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Home My WebLink About01-19-111505607121 -'' REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN /~ Hamsburg, PA 17128-0601 RESIDENT DECEDENT ~ _ ~ d ~ ~~ ~, ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 0 1 0 4 2 5 1 2 9 0 4 2 2 2 0 1 0 0 8 1 4 1 9 5 1 Decedent's Last Name Suffix Decedent's First Name MI Marti n James P (If Applicabte~ 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 OVALS BELOW a 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 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 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 - TH15 SkGI ION MU51 tat GUMF'Lk 1 kU. ALL GUKKtSt'UNUtNGt ANU GUNf•IUtN I IAL I AX INtUKMA 1 IUN SHUULU lit UIKtG I tU I U: Name Daytime Telephone Number James H T ur ner 717 232 4 55 1 Firm Name (If Applicable) - - - - - - - - ~ REGISTER OF WILLS USE ONLY Tur ner an d O' Conn el I c First line of address .~_r ii _. z ~~ ~, -, ~ ,+ 4 7 0 1 N o r t h F r o n t S t r e e t _ au..- f - Second line of address _ ~~, : ~ ~°-~ :. DA~~;FfLED ~'-_ ~~ City or Post Office State ZIP Code "r7 !~ ~x~ __ ; ~--, H a r r i s b u r g P A 1 7 1 1 0 _ ~ y CT ~'' ~~~ Correspondent's a-mail address: jht@turneralldoconnell.com Under penalties of pery'ury, 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. SIGNA F ERSO NSIBLE FOR FILING RETU DAT 47~f1 North Front Street Harrisburg PA 17110 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY 1505607121 Side 1 1505607121 J J 1505607221 REV-1500 EX Decedent's Social Security Number James P. Martin Decedent's Name: 0 1 0 4 2 5 1 2 9 RECAPITULATION 1. Real estate (Schedule A) ........................................ 1. 9 3 2 5, 1 6 2. Stocks and Bonds Schedule B 2. 1 4 1 9. 5 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. • 4. Mortgages & Notes Receivable (Schedule D) ........................ 4. • 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5. $ 0 4 1 7 8 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6• • 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ....... 7. 8. Total Gross Assets (total Lines 1-7) ........................... g, 1 8 7 8 6, 4 4 9. Funeral Expenses & Administrative Costs (Schedule H) . ........ ..... .. 9. 8 4 7 4 • 8 6 10. Debts of Decedent, Mortgage Liabilities, s~ Liens (Schedule I) ..... ..... .. 10. 2 3 5 2 3. 5 3 11. Total Deductions (total Lines 9 & 10) ............ ........ ..... .. 11. 3 1 9 9 8. 3 9 12. Net Value of Estate (Line 8 minus Line 11) .......... ........ ..... .. 12. - 1 3 2 1 1 9 5 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. 1 3 2 1 1 9 5 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 .0 0. 0 0 15. 0. 0 0 16. Amount of Line 14 taxable 0 ~ ~ ~ 0 0 0 at lineal rate X . 16 . 17. Amount of Line 14 taxable 0 ~ ~ 0 0 0 at sibling rate X .12 17. . 18. Amount of Line 14 taxable ll t t l X 1 ~ 0 ~ 0 0 0 a co a era rate . 5 1 g . 19. Tax Due .................................. ....... ..... ..19. 0. 0 0 20. FILL IN THE OVAL 1F YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505607221 150560722]_ J REV-1500 EX' Page 3 File Number Decedent's Complete Address: 0 0 Tax Payments and Credits: 7. Tax Due (Page 2 Line 19) (1) 0.00 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C } (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total InterestlPenalty (D + E) (3} 0.00 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 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B} 0.00 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" tN 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 ................................................................................................ ^ 0 ^ d. receive the promise for life of either payments, benefits or care? ....................................................... 