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Home My WebLink About01-28-11 (3)-~ REV-1500 15Q5607120 EX (06-05) OFFICIAL U8~ ONLY PA Department of Revenue county code Y r Fib Number euroau of Individual Taxes INHERITANCE TAX RETURN 2 1 Q 9 10 4 6 PO 80X.280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 190205299 10152009 04211925 Deoadent's Last Name Suffix Decedent's First Name MI DAVIS JANET ' C (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Namte Spouse's Socal Security Number FILL IN APPROPRIATE OVALS BELOW ® 1. Original Rsttmt ^ 4. Limited Estate ® 8 DaGdarrtt Died Testate (Attach Copy of VYa) ^ 9. litigation Proceeds Received Suffix Spouse's First Name MI THIS RETURN MUST BE FILED IN DUPLIC~-T~ IWiTH THE REGISTER OF WILL ^ 2. Supplemental Retum ~ 3. Rematnd R m (date of death prior to 12 132) ^ qa, Future Interest Campromlae ^ 5. Federal l~ sta~8 Tax Retum Required (date of death alter 12-12-82) 0 ^ ~. Decedent MakkaMed a Living Trust 8. Total Nur}tbert of Safe Deposit Boxes (Attach Copy of Trust) 10. Spousal Poverty Credit (d.ce or death ^ between 12.3181 and 1-1-95) ^ 11. Election t to under Sec. 9113(A} (Attach S~It. ~) Name Dsydme Tek Number JAMBS J. MCCARTHY, JR., BSQ. 71723 5 9'74 Ftrm Nams (If Applicable) REGI3TE WILLS U$~c ONLY MCCARTHY WBISHERG CIIMMING3, P.C. r --- ~ ~., First pne of address ''„~ w.m. rrt ~ .'~.~~.. -' "1 2 0 41 HBRR STRL+LT ,~ ~ ~ ~: ~ ~ ~, ' _ r Second line of address C {"~ ~, , '~.l ~" , ~' FILED '" ~`- City or Post Office State ZIP Code HARRISBURG PA 17103-1624 ..~A Correspondent's e-mail address: j a m es j m c c a rt b y c o m c a:t. n et Under penalWs of perjury, I dedaro that 1 havre examined thb rota indud((rrqtp acoomperty(ny schedules and statemonla, and to the it is true, oomect and Complete. Decisuatbn of proparer otheryis~ie person£1 re(>resentative is based on afl informatlon of which df my knowledge and belief, t has any knowledge. Mitchell A. Miller ADDRESS / II 60 Geisei Road, Harrisburg, PA 17112 r SIG TORE OF PR ARER ER THAN REPRESENT VE ~ DATE ,~ T ,~ „ ~ z ~k James J. McCarthy, Jr., Esq. ~! (L - ADDRESS i 2041 Herr Street, Harrisburg, PA 17103-1624 Side 1 L 150560712D 15051a0'~3~D -- _ _ _ __ _ - _ _ __ _ i l _i _, ~ _ _. 15D5607220 _ _ REV-1500 EX Decedent's Sdci~l Security Number oaceaenr, N+~: D A V I S, J A N E T C 19 0 2 0 2 9 9 RECAPITULATION 1. Real Estate (Schedule A) .......................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................... 2. '11,854.00 3. Ciosey Held Corporation, Partnership orSole-Proprietorship (Schedule C).......... 3. 4. Mortgages 8 Notes Receivable (Schedule D) .......................................................... 4. 5• Cash, Bank De sits 8 Miscellaneous Personal Pro po party (Schedule E) ................ 5. ~ 0 8 , 0 3 6 . 2 5 6. Jointy Owned Property (Schedule F) ^ Separate Billing Requested ............. 6. 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ............. 7, ! '7 $ , 3 7 5 . 3 9 8. Total Gross Asssts (total Linea 1-7) ....................................................................... 8, ~I ~ '9 8 , 2 6 5 . 6 4 9. Funeral Expenses i;< Administrative Costs (Schedule H) ......................................... 9. 6,893.75 '~ 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule q ................................ 10. ~~ 13, 405.05 ', 11. Total Deductions (total Lines 9 8 10) ...................................................................... 11. '', ' 2 0, 2 9 8. 