HomeMy WebLinkAbout01-13-111505610101
REV-1500 °` f°'-'°' ~
n vaMa OFFICIAL USE ONLY
PA Department of Revenue P~ ~ County Code Year F~il~e/NumJber~
Bureau ofIndivfduatTaxes ate'...°~ INHERITANCE TAX RETURN ® ® L.Ir.Lli~1rL
PO BOX 280601
Harrisburg, PA x'7128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
rT15 3~ 3 ~ 4~ ri2o szoo g os ~~ q
Decedent's Last Name Suffix Decedent's First Name MI
C o u S e t- ~' ~ ~Ta~l 0
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Sppouse's First Name MI
G O u 2~ ® I A f 1 G f A
Spouse's a~ e~ rity N ~ ber
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Return O 2. Supplemental Return O 3. Remainder Retum (date of death
prior to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required
death after 12-12-82)
~ 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's e-mail address:
GO
Under penaldes of perjury, I deGare 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 preperer other than the personal representative is based on all information of which preparer has any knowledge.
~C SIGNATU~R,yE OF PERSON~~RyyESP/nOnNSIBLE~ FOR FILING RETURN
DATE
.~~~~ ~lr~c,~-e. Or~~c ~trMn N111 P/~ Il ~ I(
SIGNATURE OF EPAREIi OTHER THAN REPRESEN ATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610101 1505610101
J 1505610105
REV-1500 EX
/ ~~D'ec~~edQent's Social Security Num'bLje~r
Decedent's Name: ~~~ ( ~ - V ~ ~ ~f e f ~ ~~ @ 1 F~1 ~.. ~.. ~ / 1
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 and Notes Receivable (Schedule D) ......................... .. 4.
5. Cash, Bank Depceits 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
(Schedule G) O Separate Billing Requested..... ... 7.
8. Total Gross Assets (total Lines 1 through 7) .......................... ... 8.
9. Funeral Expenses and AdminisUative 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.
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_
16. Amount of Line 14 taxable
at lineal rate X .0
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
15.
16.
17.
18.
19. TAX DUE ......................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610105 1505610105
O
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
DECEDENTS NAME
t r e. ~!a ~,de,,- ~ ~
STREET ADDRESS
zy ~~ a~2 l~ri~2
CITY ~ ~ ,~
„n f STATE
P ZIP/ 7 1/
0
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
(1)
Total Credits (A+ B) (2)
3. Interest
(3)
4. ff Line 2 is greater than Line 1 + Lirµ?13, enter the difference. This is the OVERPAYMENT.
Fill in oval on Pagel Z, Lime ZO to request a retund. (4)
5. If line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
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 ,,N~,,o((
a. retain the use or income of the properly transferred :.......................................................................................... ^ LJ
b. retain the right to designate who shall use the property transferred w its income : ............................................ ^ (~
c. retain a reversimnary interest: or .......................................................................................................................... ^ [~
d. receive the promise for life of either payments, benefits or care? ...................................................................... ^
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. ^ l~
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 ,ne
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.
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 Juty 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 w 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. §911ti(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-1503 EX+ (6-98)
SCFIEDYLE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NWMBER
Earl E. Clouser, Jr. 2120091159
All properly Jolntty-owned with right of survlvorahlp must lie dlacloaed on Schedule F.
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TltiX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, 8~ MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Earl E. Clouser, Jr. 2120091159
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property )olntty-owned with right of survivorship moat be disclosed on Schedule F.
(If more space is needed, insert additional sheets of the same size)
REV-1510 E%• (1971
COMMONWEALTH OP PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE G
INTER•VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
~,~ ~ E. C~ourei , .T( 2l Leo 9 11 S`1
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
iNCLUDETHENAYEOFTHETRAN6FEREE,THEIRREUTIONSHIPTDDECEDENTANDTNEDATEOFTRAdSFER.
ATTAOM A COPY OF THE DEED FTN2 REAL E6TATE. ~
DATE OF DEATH
VALUE OF ASSET % OF
DECD'S
INTEREST
EXCLUSION
iFAPFUCAa~E
TAXABLE VALUE
~. ~Q~ WO~Q~ ~o Ne J - I iQ A
Q~y
17
Dag
3 2 z~ 1~ Z
.2~
-~ o
~
~c`t- # Cv 16 - 46 3 Z~
TOTAL (Also enter on line 7, Recapitulation) I : 3 ~L' ~ 8 ~1 . y 1
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX+ (11-OS)
~' Pennsylvania
~i1 DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE
BENEFICIARIES
ESTATE OF FILE NUMBER
EG/ ~ ~ ` C~~ r~ , fir.