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ ^ 0 " " or payable upon death bank account or security at his or her death? ......... in trust for 3. Did decedent own an 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................. ^ 0 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 January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (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 zero (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 twenty-one 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 zero (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 four and one-half (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 twelve (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-1502 EX + (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RFSIr)FNT nFCFI)F_NT ESTATE OF FILE NUMBER James P. Martin 0 0 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real ~ro~erty which is iointlY-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Net proceeds from sale of 37 South 27th Street, Camp Hill Borough, Cumberland County 9,325.16 Pennsylvania; TOTAL (Also enter on line 1, Recapitulation) ~ $ 9,325.16 (lf more space is needed, insert additional sheets of the same size) REV-1503 EX + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER James P. Martin ~ 0 0 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. The Hartford 1,419.50 50 shares $28.39/share TOTAL (Also enter on line 2, Recapitulation) ~ $ 1,419 50 (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. IN R S DENT D EDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER James P. Martin 0 0 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointty-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Proceeds from sale of 1997 Volvo 960 1,252.50 VIN: YV1 KW9604V1039060 2. Balance of Wachovia accounts 2,197.50 Account number: 1010208656986, Balance: 106.76 CD account number: 247402053766117, Balance: 2090.74 3. Proceeds from auction of personalty 3,552.13 4. I Travelers I 487.00 Insurance refund f 5. I B{ueCross BlueShield of Alabama I 386.65 Insurance refund 6. IThe Hartford Financial Services Group, Inc. I 7.50 Stock dividend 7. IThe Hartford Financial Services Group, Inc. a 2.50 Stock dividend II 8. Progressive 156.00 Draft refund TOTAL (Also enter on line 5, Recapitulation} I $ 8 041.78 (If more space is needed, insert additional sheets of the same size) RSV-1511 ESC + (10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER James P. Martin 0 0 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A FUNERAL EXPENSES: . 1. Schwartz-Adamo Funenral & Cremation Services 1,111.00 2. Diocesan Cemeteries 665.00 3. St. Francis of Assisi 300.00 4. Teleflora -flowers 85.69 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Street Address City State Zip Year(s) Commission Paid: 2, Attorney Fees Turner and O'Connell 3,500.00 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees Register Of Wills 317.50 5 Accountant's Fees 6. Tax Return Preparers Fees 7. Estate advertising: Cumberland Law Journal; The Sentinel 273.16 8. PPL electric service 419.67 9. UGI gas service 938.90 10. PA American Water 221.81 11. Death certificates 12.00 12. Penn Waste 68.75 13. Duty's Locksmith 231.18 14. Sweet'N Gro lawn services 330.20 TOTAL (Also enter on fine 9, Recapitulation) $ 8,474.86 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12-03} SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER James P. Martin 0 0 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. West Shore Meals on Wheels 44.00 101 North 23rd Street, Camp Hill, PA 17011 2. International Media Concepts, Inc. 41.44 The New York Times, PO Box 371456, Pittsburgh, PA 15250 Account number: 882006240 3. We11s Fargo Card Services 4,271.20 PO Box 6412, Carol Stream, IL 60197 Account number: 4312434890488865 4. Discover Card 4,047.50 PO Box 71084, Charlotte, NC 28272 Account number ending in 0734 5. Kantor and Tkatch Assoc, PC 25.00 205 South Front Street, Harrisburg, PA 17104 Chart number: MARJA004, Date of service: 3/24/10 6. Associated Cardiologists 39.75 856 Century Drive, Mechanicsburg, PA 17055 Account number: NZE087, Date of service: 1 /28/10 7. Apria Healthcare 33.19 1328 S. Highland Ave, Jackson, TN 38301 Account number: 0370AKF192 8. HBCS, 2424 Northgate Drive, Suite 100, Salisbury, MD 21801 1,217.16 Holy Spirit Hospital Account number: 36387173, Date of service: 1/27/10 9. Quantum Imaging and Therapeutic Associates 164.40 PO Box 62165, Baltimore, MD 21264 Account number: 94846 10. Accounts Recovery Bureau, Inc, PO Box 6768, Wyomissing, PA 19610 174.19 Pinnacle Health