
b. retain the right to designate who sh~l use the property transferred or its incxxne; ..............................
c. retain a reversionary interest; or ................................................................................................,
d. receive the promise for life of either payments, benefits or care? .......................................................
2. N death oaxrrred after December 12,1982, did decedent transfer property within one year of death '
without receiving adequate cor-sideration? .......................................................................................' ^
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 ~ S 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 ~r frbr 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 survi m 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 requ~rer~nts 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 afar July 1, 2000: ~'I
• 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 {he fuse of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(x)(1.2)]. I
• The tax rate imposed on the net value of transfers to or for Hte use of the decedents lineal beneficiaries is 4.5 percent, ~!,exc~ept as noted in
72 P.S. §9116(1.2) (72 P.S. §9116(x)(1)]. ~
• The tax rate imposed on the net value of transfers to or for the use of the decedents siblings is 12 percent (72 P.S. §91',16 )(1.3}]. A sibling is defined, under
Section 9102, as ~ individual who has at least one parent in common with the decedent, whether by blood or adoption'.
REV-f 507 EX + (8-98)
SCHEDULE D
COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES
IN RESDENT DECEDENTRN RECEIVABLE
ESTATE OF FILE NUMBER ',
HAZEL ERB 21 10 1128 ~
AU properly joirMly-0wned with the right of survivorship must be dhklesed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION j ~I ' OF DEATH
1. Promissory Note between Jerry L Erb (Borrower) and Hazel Erb (Lender) dated 128,520.02
June 3, 2010; Face Value $149,267.00; 22 month term ~ 2% interest; ',
unpaid balance: $128,520.02
TOTAL (Also enter on line 4, Recapitulationb~ ;
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX+ (08-09)
Pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBE
HAZEL ERB 21 10 1'~2>~
This schedule r~wst be completed and filed H the answer to any of questions 1 through 4 on page three of the REV-t 501b is yes.
BEM
NUMBER DESCRIPTION OF PROPERTY
MICLUDE TFE NAME OF TFf TRAlSFEAEE, THEIR RELATIONSHIP To DECEDENT AND
THE DATE OFTRAlISF6t.ATTACHACOPYOFTHEDE~FORREALESTATE
DATE OF DEATH
VALUE OF ASSET
% OF OECD S
INTERES
EXCLUSION
;pFAPPIICAB~~
TAXABLE
VALUE
1. Gift to son, Jerry L. Erb, June 2010 160,000.00 100.00 ! 3,000.00 157,000.00
2. PNC Bank 4,483.42 100.00 I'~ 4,483.42
Checking account xx~oooc7354 I
joint with son, Jerry L Erb, within 1 year of death ',
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TOTAL (Also enter on Line 7, Recapitulati~) ~ ~~ 161 483 42
If mae space is needed, use additional sheets of paper of the same size.
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REV-1511 EX+ (10-09)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
w ~ n~ c yr FILE NUMBER '', __.
HAZEL ERB 21 10 1128''
Decederk'e debts must be reported on Schedule L
ITEM
NUMBER DESCRIPTION I~ I' AMOUNT
A. FUNERAL EXPENSES:
1. Emig Funeral Home ~! ' 96.15
2. clergy fee I' 60.00
3. funeral luncheon ~' 250.00
4. gravermarker ' 185.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: ' !,
Name(s) of Personal Representative(s)
Street Address ~
CKY State ZIP
Year(s) Commissbn Paid:
2, Atlomey Fees: Jan L. Brown & Associates 2,200.00
3. Family Exerr~tion: (If decedents address is not fhe same as daimanYs, attach explanation.)
Clakrrant ~~
Street Address ~'~ I
Chy State ZIP
Relationship of Claimant to Decedent
4. ProeateFees: Cumberland County Register of Wills '~ 297.50
5. AocouMant Fees:
6. Tax Retum Preparer Fees: ',
7. Register of Wills; filing fees for Inventory and Inheritance Tax Return ~' 30.00
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TOTAL (Also enter on Line 9,
If more space is needed, use additla-al sheets of paper of the same size.
