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Home My WebLink About12-28-10 505610101 a coi-~o> REV-1500 '~ PA Department of Revenue Pennsylvania Bureau of Individual Taxes DEV~RTMENTOF INDHERITANCE TAX RETURN PO BOX 280601 Harrisburg, PA 1128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number OO i III Date of Death MMDDYYYY Decedent's Last Name Suffix (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix ~~ S Ouse's Social Security Number Date of Birth MMDDYYYY Decedent's First Name MI a. _.. F Spouse's First Name MI ~'~t ~ -.S~r .~.hL:c.,.:.a~ ..~, p THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~r 1. Original Return O 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 T0: Name Daytime Telephone Number ' ~ tl I r REGIS7~ SILLS t ~ ONL~~ J~ ~~ N ~ ' ~ ~ _~ - First line of address r'W ,< , ... ..~ .~ Second line of address ..~~ _._.. ,. _ ~ tTti City or Post Office State ZIP Code DATE FILED Correspondent's a-mail address: 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. GNATURE OF PERSON RES SIBLE F ILING TURN ATE l ~ \ AD~ l~ ~ \1-~ ~ ~ `~~~~t V`1~ ~ \~Z~ll V ~Y . _ ~! _~_\ l~~O~~a~I.J V~ ~~ C~ ~ . ~ \ ~\~ SIGNATURE OF PREPARER OTHER THAN RE ADDRESS PLEASE USE ORIGINAL FORM ONLY 1505610101 OFFICIAL USE ONLY Code Year File Number Side 1 1505610101 J 1505610105 REV 1500 EX Decedent's Social Security Number Decedent's Name: ~ Jv~i--~ ~ ~/~~ 23~r-- ~ ~' ~ ~ ~ ~~ ~ ~ s RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. a 2. Stocks and Bonds (Schedule B) ....................................... 2. ~~ "' ~ off='?'~` :4 3. Closely Held Corporation, ParMership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. F . ~: 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. ~ ~ , ,~x, -~..~-. s 6. Jointly Owned Property (Schedule F) ®Separate Billing Requested ....... 6. ~_ ~ 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property ~":,.r~;~. °`~^`°~'Y' ^"'` ~ (Schedule G) p Separate Billing Requested........ 7. ` ', ~~ ; 8. Total Gross Assets (total Lines 1 through 7) ... ........................ 8. ~ ~ f 8' ~` P 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. ~' r x 10. Debts of Decedent, Mort a e Liabilities, and Liens Schedule 9 9 ( ) .............. 10. , ~~ 11. Total Deductions (total Lines 9 and 10) ................................. 11. / ~ U S ~ HH 12. Net Va{ue of Estate (Line 8-minus Line 11) .............................. 12. ~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ~` ' 7 ~ ''"' ~ ~ ' ~~" y ~~~"~ :~~R;~:; an election to tax #~as not been made (Schedule J) ........... ........... 13. s ~ :, 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. ._ _ ..y~ - ~_#_.:. .. _ , TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 ~ ~~ ~ ~. 16. Amount of Line 14 taxable ~ ~ ° ~ _{ ~''m: `` ~ `'~~~- - ~~ at lineal rate X .0 _ ~~ ,: ~' 16. 17. Amount of Line 14 taxable $" ' ~~~ ` ~~ ' ` ~ " ~~~.~y~,'~~x ~ "~'~~~" 18. at sibling rate X .12 Amount of Line 14 taxable ~ ~~ ~~` ~ ~ £ w.5 ~ r A C ~~`'~~' " ~ "`"~ ~ ~' ~~ }~~~ 17. at collateral rate X .15 Sf x ~ ~ °~ ,~r:,~ { _ 18 19. TAX DUE .............. ........................