8 0 I 12. Net Value of Estate (Line 8 minus Line 11) ............................................................. 12, ~!~ ~ 7 7 , 9 6 6 . 8 4 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, ~ 7 7 , 9 6 6 . 8 4 TAX COMPUTATION -SEE IN3TRUCTION3 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 1 7 7, 9 6 6. 8 4 at Uneal rate X .045 16. ', 8, 0 0 8. 5 1 17. Amount of Line 14 taxable at sibling rate X ,12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 1 s. Tax Due ..................................................................................................................... 1 s. 8, 0 0 8.51 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ~I ^ !, Side 2 ~,~, 1505607220 I '~ 150560~2~20 J ~_ __~ L_ . REV-151 EX Page 3 Decedent's Complete Address: Davis, Janet C STREEI'ADDRESS 222 Messiah Circle CITY Mechanicsburg STATE ' ~ ZIP 17055 File Number 21 - 09 - 1046 Tax Payments and Credits: 1. Tax Due (Page 1 Llne 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Inbrost/Penalty if applicable p, interest E. Penalty 326.81 Total Credits (A + B + C) Total inbrest/Penalty (D + E) 4. if Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Ct»ck box on Page 2 Line 20 to rogwst a refund 5. If Line 1 + Line 3 is greater than line 2, enter the difference. This is the TAX DUE. A. Enbr the inbrest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Melee Check Payable to: REGISTER OF WILLS, PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE (1) 8,008.51 (2) 0.00 ~, (3) 326.81 (4) (5) 8,335.32 (5A) (5B) 8,335.32 TE 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 :.................i.....;............, x c. retain a reversionary interest; or ...............................................................................................~.................. x p ym .........................~...;............. x d. receive the promise for life of either a ants, benefits or care? .................. ^ ^ 2. If death occurred after December 12, 1882, did decedent transfer ro wfthin one ear ofd at receiving adequate consideration? .................................................p... ~~.................. Y.................~ without 3. Did decedent own an "in trust for° or payable upon death bank account or security at his or her ~ at}-?,........ ^ ^x 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneflcary designation? ...................................................................................................~.~........... ~ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND I fiT 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 trer~sfe~s lto or for the use of the surviving spouse is throe (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or afbr January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of th surviving spouse is zero (0) psrosnt [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the sdatutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates ofdeath on or after July 1, 2000: The tax rab imposed on the net value of transfers from a deceased child twenty-one years of age or younger at dea~h t~ or for the use of a natural parent, an adoptnre 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 {~ne~hplf (4.5) percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)1• '. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is tweMe (12) percent [[~~72 .