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REV-1512 EX+ (12-0a)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, ~ LIENS
c~ ~ ~~ c yr FILE NUM~tR
HAZEL_ERB 21 10 1'~2~'
Report debts hrcurred by the decedent prior to death that remained unpaid at the date of death, including unroim'bur~eld medkal expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION I ~ OF DEATH
1. Golden Living Centers; outstanding medical bills ', ~, 8,628.46
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2. Philhaven; outstanding medical bill '~ 11.36
3. PharMerica; outstanding medical bill ~! 25.00
TOTAL (Also enter on Line 10, Recapitul ) I :
H more space is needed, insert additional sheets of the same size.
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REV-1 St$ FX+ (01-10)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF: FILE NUMB
HAZEL ERg ~fe ~n ~.ines'
RELATIONSHIP TO DECEDE T AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trusts~s) ~~ OF ESTATE
I TAXABLE DISTRIBUTIONS [Include oubi~ht I distributions and transfers under
Sec. 91 f6 (a (1.2).] !~
1. Jerry L. Erb Lineal I'~~ 200,395.61
856 Traver Road ~, Sch G, and 1/3 residue
Lewisberry, PA 17339
2. Dale E. Erb Lineal ~ ~ 38,912.18
105 Park Drive ! ~~, 1/3 residue
Dover, PA 17315 ', ',
3. Gary L. Erb Lineal !
I 38,912.18
625 Elliott Drive ,
I 1/3 residue
Lewishberry, PA 17339 I
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ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T ',
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HROUGH 18 OF REV-1500 CO E
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EET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: ~'
1. I
I
II
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B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
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TOTAL OFPART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. t
~~ gn,re spay is neeaeD, use aaaiuonal snee(s or paper of me same site.
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i~ixst dill ~rrd (~~stt~ment
i, HAZEL ERB, of Wellsville Borough, York County, Pennsylvania,
declare this to be my Last Will and Testament and hereby revoke any
Will previously made by me.
ITEM 1: I direct that my just debts and funeral expenses shall be
paid from the assets of my estate as soon as practicable after my
death.
ITEM 2: I give, devise, and bequeath all the rest, residue, and
remainder of my estate of every nature and wherever situate to my
husband, Reuben O. Erb, provided that he survive me by thirty days.
ITEM 3: Should my said husband, Reuben O. Erb, predecease me or not
survive me by thirty days, then I direct that all the rest, residue,
and remainder of my estate of every nature and wherever situate, i
give, devise, and bequeath unto my three (3) sons; Dale E. Erb,
Gary L. Erb, and Jerry L. Erb in equal shares, per stirpes.
ITEM 4: I appoint my three (3) sons; Dale E. Erb, Gary L. Erb,
and Jerry L. Erb as Co-Executors of this my Last Will and Testament.
I direct that my personal representatives shall not be required to
give bond for the faithful performance of their duties in this
or any other jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
day of June, 1979.
(SEAL)
This instrument, consisting on one( ) typewritten page bearing
the signature of the above named Hazel Erb, was by her on the date
hereof signed, published and declared by her to be her Last Will and
Testament, in our presence, who at her request and in her presence
and in the presence of each other, we believing her to be of sound
and disposing mind and memory have hereunto subscribed our names as
sses:
~ ' ~~
of
o f ~ ~_
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LOAN AGREEMENT
Amount of Loan: 5149,267.00 Dl~t~: (~~ 3 , 2010
FOR VALUE RECEIVED, the undersigned, JERRY L. ERB, of 85~ 'I~raver Road,
Lewisbeny, Pennsylvania 17339 (hereinafter referred to as "Borrower"), h b 1Dromises to pay
to the order of HAZEL ERB (hereinafter referred to as "Lender', in lawful njey of the
United States of America the principal sum of One Hundred Forty Nine Tho Two Hundred
Sixty Seven Dollars and 00/100 Cents ($149,267.00), together with interest c ng on thc
outstanding principal balance from the date hereof, subject to the terms and n 'loons set forth
below:
1. REPAYMENT TERM. The "Repayment Term" shall be 22.00 III o tlhs
beginning June 3, 2010. If on March 3, 2012, the Borrower still owes amour er this Loan,
the Borrower will pay those amounts in full on that date, which is called the ` turity date".