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUEST{NG A REFUND OF AN OVERPAYMENT Slde 2 1505610105 15056101U5 O J REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDE NAME ---z STREET ADDRESS CITY ~-~-- STAT ZIP Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount (1) Total Credits. (A + B) (2) (3) (4) (5) 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 ZO 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 :.......................................................................................... ^ 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. tf 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 ANSIAIER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE CT AS PART 0 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 far 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. REV-1508 EX + (1~7) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER Include the pnxeeds of litigation and the date the proceeds were n3ceived by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Ci~H ~gl,oo 13AaK (~c~ou~ ~W~~~FoCZvs~'~ `q~`llo.9(~ see, i~~~ Eic~E~ ~ 9qs ~,~d~z ~~1 ~ c, ~1t~.2.3 2ioDv, f~D TOTAL (Also enter on line 5, Recapitulation) I $ ~~c /`~~%^ ~ (If more space Is needed, insert additional sheets of the same size) REV-1511 EX+ (i0-06) SCI~EDI~ILE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER --~ .- Debts of decedent must be reported on Schedu a I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~ ~~ ~~~ 1. ` ~u ~~~t~ ~ ~~~~~ `~'`l~~o~~ ~~ ~ ~,~ ~? ~ d ~~ ~ht~ ~ ~~~~~ ~ ~n ~ n ~ S B. ADMINISTRATIVE COSTS: ~ .~ ~~~--?1 ~ 't'J S u. `~' 1. Personal Representative's Commissions ~~ " Name of Personal Representative(s) __ Street Address ___ - - City State Zip Year(s) Commission Paid: _. 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation} Claimant Street Address City State Relationship of Claimant to Decedent _ 4. I Probate Fees 5. 1 Accountant's Fees 6. ~ Tax Return Preparer's Fees 7 Zip TOTAL (Also enter on line 9, Recapitulation) I $ ~,0! 4 ~ 3,"73 .---- (If more space is needed, insert additional sheets of the same size) OFFICE OF THE CORONER ,.,~u. TODD C. ECxENRODE `` RICHARD C. MIDDLEKAUFF CORONER DEPUTY CORONER ~i_S .g ~ MATTHEW S. STONER ~ KEITH O. BRENNEMAN CHIEF DEPUTY CORONER ~ SOLICITOR ~: .. CUM B E RL~~ND COUNTY ` ~'~~ 6375 BASEHURE ROAD, SUITE 1 MECHANICSBURG, PA 17050 PHONE 717-766-6418 FAX 717-766-6419 The following personal effects were collected from Robert Motter, Case #32-338 at the scene of the death investigation and are being released to the below named Legal Next- of-Kin or Legal Personal Representative(s). i. Blue Verizon Cell Phone 2. Key ring containing ~l keys 3. i- Woodforest National Bank master card 4. i- Citizens Bank visa card 5. $29i.oo Cash 6. Black personal phone directory book Name Address ' ,~ i ~ ~. ity, State, Zip ~" ._ P e ~ c ~ Relation ip Date ~, , \r __. Signature .. ,, __.__> .. i~ ~.. , ,~ Deputy form 025-01/10 u~ O r ~_ .. O w O r LJ1 O .. O O 0 Q'7 r 0 a 93001 Nsw 3/09 x~ ~~ C~ 3 tf n ~• w i~c' D y m~ M 30557-0 .j _. ~ ~?O I + ~ .. ~' /// ~~~ m ~ ~ 0 ~ ° ~'- G n ~~ ~ ~ ~ O ~ ~ M. * ~ ~ ~ ~~ ~ oo ~ ~; C ~ -_ ~ ~ O ~ o. •.,~ _: rn ~ ~ ~ ~ o` ~ ~ p !