Hospitals Account number: 100168627, Date of service: 1 /1 /10 11. Computer Credit, Inc, PO Box 5238, Winston-Salem, NC 27113 100.00 Pinnacle Heath Hospitals, PO Box 2353, Harrisburg, PA 17105 Account number: 100155684 O, Date of service: 12/7109 12. Charan's Family Medicine 25.00 890 Poplar Church Road, Suite 200, Camp Hill, PA 17011 Account number: Martin, Date of service: 2/23/10 13. HBCS, 2424 Northgate Drive, Suite 100, Salisbury, MD 21801 1,092.24 Holy Spirit Hospital, Account nos: 34778308, 34929976, 35043371 Dates of services: 6/8/09, 6/30/09, 7/16/09 14. East Pennsboro Ambulance Service 689.00 PO Box 726, New Cumberland, PA 17070 Invoice number: 10-101975, Date of service: 4/12/10 15. West Shore EMS-ALS 889.40 205 Grandview Ave, Suite 211, Camp Hill, PA 17011 Patient number: 90380, Date of service: 4/12/10 TOTAL (Also enter on line 10, Recapitulation) $ 23.523.53 (If more space is needed, insert additional sheets of the same size) . Continuation of REV-1500 Inheritance Tax Return Resident Decedent James P. Martin Decedent's Name Page 1 File Number Schedule I -Debts of Decedent, Mortgage Liabilities, & Liens ITEM NUMBER DESCRIPTION AMOUNT 16. Verizon 103.27 PO Box 28000, Lehigh Valley, PA 18002 Account number: 717763-171953778Y 17. North Shore Agency 30.00 PO Box 9205, Old Bethpage, NY 11804 18. AOL Member Services 11.99 PO Box 30622, Tampa, FL 33630 Account number: 0199172917 19. Cumberland County Per Capita Tax 5.50 20. Discover Card Services 3,790.44 Estate Information Services, 2323 Lake Club Drive, Suite 300, Columbus, OH 43232 Reference number: 2697591 21. Camp Hilf Fire Company No 1 519.70 PO Box 726, New Cumberland, PA 17070 Invoice number: 09-56690, Date of service: 9/19/09 22. Camp Hill Fire Company No 1 502.35 PO Box 726, New Cumberland, PA 17070 Invoice number: 09-49078, Date of service: 8120109 23. Camp Hill Fire Company No 1 519.70 PO Box 726, New Cumberland, PA 17070 Invoice number: 09-66781, Date of service: 11/2/09 24. Quantum Imaging & Therapeutic Associates 2.40 PO Box 62165, Baltimore, MD 21264 Account number: 94846 25. Apria 279.42 CBCS, PO Box 2589, Columbus, OH 43216 Account number: 22-16084692, Dates of services: 6/16/09 and 8/16/09 26. AAA 75.00 Account number: 4381958563011006 27. Pulmonary & Critical Care Med Asso PC 416.50 1631 N Front Street, Harrisburg, PA 17102 Account number: 376160, Dates of service: 1!26/10-1/28/10 28. HBCS, 2424 Northgate Drive, Suite 100, Salisbury, MD 21801 69.00 Holy Spirit Hospital Account number: 35125202, Date of service: 7/28/09 29. HBCS, 2424 Northgate Drive, Suite 100, Salisbury, MD 21801 69.00 Holy Spirit Hospital Account number: 36053981, Date of service: 12/5/09 30. Pulmonary & Critical Care Med Asso PC 416.50 1631 N Front Street, Harrisburg, PA 17102 Account number: 376160, Date of service: 4/21 /10 SUBTOTAL SCHEDULE I 6,810.77 Continuation of REV-1500 Inheritance Tax Return Resident Decedent James P. Martin Decedent's Name Page 2 File Number Schedule I -Debts of Decedent, Mortgage Liabilities, & Liens ITEM NUMBER DESCRIPTION AMOUNT 31. NCO Financial Systems, Inc, 30600 Telegraph Rd, Suite 4235, Bingham Farms, MI 48025 150.00 Carlisle Regional Medical Account number: 49093169 32. Accounts Recovery Bureau, Inc, PO Box 6768, Wyomissing, PA 19610 100.00 Pinnacle Health Hospitals Account number: 101580289 33. Accounts Recovery Bureau, Inc, PO Box 6768, Wyomissing, PA 19610 274.19 Pinnacle Health Hospitals Account number: 101790334 34. Holy Spirit Hospital 101.69 503 N 21st Street, Camp Hill, PA 17011 Account number: 32561169, Dates of services: 7/15/08-7/18/08 35. Holy Spirit Hospital 215.26 503 N 21st Street, Camp Hill, PA 17011 Account number: 33387614, Dates of services: 11/18/08-11/24/08 36. Wachovia Card Services, NA 3,018.15 PO Box 105204, Atlanta, GA 30348 Account number: 4312-4348-9048-8865 SUBTOTAL SCHEDULE I 3,859.29 GRAND TOTAL SCHEDULE I $ 23,523.53 REV-1513 ~X ± (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER James P. Martin n n RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)J 1. Sherman H. Martin Sibling 0.00 15455 Glenoaks BI #507 Sylmar, CA 91342 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 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)