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Home My WebLink About12-29-101505610143 REV-1500 EX (01-10) OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes oEVnrtTMENTOFREVEWUE Po Box.2sosol INHERITANCE TAX RETURN 21 10 0 672 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~, ,~ 187 56 3732 06 11 2010 04 15 1970 ' ~ ~~' Decedent's Last Name SufFix Decedent's First Name O =~ n C~ " ` r-r't t~ ~ Ml~t.., ~,,. ~~_; BAILEY NICOLE --cr' ~~ t~~ t~.~ ~1r ~ ~.~ ~.x: ~ r~ X ~ - (If Applicable) Enter Surviving Spouse's Information Below ~~t~ =a* *~:~ ~ " . -. , ter..; '~ Spouse's Last Name Suffix Spouse's First Name ~,~ ~ Mlw;r ~ ~ ~- 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 ~ 4a• Future Interest Compromise death after 12-12-82) (date of ~ 5. Federal Estate Tax Return Required 6 Decedent Died Testate (Attach Copy of Will) ~ rrl1 ~• AttaoheGoMaiof~fnust a Living Trust ) PY 8. Total Number of Safe Deposit Boxes 9. Litigation Proceeds Received ~ C p 4 10. b8tweenl2 31 ~1 a dt~dat8e5~f death ~ 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 Teleph a Number c ,; s ROBERT G RADEBACH 717 8 9 6 6 ~, ~ ~' r~'~ ~ C~ ~:~ REGISTER O SE ~hDLY -~ ~ ~`+~i CO - • C~ First line of address ~~~ -~ ~~ _~ ~,n .;~.~ 912 NORTH RIVER ROAD = ~ ~ .-._ rn " -`~ ~,. Second line of address ,.~ C~..: ~, ~. DATE FILED ~~ City or Post Office State ZIP Code HALIFAX PA 17032 Correspondent's a-mail address: missyswartz51 cLDaoI.COm Under penalties of perjury, 1 declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, corr complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT P SON RESPONSIBLE F R FILING RE URN DATE Robin M. Hoffman 127 Ni an riv M ch s r PA 17055 SIGNATUR P A R RE NTATIVE Djj'~TE Robert G Radebach ~s~/~D ~~lU ADDRESS 912 North River Road, Halifax, PA 17032 Side 1 1505610143 1505610143 J a , 15D5610243 REV-1500 EX Decedent's Name: Bailey, Nicole Marie ecedent's Social Security Number 187 56 3732 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 ~ Notes Receivable (Schedule D) ........................................................ 4. 5• Cash, Bank Deposits 8~ Miscellaneous Personal Property (Schedule E) ............... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 55 , 587.99 7. Inter-Vivos Transfers 8 Miscellaneous 1~; Probate Property Se arate Billin Re uested S h d l G 19 , 315.7 5 p g ............ q ( c e e ) X u 7. 8. Total Gross Assets (total Lines 1-7) ..................................................................... g, 7 4 , 9 0 3.7 4 5,912.28 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 25,781.75 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) .............................. 10. 11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 31, 6 94.0 3 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 43,209.71 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. 4 3 , 2 O 9.71 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. 16. Amount of Line 14 taxable 0 0 0 16 . at lineal rate X .045 . 17. Amount of Line 14 taxable at sibling rate X .12 4 3 , 2 0 9.71 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 . 0 0 18. 19. Tax Due ................................................................................................................. . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 1505610243 0.00 0.00 5,185.17 0.00 5,185.17 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-10-0672 DECEDENT'S NAME Bailey, Nicole Marie STREET ADDRESS CITY Mechanicsburg STATE PA ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 0.00 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box 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. (1) Total Credits (A + B) (2) (3) (4) (5) 5,185.17 0.00 5,185.17 Make Check Pa able to: REGISTER OF WILLS, AGENT. ~z . 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 :............................................................................... ^ ^x b. retain the right to designate who shall use the property transferred or its income :.................................. ^ ^x c. retain a reversionary interest; or ............................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ............................................................ ^ ^x 2. If death occurred after December 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?....... ^ ^x 4. Did decedent own an Individual Retirement Account annuity or other non-probate property which o ^ . , 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. ter. ~ ~.... a?~~ s:.,~ J~.. ~ ~,„.. - ~. ... , .~.x k . 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 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)]. 