Payments received will be applied to charges, fees and expenses (including a o ys' fees),
accrued interest and principal in any order the Lender may choose, in her sole, di tion.
2. INTEREST RATE. Amounts outstanding under this Loan will ~ interest at a rate
of 2% percent per annum beginning on the 3rd day of June. Interest will be co ulted on the
basis of a year of 365 days and paid on the actual number of days elapsed. In ~o dvent will the
rate of interest hereunder exceed the maximum rate allowed by law.
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3. MONTHLY PAYMENT. The Borrower shall repay the.loan in e
installments of principal and interest, with no deferral and no balloon paymen
amount of Six Thousand Nine Hundred Fifteen Dollars and 66/100ths ($6,91!
payment due and payable on June 3, 2010 and subsequent payments due and 1
day of each month thereafter until the entire balance due hereunder, including
and any other charges owed by Borrower under this Loan are paid.
4. PROHIBITION ON CANCELLATION. Upon the death of the
balance then due under this Loan shall not be cancelled.
5. DEFAULT AND ACCELERATION. If Borrower fails to coml
payment obligations herein, and upon thirty (30) days advance written notice
such failure, Borrower has not rectified such default by paying the entire amc
this Loan, the entire principal balance under this Loan shall become due and ~
6. NON-ASSIGNMENT. This Loan is not an instrument governed
Uniform Commercial Code, is not negotiable and shall not be assigned by Le
shall have no right and no power to assign this Loan and any attempted assign
and ineffective for all purposes. Borrower's obligation under this Loan is to
Lender's estate. Notwithstanding any purported voidness, statutory or otherv
prohibition of assignment by Lender, under no circumstances shall Borrower
under this Loan to Lender's purported assigns. Nor shall Lender have the po~
G monthly
ode, in the
with the first
ale on the third
icipal, interest
,~ any
any of the
ewer of
i due under
-tticle III of the
. 'The Lender
it',, shall be void
~ only, or to
df this
any obligation
-r authority to
assign the income stream from this Loan to anyone, including factor companies pr other
prospective secondary market purchasers.
7. MODIFICATION & WAIVER. No modification or waiver of a~y',terms of this
Loan shall be permitted unless evidenced by a written agreement signed by alb t e parties or their
duly authorized Agents under Power of Attorney. Failure of the parties hereto t exercise any
rights they may have in the event of any default hereunder shall not constitutel, a .fiver of the
right to exercise such rights or any other rights in the event of any sdbsequentld fault, whether of
the same or different nature. ' '~~
8. SEVERABILITY. The unenforceability or invalidity of any prov~si~m of this Loan
shall not affect the enforceability and validity of the remainder of this Loan, v~hi~Clt shall continue
in full force and effect.
9. BINDING EFFECT. The covenants, obligations and conditions ~o tdined herein
shall be binding upon and inure to the benefit of the Borrower, the Borrower's h firs, legal
representatives and assigns, the Lender, the Lender's estate, and not to any otl{erientity.
10. DESCRIPTIVE HEADINGS. The descriptive headings used her~ei are for
convenience of reference only and are not intended to have any effect whatsodve in determining
the rights or obligations under this Loan.
11. GOVERNING LAW. This Loan shall be governed, construed, in reted, and
enforced by, through and under the laws of the Commonwealth of Pennsylvan a d the United
States of America. It is intended to comply with federal law requirements of 2,S.C. Section
1396p(c)(1 xI), so as not to be construed as a transfer of assets.
IN fi'ITNESS WHEREOF, this Installment Loan has been executed, f the date first
above written, with the intent to be legally bound hereby, by Borrower and lee on this T
day of t`3'U N ~ , 2010. ~,
SIGNED, SEALED AND WITNESSED ~ I'
in the presence of: LENDER:
}~`.
~~iF-~7~-y LAS -~"Y'Y L/ ~.~~--~- ~ r' ~ -4rti
HAZEL ERB
-' ? f
l ~~~~:~ ~~ ~f
;~
BORROWER: