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Home My WebLink About12-21-10r 1505610148 REV-1500 Ex (°'-'°> PA Department of Revenue OFFICIAL USE ONLY Bureau oflndividualTaxes County Coda Year FilaNumber Po Box 2eosot INHERITANCE TAX RETURN 21 10 10 4 8 Harrisburg, PA 17728-0801 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYW 173-14-8556 03202010 04011916 Decedent's Last Name Suffix Decedent's First Name M I EY HELEN M (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 BOXES 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 (date of ^ 5. Federal Estate Tax Return Required ® death after 12-12-82) 6. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust ~ B. Total Number of Safe De (Attach Copy of Will) (Attach Copy of Trust) posit Boxes ^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit (date of death ^ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST I3E COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JEFFREY A. ERNICO, ESQ• 717-232-5000 First line of address 3401 NORTH FRONT STREET Second line of address PO BOX 5950 City or Post Office HARRISBURG Correspondents e-mail address: J A E R N I C O a M E T T E• C O M 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 proparer other then the percanal presentetlve is based on a information of which preparer has any knowledge, SIGNATURE OF PERSON RFSIx,NCIRI c cno cu iwir_ orn ~o.~ HELEN E• SHUMAN REGISTER OF 1~ USE ONLY [~ C7 ~ ~ `~ 8 Z C.ri ~ ?" ~ ~ r~ State ZIP Code ~f ~-1 DAT~flLED i~~r PA 171100950 ~" ~~ r i n ~ 260 CREEK ROAD CAMP HILL, PA 1 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE JEFFREY A. ERNICO, METTE, EVANS & WOODSIDE ADDRESS ~ 3401 N• FRONT STREET, PO^BOX 5950_ HARK URG, PA 17110-0950 ~.~, 1505610148 Side 1 8M4947 4.000 1505610148 1~a J ~~ 1505610248 REV-1500 EX Decedent's Name: E Y H F I F N Decedent's Social Security Number 173-14-8556 M RECAPITULATION 1 . Real Estate (Schedule A) ............... ............. 1 153,000.00 2 . Stocks and Bonds (Schedule B) . ... ... . . ... .. .. ... 2. 0 ~ O 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) , 3 0 • 00 4. Mortgages and Notes Receivable (Schedule D) 4 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) 5, 18 8 , 6 7 b . 9 7 B. Jointly Owned Property (Schedule F) ~ Separate Billing Requested _ 6. 0 • 0 0 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested 7. 1 ~ 0 ~ 0 • 0 0 8. Total Gross Assets (total Lines 1 through 7) . 8. 3 4 2 , 6 7 6.97 9. Funeral Expenses and Administrative Costs (Schedule H) , ..9. 2 2 , 6 9 3.18 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) • . 10 . 38 , 297.25 11. Total Deductions (total Lines 9 and 10) , , •.11. 60,990.43 12. Net Value of Estate (Line 8 minus Line 11) 13. , 12 Charitable and Governmental Bequests/Sec 9113 Trusts for which 2 81, 6 8 6 • $ 4 an election to tax has not been made (Schedule J) , 13 0.00 14. Net Value SubjacttoTax (line 12 minus Line 13) • . 14. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 2$1, 686.54 15. Amount of Line 14 taxable at the spousal tax rate, or transfers unQer Sec. 9116 (a)(1.2) x .o - 0.0 0 15. 0.0 0 16. Amount of Line 14 xable 4~ atiinealratex o 17. . 281,686.53 Amount of Line 14 taxable 16. 12,675.89 at sibling rate X.12 0 • 00 18. 17. Amount of Line 14 taxable 0 • 00 at collateral rate X .15 0. 0 0 18. ~, ~ ~ 19. TAX DUE .19. 12,675.89 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610248 1505610248 J 9M4646 4.000 REV-1500 EX Pape 3 3. Interest Total CredRa (A + g) (2) 0 ~ 0 ^ 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3) ^ ^ ^ Fill In box on Page 2, Line 20 to request a refund. (4) ^ . 0 (] 5. If Line 1 + Lina 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ,675 89 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 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. Ii death occurred after Dec. 12, 1982, did decadent 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 ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, No d 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)]. Far 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)J. 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 rata 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, ~ an individual who has at least one parent in common with the decedent, whether by blood or adoption. 9M4671 2.000 tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments (1) 12,675 8 A. Prior Payments _ ^ ^ ^ B. Discount _ ^ ^ ^ REV-1502 E% ~ (0140) pennsyivania SCHEDULE A OEPARTAEPIf OF REVENUE INHERITANCE TA%RETURN REAL ESTATE RESIDENr pECEOENT ESTATE OF: FILE NUMBER: Helen M. Ev 21 10 1048 All real property owned wlaly or as a bnant In common must M reporbd at hlr market value. Fair market value is defined as the price at which p would be exchanged between a willing buyer end a willing seller, neither being compelled to buy ar sell, both having reasonable knowledge of the relevantr~facts. Real propeAy that Is Joindyowned with right of survlvorehlp must be dlwbaed on Schedule F. Attach a copy of the settlement sheet N the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. NUMBER DESCRIPTION VALUE AT DATE OF DEATH ~. Real estate situate in the Borough of Camp Hill, Cumberland County, Pennsylvania, known as 207 South 19th Street; further identified as Tax Parcel Number 01-22-0536-110. 3es attached appraisal by Mark Heckman Real Estate 153,000.00 Appraiser TOTAL {Also enter on line 1, Recapitulation.) i 153, 000. 9W4895 2.000 If more space is needed, use additional sheets of paper of the same size. REV-1508 EX a (8-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH BANK DEPOSITS INHERITANCE TAX RETURN r r & MISC. RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF FILE NUMBER Bolen M. Ev 21 10 1048 Include the proceeds of litigataxt end the date the proceeds were received by the estate. All pro ointl owned with the rl ht of survivorship must t» disclosed on Schedule F. ITEM NUMBER VALUE AT DATE DESCRIPTION OF DEATH 1 M6T Bank Checking Account #10109900 Sea attached correspondence Interest accrued to 3/20/2010 2 ffi6T Bank Checking Account #950206395 Sae attached correspondence Interest accrued to 3/20/2010 3 M6T Savings Account #15004208613221 See attached correspondence Interest accrued to 3/20/2010 4 PNC Savings Account #50-8004-0426 Interest accrued to 3/20/2010 5 Property tax rebates - two at $750 each 6 Bridges at Bent Creek - refund, nursing home services 10,835.40 0.06 161,337.96 1.06 4,848.35 0.12 8,928.82 0.26 1,500.00 1,224.94 1 V 1 qL ,vlso enter on Tine 5 Roca 'tulation $ 188 , 676.97 3Wa8no t.00o (It more space is needed, insert additional sheets of the same size) REV•1510 EX + (08-09) Pennsylvania DEPARTAAENT OF REVENUE INHERRANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY _~ ~ ~ ~ ~ ..~ FILE NUMBER Helen M. E 21 10 1048 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 ----. _..._.. _. ....., ~.. INCLWE TIE fYME OF TIE TRARSFEREE, TIEIR REIATiONBHP TO OECEOENT ArD NYIBE TIE 6ITE OF 7RN•EFER ATTACMACOPY OF TfE OEEO FOR REAL ESTATE. ~• Cash gift made on 6/1/2009 to decedent's son, Thomas P. Ey DATE OF DEATH I %OF DECl75 I EXCLUSION 4,000.OOI100.0000 I 3,000.00 TAXABLE 1,000.00 TOTAL (Also enter on line 7 Recapitulation) $ If more apace is needed, use atldlhonal sheets of paper of the same size. 1 9W46AF 2.000 REV•1511 Ex+ (10-0D) Pennsylvania DEPARTAENTOF REVENUE INHERITANCE TAx RETURN SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Helen M. Ev 21 10 i~aa Decedent's debts must be reported on Schedule 1. ITEM NVMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t. Myers-Harper E~neral Home Ftizneral services 2,651.00 B. t ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: State ZJP 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant 4. 