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-1509 EX+ (6-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Baffle ,Nicole Marie 21-10-0672 H an asset was made Joint within one year of the decedent's date of death, it must be reported on schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Robin Hoffman 127 Nittany Drive Sister Mechanicsburg, PA 17055 B. C. JOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSE % OF DECD'S INTEREST DATE OF DEATH DECEDENT'S NTEREST 1 03/27/2010 Joint Checking Account -Members 1st 10,935.61 100.000% 10,935.61 Federal Credit Union 2 03/27/2010 Joint Holiday Club Account -Members 1st 200.19 100.000% 200.19 Federal Credit Union 3 03/27/2010 Joint Money Management Account -Members 3,000.73 100.000% 3,000.73 1st Federal Credit Union 4 03/27/2010 Joint Savings Account -Members 1st Federal 40,951.05 100.000% 40,951.05 Credit Union 5 03/27/2010 Joint Supplemental Savings Account - 500.41 100.000% 500.41 Members 1st Federal Credit Union TOTAL (Also enter on Line 6, Recapitulation) I 55,587.99 (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 F (Rev. 6-98) Rev-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Baile ,Nicole Marie 21-10-0672 This schedule must be completed and filed if 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 INCLUDE NAME OF TRANSFEREE THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACK A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET °~ OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 Fidelity Investments - 401(k) - 3 Beneficiaries -Robin 16,465.75 16,465.75 M. Hoffman, Norman C. Bailey and Bridget L. Bailey Robin M. Hoffman's share is being taxed within this return Separate Billings Requested: Norman C. Bailey (Father) 31 Hickory Road Mohnton, PA 19540 Norman's share was $16,000.00 Bridget L. Bailey (Sister) 31 Hickory Road Mohnton, PA 19540 Bridget's share was $16,000.00 2 Roth IRA with Alliance Bernstein - 2 Beneficiaries - 2,850.00 2,850.00 Robin M. Hoffman (Sister) and Bridget L. Bailey (Sister) Robin M. Hoffman's share is being taxed within this return Separate Billing Requested: Bridget L. Bailey (sister) 31 Hickory Road Mohnton, PA 19540 Bridget received $2,850.00 TOTAL (Also enter on Line 7, Recapitulation) ( 19,315.75 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) REV-1151 EX+ (10-06) COMM_Q~NVNEA, NT DEGEDtN~RL_YANIA SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Bailey, Nicole Marie 21-10-0672 ITEM DESCRIPTION AMOUNT A. FUNERAL EXPENSES: See continuation schedule(s) attached 1,048.00 B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zio Year(sl Commission paid 2. Attorney's Fees 1,000.00 See continuation schedule(s) attached 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 3,500.00 Claimant Robin M. Hoffman Street Address 127 Nittany Drive city Mechanicsburg state PA zio 17055 Relationship of Claimant to Decedent SlSter See continuation schedule(s) attached 4. Probate Fees 80.50 See continuation schedule(s) attached 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 283,7$ See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 5,912.28 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 Bailey, Nicole Marie 21-10-0672 ITEM NUMBER DESCRIPTION AMOUNT 1 Funeral Ex ep rases Funeral Home 72.00 2 Mailing Pictures 300.00 3 Obituaries -Albuquerque, Daily Item, and Reading 435.00 4 Pictures for Services 241.00 H-A 1,048.00 5 Attorne es Robert G. Radebach, Esquire 1,000.00 H-B2 1,000.00 6 Familv E„ xem tQ ion Robin M. Hoffman 3,500.00 H-B3 3,500.00 7 Probate Fees Register of Wills -Open Estate 80.50 H-B4 80.50 8 Other Administrative Costs Advertising Fee -Cumberland Law Journal 75.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) __.__ SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF (FILE NUMBER Bailey, Nicole Marie 21-10-0672 ITEM NUMBER DESCRIPTION AMOUNT 9 Advertising Fee -The Sentinel 208.78 H-B7 283.78 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 OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Baile ,Nicole Marie 21-10-0672 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 American Express -Payoff 1,420.00 2 Care Giving Services (560 hours @ $15.00 per hour) -Provided by Robin M. Hoffman 8,400.00 3 Care Giving Services Provided to Client -Driving to Appointments, etc. (167 hours @ $15.00 2,505.00 per hour) -Ted Hoffman 4 Mileage to Drive to Doctor Appointments (1,720 miles @ $0.165 per mile) -Ted Hoffman 283.80 5 UNM Health Sciences Center CHD 10,746.95 6 UNM Medical Group, Inc. 2,426.00 TOTAL (Also enter on Line 10, Recapitulation) I 25,781.75 (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) COMMA„°, ID~NT DECEDtN~RN ANIA SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Bailev. Nicole Marie 2~_~n_na~~ NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT (Words) ($$$) I TAXABLE DISTRIBUTIONS [include outright spousal • distributions, and transfers under Sec. 9116 a 1.2 1 Norman Bailey Father 1/3 of the residue 31 Hickory Road Mohnton, PA 19540 2 Robin M. Hoffman Sister 1/3 of the residue 127 Nittany Drive Mechanicsburg, PA 17055 3 Bridget Bailey Sister 1/3 of the residue 31 Hickory Road Mohnton, PA 19540 4 Tyler Miller Nephew 5,000.00 127 Nittany Drive Mechanicsburg, PA 17055 5 Alexis Hoffman Niece 5,000.00 127 Nittany Drive Mechanicsburg, PA 17055 See continuation schedule attached Continuation 5,000.00 Total 15,000.00 Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 150 0 cover sheet as a r o riate. II NON-TAXABLE DISTRIBUTIONS: . A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FO R WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART tl -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) SCHEDULE J BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: Nicole Marie Bailey 06/11/2010 187-56-3732 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) 6 Hailey Hoffman Niece 127 Nittany Drive Mechanicsburg, PA 17055 5,000.00 Total 5.000.00