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT
Do Not List Trustee(s) AMOUNT OR SHARE
OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 2116 (a) (1.2).]
1.
PG~~~fa ~~ 350, szq. ~/
ouf~
~, ~~
,
zy ~,rJGt ~~ .
,,
~~r Nf11, ~~ 17~ ~1
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. #
It more space is needed, insert additional sheets of the same size.
. ~~ ,
Will of Earl E. Clouser, Jr.
I, Earl E. Clouser, Jr., a resident of, Pennsylvania,
County of Cumberland, declare that this is my will. My
Social Security Number fs 195-30-3148.
FIRST: I revoke all wills and codicils that I have
previously made.
SECOND: I am married to Patricia A. Clouser.
THIRD: I have the following children now living: a son,
Earl R. ...Clouser, a daughter, Sheri L. Segiel, a son, Mark E.
Clouser, a son, Michael A. Clouser and a daughter, Julie A.
Simpson.
FOURTH: As used in this will, the term "specific
bequest" refers to all specifically identified property, both
real and personal, that I give to one or more beneficiaries
in this will. The term "residuary estate" refers to the rest
of my property not otherwise specifically disposed of by this
will or in any other manner. The term "residuary bequest"
refers to my residuary estate that I give to one or more
beneficiaries in this will.
FIFTH: All personal property I give in this will through
a specific.or residuary bequest is given subject to any
purchase.-money security interest, and all real property I
give in this will through a specific or residuary bequest is
given subject to any deed of trust, mortgage, lien,
assessment, or real property tax owed on the property. As
used in this will, "purchase-money security interest" means
any debt secured by collateral that was incurred for the
purpose of purchasing that collateral. As used in this will
"non-purchase-money security interest" means any debt that is
secured kyy collateral but which was not incurred for the
purpose of purchasing that collateral.
SIXTH:. When this will states that a beneficiary must
survive me for the purpose of receiving a specific bequest or
residuary bequest, he or she must survive me by 45 days,
except that property left to my spouse shall pass free of
this 45 dray survivorship requirement.
SEVENTH: I hereby leave $1.00 to each of the following
persons: a son, Earl R. Clouser, a daughter, Sheri L. Segiel,
a son, Mark E. Clouser, a son, Michael A. Clouser and a
daughter, Julie A. Simpson. These bequests are in addition
to and not instead of any other specific bequest that this
will makes to these persons.
EIGHTH: I give my residuary estate to my
A. Clouser. However, if any beneficiary named
paragraph to receive my residuary estate fails
Page 1 Initials: <~~ '_-: r•
wife, Patricia
in this
to survive me,
Date: 7 /? ~,1-"
Will of Earl E. Clouser, Jr.
the residuary estate shall qo to Earl R. Clouser, Sheri L.
Segiel, Mark E. Clouser, Michael A. Clouser and Julie A.
Simpson, to be divided equally.
NINITH: Any specific bequest or residuary bequest made in
this will to two or more beneficiaries shall be shared
equally among them, unless unequal shares are specifically
indicated.
TEN4'H: If my spouse and I should die simultaneously, or
under such circumstances as to render it difficult or
impossible to determine who predeceased the other, I shall be
conclusively presumed to have survived my spouse for purposes
of this will.
ELEiVENTH: I name my wife, Patricia A. Clouser as my
personal representative (executor), to serve without bond.
If this person or institution shall for any reason fail to
qualify or cease to act as personal representative, I name
Earl R. Clouser as personal representative (also to serve
without bond), instead.
TWELFTH: I direct my personal representative to take all
actions legally permissible to have the probate of my will
done as simply and as free of court supervision as possible
under the laws of the state having jurisdiction over this
will, including filing a petition in the appropriate court
for the independent administration of my estate.
THIRTEENTH: I hereby grant to my personal representative
the following powers, to be exercised as he or she deems to
be in the best interests of my estate:
1) To retain property without liability for loss or
depreciation resulting from such retention.
2) To dispose of property by public or private sale, or
exchange, or otherwise, and receive and administer the
proceeds'as a part of my estate.
3) ~o vote stock, to exercise any option or privilege to
convert bonds, notes, stocks or other securities belonging to
my estate into other bonds, notes, stocks or other
securities, and to exercise all other rights and privileges
of a person owning similar property.
4) mo lease any real property that may at any time form
part of my estate.
5) To abandon, adjust, arbitrate, compromise, sue on or
defend amd otherwise deal with and settle claims in favor of
or against my estate.
6) To continue or participate in any business which is a
part of my estate, and to effect incorporation, dissolution
or other change in the form of organization of the business.
7) 'Po do all other acts which in his or her judgment may
be necessary or appropriate for the proper and advantageous
management, investment and distribution of my estate.
Page 2 Initials: ~'1l ' ~ ~~_ G! ~ Date• '~ 3 ~.~..-
i
Will of Earl E. Clouser, Jr.
The foregoing powers, authority and discretion granted
to my personal representative are intended to be in addition
to the powers, authority and discretion vested in him or her
by operation of law by virtue of his or her office, and may
be exercised as often as is deemed necessary or advisable,
without 'application to or approval by any court in any
jurisdiction.
FOUIRTEENTH: Except for purchase-money security interests
on persanal property passed in this will, and deeds of trust,
mortgages, liens, taxes and assessments on real property
passed in this will, I instruct my personal representative to
pay all 'debts and expenses, including non-purchase-money
secured 'debts on personal property, owed by my estate as
provided for by th® lawa of Pennsylvania.
FIFTEENTH: I instruct my personal representative to pay
all estate and inheritance taxes assessed against property in
my estate or against my beneficiaries as provided for by the
laws of Pennsylvania.
SI}CTEENTH: If any beneficiary under this will in any
manner, directly or indirectly, contests or attacks this will
or any of its provisions, any share or interest in my estate
given to the contesting beneficiary under this will is
revoked and shall be disposed of in the same manner as if
that contesting beneficiary had failed to survive me and left
no living children.
I, Earl E. Clouser, Jr., tY~e testator, sig my name to
this instrument, this ~ ~'~ ~ day of ,
~ I hereby declare that I sign and execute h s
nstrument as my last will, that I sign it willingly, and
that I execute it as my free and voluntary act for the
purpose$ therein expressed. I declare that I am of the age
of majority or otherwise legally empowered to make a will,
and under no constraint or undue influence.
/~ ~
S gned)
We, the witnesses, sign our names to this instrument,
and do hereby declare that the testator willingly signed and
executed this instrument as the testator's last will.
Eaph of us, in the presence of the testator, and in the
presence of each other, hereby sign this will as witness to
the testator's signing.
To the best of our knowledge, the testator is of the age
of majority or otherwise legally empowered to make a will, is
Page 3 Initials:( ~1aC. k~~ ~~ ``~~ Date: `/ /~ % ~ ~
Will of Earl E. Clouser, Jr.
mentally competent, and under no constraint or undue
influence.
We declare under penalty of per~ury, that the foregoing
i true and correct,' this f3 . day of
X49 S .
Witness ,~1:
Residing at:
Witness ~2: ~/~,,~ ~~~_
Residing at: _ /~ Par! ~,,,,__.6a~„_( g,,,9,( ~ p~ I ~ 0 7C
witness ,~3: `,~~ ~es.,.._ ~.t,~.Q.~>
Residing at:
{ ~ ~ ~.
Page 4 Initials: ~_~'V~.:~,,,~ c_`c' r Date: `' /3 ` j
AFFIDAVIT
We, ~
nd Q,~ _~ -- ~. the
to or and the witnesses, respectively, who a nacre
sig ed to the attached or foregoing instrument in those
capacities, personally appearing before the. undersigned
authority and being first duly sworn, declare to the
undersigned authority under penalty of perjury that:
1) the testator'declared, signed and executed the instrument
as his/her last will;
2) he/she signed it willingly or directed another to sign
for him/her;
3) he/shei executed it as his/her free and voluntary act for
the purposes therein expressed; and
4) each of the witnesses, at the request of the testator, in
his/her presence, and in the presence of each other, signed
the will as witness and that to the best of his/her knowledge
the testator was at that time of full legal age, of sound
mind and under no constraint or undue influence.
Testator: G~`~~ ~ ~ _,
Witness: ~~'t.S-~.-__-~ C.,:,~~~
witness: ~/~ ~ ~~e
Witness: _~, ~~(~,;~~
Subscribed, scorn to and acknowledged before me by
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w t saes, th s ; ; rf~
day of L4QS .
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My Commiss~ Expires M3r~h 21,1 7
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