$. §9116 (a) (1.3}]. A sibling is defined under Section 9102, as an individual who has at teaat one parent in common with the decedent, w IlhetF~ert by blood or adoption. COMMDNWEALTN ov raaNSV~mw~n NNERRANCE TAX RETURN RESIDBIT DECEDENT SCHEDULE B STOCKS & BONDS FILE Nl~MB6R ESTATE OF ~aViS, Janet C 21 - 09 'r 1 p46 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM DESCRIPTION UNIT V/~LUE VALUE AT DATE OF NUMBER DEATH 1 Gov. Savings Bond SVGS BD RD ~01~24.00 10,824.00 2 Bur of Pub Debt H/HH Redmt '; 1000 1,000.00 3 Bur of Pub Debt H/HH Redmt 30 30.00 TOTAL (Also enter on line 2, 11,854.00 I ' .__. ~ _. _ ~ 1 ~ __-- - _ - __ .__ _ SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMONwEALn~oF reNNanvAN1A PERSONAL PROPERTY ~~. INFIERfTANCE TAX RETURN RESIDENT DECEDENT I FILE NUhA ER ESTATE OF Davis, Janet C 21 - 09 t 1 46 Include the pproceeds of litigation and the date the proceeds were received by the estate. All property jolnt{y-io l F h d l d wlth the right of . e u e on sc ose survlvorshlp must be disc ITEM DESCRIPTION VALUE AT DATE OF DEATH NUMBER 1 Northwest Bank Certificate of Deposit - 0001 5Q 0024 ', ' 12,264.68 2 Northwest Bank Certificate of Deposit - 0001 SQ 0025 23,965.03 3 Northwest Bank Certificate of Deposit - 0001 SQ 0026 ' 17,036.18 4 Northwest Bank Certificate of Deposit - 0001 SQ 0027 ' ', 13,909.97 5 Internal Revenue Service -Refund of taxes ', 396.00 6 Northwest Savings Bank -1276021142 (Close Account) I 7,547.79 7 Northwest Savings Bank - 274001973DD (Close Account) ' 4,217.68 8 ~ Northwest Bank Certificate of Deposit - 0001 SQ 0028 I 28,698.92 TOTAL (Also enter on Llne 5, Recapltulatl n) 108,036.25 COMMONWEALTH OF PENNSYLVANIA SCHEDULE G INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS ~ RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY ESTATE OF Davis, Janet C FILE N21 B~~ - 1046 This schedule must be completed and fited if the answer to any of questions 1 through 4 orh page 2 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY Inducts the name of tM traneNrse, their reletioneMp to decadent and the date of trensfar. Attach a copy of the deed for real estate. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EX LU ION (IF APIPLI~A~LE) TAXABLE VALUE 1 MetLife Annuity 060255363 VM 2,741.80 100% ', 2,741.80 2 MetLlfe Annuity 010226202 AB 14,452.80 100% ', ' 14,452.80 3 MONY -Contract 81201-92-56 14,689.16 100% 14,689.16 4 UBS Financial Services, Inc. -IRA 1A D3015 T3 5,701.15 100% ' 5,701.15 5 Ameriprise Financial -1308 5410 2 001 -annuity 40,790.48 I 40,790.48 TOTAL (Also enter on line 7, Recapitulation) 78,375.39 DOMMONVMEALTN of PENNSnv~Nln xxieirtw+ceriuc RETVRN RESgENT DECEDENT SCF'~ULE H /FLU^I~E~F~~ALp~~/ ~ ML11~"~71 fN'\ I IYG ESTATE OF Davis, Janet C I FILE NU~1A8E'R 2h -'09 - 1046 Debts of decedent must bs roported on Schedule 1. ITEM AMOUNT NUMBER FUNERAL EXPENSES: DESCRIPTION A. 1 Girard Cemetry -Internment fees ' 1,177.00 2 Springfield Monument Company ' 90.00 3 Pastor Greenawalt -Church Service 450.00 B. 1 2. 3. a. ADMINISTRATIVE COSTS: Persona! Representative's Commissions Mitchell A. Miller Social Security Number(s) / EIN Number of Personal Representative(s): 198-40-0913 Street Address 60 Geisel Road city Harrisburg state PA zip 17112 Year(s) Commission paid Attorney's Fees McCarthy Weisberg Cummings, PC 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 Probate Fees Register of Wills Register of Wills -Inventory and Inheritance return fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7, Other Administrative Costs 1 Vital Records 0.00 4,500.00 574.00 30.00 45.00 TOTAL (Also enter on Ilne 9, Recapitulation) 6,883.75 ~~^~ I __-- _ -- _~__- -._ _ - __ _,_ _ --1- i__~__ G ~.,Sc~edt~ie H p- COMMONYVEALTH OF PENNSYLVANIA ~ ~w « INHERITANCE TAX RETURN ~",„'*'~~~ ~ ,~ ESTATE OF Davis, Janet C FILE NUI~ABEEi 21 - 09 ~ 1 U4i6 2 Northwest Savings Bank -bank service fees 27.75 Page~~2 c~fSchedule H COMMONYVEKTH of r+v~wsvwnNu INHERRMICE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF DaVIS, Janet C FILE NU Eli 21 -09+1 46 Include unrsimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1 Mobile X-Ray '~ ' 65.21 2 Master Card -Credit Card Bill ', ~ 2,331.32 3 Alert Pharmacy II 254.12 4 Messiah Village -residence care ' 9,700.15 5 Philhaven -medical care 21.50 6 Dr. Paul Dalbey -medical care 15.68 7 Special Event Emergency ' 76.72 8 Capital Area Health Association -Medical Care 316.96 9 PSERS -Reimburse retirement check I 529.70 10 Pinnacle Health -Harrisburg Hospital (paid to Account Recovery) 93.69 TOTAL (Also enter on Line 10, Rscapitula~lor~) ~ 13,405.08 Rev.~s~s tx+(si.oo) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NU ER ~~ Davis, Janet C 9 - 1046 2 1 RELATIONSHIP TO SHARE OFD E TATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Worlds) i ($$$) RECEIVING PROPERTY Do Not Ust TruaRM(s) _-i I~ TAXABLE DISTRIBUTIONS [include outright spousal distributions and transfers ce i ' ', under Sec. X116 (a) (1.2)] i 1 Mitchell A. Miller Son 1/5th sham ', 60 Geisel Road Harrisburg, PA 17112 ~, j 2 Margaret M. Rogers Daughter 1/5th sham 6084 Tryon Road Longview, TX 75605 ', 3 Charles E.P. Miller Son 1/5th sham 338 West 1st Street Boiling Spring, PA 17007 ~, '~ Enter dollar amounts for distributions shown above on lines 1 5 through 18, as appropriate, on Rev 1500 cov s e81 II NON-TAXABLE DISTRIBUTIONS: I' I I A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS I NOT BEING MADE ' I ~ '. ~,I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS I I TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER HE t 0.00 SCHEDULE J COMMONWEALTH OFPENNSYIVANIA BENEFICIARIES continued INHERITANCE TAX RETURN RESIDENT QECEOENT ESTATE OF Davis Janet C FILE NUIM ER , 21 - X09 - 1046 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Worlds) ($$$) RECEIVINQ PROPERTY oo Not ua Tru~tN(s) I~ TAXABLE DISTRIBUTIONS [include outright spousal distributions and transfers ', under Sec. X116 (a) (1.2)J 4 Thomas P. Miller Son 1/5th sham ', 7810 East Oakwood Place Tucson, AZ 85750 ' 5 Kylee Grace Miller Great Granddaughter 1/5th sham 8565 Barker Road Girard, PA 16417 (per stirpes Kirk C. Miller) I Flagje 2 of Schedule J ______i_L___ . LAST WILL AND TESTAMENT OF JANET C. DAVIS I, JANET C. DAVIS, of the Borough of Lake C~itjy, County of Erie and Commonwealth of Pennsylvania, being of sound and disp sing mind, memory and understanding, do make, publish and declare this as and f rimy Last Will and Testament, hereby revoking and making null and void any ar~d'iall Wills and Codicils, or writings in the nature thereof, at any time Y~er~etofore made by me. FIRST: I direct that all my just debts, i~'alny, and my funeral expenses shall be paid as soon as possible after my death~~lby~ my Executor out of my residuary estate. ~', SECOND: I direct that if my mortal remains c}an be used for ',, organ donation, transplants and the like, that such use b~ made of them. THIRD: I give, devise and bequeath all th~ hest, residue and remainder of my estate, whether real, personal or mixed, ~f',whatever kind or nature and wheresoever situate, in which I may have any ir~t~rest at the time of my death, including any property over which I may have a ~o~er of appointment, unto my children, MARGARET M. ROGERS, CHARLES E.P. MILLER MITCHELL A. MILLER, THOMAS P. MILLER, and my grandson, KIRK C. MILLER, in equ~lshares, per stirpes, subject to the guardianship and trust provisions hereinaf~e~^ contained. r;; ~., `~~ ~ i _~ t.~~ - . ~ :- = 4. a 7 ~ v~ ,,-~ I ' `G U f I ~. ~~ .._ ,__. ~, , o I ~ FOURTH: In the event my grandson, KIRK C. M~LLER, shall be less my-one (' 21) years of age when he becomes entitle ~o any share of my ~I -1- a ,~ !~ i ~~ ,. __ _ - _ _ __ _ _l ~_ `I sufficient deeds and bills of sale thereto. ~~ i, it '', I estate hereunder, I give, devise and bequeath that share to which he would otherwise be entitled unto CHARLES E.P. MILLER, in trust,'~n~vertheless, to invest and reinvest, and to pay all of the income and as tnu~h of the principal as may, in my said Trustee's sole discretion, be necessarly ~'or the health care, maintenance, support and education of my said grandson. ' ', Upon the attainment of the age of twenty-o#~el'~,(21? years by my said grandson, my said Trustee shall pay the remaining pr~.n~ipal and any undis- tributed income unto my said grandson, per stirpes, and s~a~l close and termin- ate this trust thereby. No beneficiary under the above trust shall',h$ve any power of anticipation, alienation, or assignment of any income andYo~ principal so to be paid to him and the same shall be paid to him personally,'o~ to the Guardian of his person, free from the interference or control of the ~r~ditors of such beneficiary. ', I FIFTH: I nominate, constitute and appoint'm~ husband, WILBUR K. DAVIS, to be the Executor of this, my Last Will and Testa#ne~t. In the event that WILBUR K. DAVIS is unable or ceases to act for any r~a~on whatsoever, then I nominate, constitute and appoint my son, CHARLES E.P. M~L~ER, to be the Executor of this, my Last Will and Testament. My herein-~a~n~d Executor is to serve without bond and I hereby authorize my Executor to jse~l any and all real estate, mixed or personal property, of which I may die po~s~ssed, to such I I person or persons, for such price or prices, upon such te~m~ and at such times as he deems advisable and to make, execute, acknowledge a~dldeliver good and . y ~~ -2- i! ~ '~ ~~ ~~ __ _ - I _ i ~ _:. IN WITNESS WHEREOF, I seal to this, my Last Will and Testa pages, the first two (2) of which be of identification this 5th day of Au s i ~~ r' ;~ .. .(- i~itness -3- AFFIDAVIT AND ACKNOWLEDGMENT We, the witnesses and Testatrix whose sig whose names are signed to the foregoing instrument, bein declare to the undersigned authority that the said Testa said instrument as her Last Will and Testament and that that she executed it as her free and voluntary act for t expressed and that each of .the said witnesses in the pre Testatrix signed the Will as witnesses and that to the b the Testatrix was at the time she signed said Will eight older, of sound mind and under no constraint or undue in res appear below and ly sworn, do hereby signed and executed signed willingly and urposes therein e and hearing of the of their knowledge, (18) years of age or nce. ~- . Davis ss I Ad ress r f ', ...~.~- - ~ ~I ~ress Subscribed, sworn to and acknowledged befole~me by the above signed Testatrix and the above signed witnesses this 5th ~ay~ of August, 1982. ~~llh A 'd L ~I ~rily~~. I'fxS:ori~ri~k,'Notary Y~lbta: i Girnrtl xo, ~ri~ i:oL~ty Penasylvsnie 1~~ ~y Ct+rrr,,issiGn !:n~lir$s Gx. 1a, 1Y~Et2 it ii i E~ :, a _ 1~.- _. _ _. _.. _.. .. - __. _ _. _._.. _ ._.. . _._.. ...._ .. ~ ~L, i __. _. _. ~ _