5. 6. 7. 1 2 9W48AG 2.000 Street Address City State ZIP _ Relationship of Claimant to Decedent Probate Fees: Accountant Faes: Tax Return Preparer Fees: Camp Hill Borough Sewer rental fees Cumberland Law Journal Legal advertisement Total from continuation schedules TOTAL (Also enter on Line 9 Rewpil If more space Is needed, use additional sheets of paper of the same size. 12,000.00 449.50 224.75 75.00 7,292.93 693.1 Estate of: Helen M. Ey 21 10 1048 Schedule H Part 7 (Page 2) 3 Farmers Insurance Homeowner's insurance 923.00 4 Pennsylvania American Water Co. Water utilities 100.00 5 Helen E. Shuman Labor and materials for painting and minor home improvements at decedent's residence to prepare house for sale 1,782.29 6 PPL Electric Electric utilities 50.00 7 Helen E. Shuman Postage expense 22.89 8 M&T Bank Wire transfer fee 30.00 9 M&T Bank Check printing charges 18.00 10 Mark Heckman Real Estate Appraiser Real estate appraisal for 207 S. 19th Street, Camp Hill, PA 375.00 it Penn Waste Trash removal services 97.50 12 Tax Collector, Camp Hill Borough 2010 county/municipal real estate taxes 757.17 13 Tax Collector, Camp Hill Borough 2010-11 school real estate taxes 1,790.16 14 The Sentinel Legal advertisement 176.92 15 Thomas P. Ey Painting services at 207 S. 19th Street 1,170.00 Total (Carry forward to main schedule) 7,292.93 REV-1512 EX * (12-08) pennsylvania SCHEDULE I DEPARibENTOF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Helen M. EV 21 10 1048 Report debts Incurred by the decedent prior to death that remained unpaid at the date of death, Including unreimbursed medical expenses. ITEM DESCRIPTION ~ (Lehigh Respiratory Care - Lancaster Medical bill 2 IM&T Bank Safe deposit box rental and box opening charges; see attached information on empty box. 3 (Reading Foot & Ankle Medical bill 4 (Pennsylvania American Water Co. Water utilities 5 William H. Ey Replace uncaahed, stale dated checks payable to William H. Ey for gifts made by decedent more than one year prior to her death 6 IPPL Electric Electric utilities 7 Helen E. Shuman Monies advanced by decedent's daughter (and acting POA) for the support and care of decedent and decedent's home prior to her death. These include prescription medicine; dental bills for tooth extraction and dentures; hospital charges; nursing home services; personal hygiene supplies; real estate taxes; property maintenance expenses such as lawn cutting, snow removal, heating oil and furnace maintenance. Receipts for these items will be provided upon request. 8 W4BAH 2.000 If more space is needed, insert additional sheets of the same size. VALUE AT DATE OF DEATH 76.26 104.00 39.07 100.00 21,310.00 100.00 16,567.92 2 REV-1513 EX+(Ot-10) SCHEDULE J Pennsylvania DEPARTMENrOF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENTDECEDENi ESTATE OF: FILE NUMBER: len M. E 1 4 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. Helen E. Shuman 260 Creek Road Camp Hill, PA 17011 One Third of Residue: 93,895.51 Daughter 93 895.51 2 Thomas P. Ey ' 3500 Paul Sweet Road Santa Cruz, CA 95008-4267 Ons Third of Residue: 93,895.51 Son 93,895.51 1 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 1 B OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9i 13 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET ~ S 0 9W48AI 2.000 If more space is needed, use addlttonal sheets of paper of the same size. Estate of: Helen M. Ey 21 10 1048 Schedule J Part 1 (Page 2) Item No. Description Relation Amount 3 William H. Ey 325 Union Avenue #323 Campbell, CA 95008-4267 One Third of Residue: 93,895.51 Son 93,895.51