•: ~< ~. . r ~'~ 3 ~' ,~ w 4~ ~ ~ (l ~ c R: ~ ~ a I ~~~ t,n ,~ ~ w ~ Ti' ~ j ~ `; ~ ~ : Q ` , ~ a';; Q:< ~ ~ i t ~ ~ u~ ~ ~ ~ _._ m v ~ ~ ~ r t~D y~ ~ _ _ _ o c ~ ~ ~ ~ ! ~ n ~ ~ ~~ ~ GA N rf ~ O ~ a R s., ~ Efl v ~" ~ _ '~~ R, ~ v ~ o f ~ ~ Q s ` ° ~ ^. r CO < 1 /~ V/ r n~' ~'' r r y e Y ` A a ~ iT,~ x _ ~ )) \\MMj ~'.. rn ~ ,; RECEIPT COPY C~ O -~ o ~ ~ 'c ; ~ -, ~ ~ ~m ~ _ ~" -- rn * v ~o m ~ y a O °' v °~ o n m ..~ ~ m rn T s a~ ~ ~ n ~ c ° 7C ° to ~ o D ~ -~ Z ~ _< ~ v °$ 3 ~ ~ v ~ ~ ITI ~o ~s ~ rn ~~z ~ Ng Z w~~ ;N ~,$a 0 ~ ~~C Q C z ~zC7 v ~9~ r O rn v ~~ -1 ~ z ~ rn a~~ Z n v 0 r o Z to o Z a Z wo ~ o N v N o ~ -~ ~ ~°° N ~p ~ °~ o 'V rn W z -' N ~ g~ ~.~ 219 ~ Carlyle, ~''`' ~ - ~' toll fr 1, . W ~' , FUNERAL HOME bi CREMATORY, INC. ~, ,~ Mrs. Constance Molter 28 South Alydar Blvd. Dillsburg, PA 17019 October 7, 201 t Statement of Funeral Expenses for: Robert Paul Molter Date of Death: September 10, 2010 Account ld: 16048- PACKAGE: Traditional Funeral Service TRADITIONAL FUNERAL SERVICE PACKAGE $ 4,550.00 . ~ Sub Total: S 4,550. MERCHANDISE: Casket: Livingston $ 2,690.00 Outer Container:. Monarch -Concrete Vault $ 1,220.00 Sub Total: Z 3,810, TOTAL FUNERAL HOME CHARGES: CASH ADVANCES: s 8,4so. 12 Certified Death Certificates at $ 6.00 each $ 72.00 Newspaper Notice -Sentinel $ 111.24 Additional Death Certificates $ 72.00 Flowers $ 159.00 Sub Total: S 414. Total Funeral Expense: S 8,874. Total Payments Made: $ 8,874, Payments Made: Constance Molter/Clearing Robert's AcctCheck500188548 Oct 7, 2010 216. Constance Mo>tteriWoodforest Natal Bank Clear AcctCheck507687870ct 7, 2010 2,710, Constance Moter/Prudential Alliance AcctCheck 102 Oct 7, 2010 5,947: Balance: s °. Please return this portion with your Remittance. S Amount Enclosed Robert Paul Molter Service ID#: 16048-221 KONL'S Carlisle Carlisle, PA 17013 (717) 243-4595 09-13-10 1:0$P 018$/0003/1944!8 1730XXX ID# 999-9086-8986-9159-9811-9680-5603 115 DRESS SHIR 089467271963 ~ 19.99 T6 IternPrlce 38.00 YouSave 18.01 SUBTOTAL 15X PICK YOUR DAY T6= 16.99 ~r Q.0%; :, TAX,. T 1= 0 . p0 ~ 6.09K~_ __ TAX _ . ~-,- ~ TO~~. `,. KOhi~ NG XXXXXXXX$005 APPRO 19.99 3.00- . o. 00 -... Q. ~16~J~ .9 ToT~. s~~. ~i , of TMAM( YOU F'OR SFpPPING AT KOFL'S NOW HIRING PART TIME SEASONAL POSITIONS For early morning stocking Immediate Associate discount Apply at Kohlscareers.cam ~ ~ ~ ~"''~ _ t . ~~ livin J ~ ~ ~ ~. ,~„ ~, Cta~m Against Decedent s Estate ~, t.. ~~ ~~ -~, ~ ~ .~ ~i ~~' ESTATE OF: GLORIA LOVE Case# 212010-300 The undersigned hereby presents for filling against the above estate this statement of claim and alleges: Golden Livingcenter- WEST SHORE PITTSBURGH, PA LLC PO BOX 180970 Fort Smith, AR. 72918-0970 The basis of claim is: SEE ATTACHED: The amount of the claim is $1030.80 NOTE- If there is insurance pending on this account and the insurance fails to pay then amount will become due privately Linder penalties of perjury, 1 declare that I have read the foregoing, and the facts alleged are true to the best of my knowledge and belief. Signed ON: December 20, 2010 GI ' Tankersley, Collections Manager 1 SWEAR THIS STATEMENT IS CORRECT Subscrib d and sworn to before me ,~ :•a 4~ On C~~ Q ~ ~ '9'7q ~p~ ,~,re No ry Public My Commission Expires C~ P.o. Box 180970 Fort Smith, AR 72918 Phone: 479-201-2000 Toll-Free: 877-823 -8375 www.goldenliving.com