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HomeMy WebLinkAbout02-04-11 (3)__ ~' 15056101,40 REV-1500 EX (01-10) PA Department of Revenue OFFICIAL USE ONLY County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 2 1 1 0 1 2 5 4 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 2 0 3 1 0 4 0 6 2 1 1 0 4 2 0 1 0 1 2 1 0 1 9 2 0 Decedent's Last Name Suffix Decedent's First Name MI F L O '~ D D A L E L (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First NamE~ MI F L O 'I~ D V I R G I N I A S Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 1 7 9 1 2 3 3 1 o REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return ~ 2. Supplemental Return ~ a. Remainder Retunn (date of death prior to 12-13-82) Q. Limited Estate ~ 4a. Future Interest Compromise (date of ~ !i. Federal Estate Tax Return Required death after 12-12-82) 0 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust F3. 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. J113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - TH15 5EG iIUN MU51 tit GUMI'Ltt tU. ALL GUKKt51'VNUtNIa HNU WNrwtN r rH~ r H~ rrvrvrcmr~r rvrv ~n~ruw ar urRr_~ ~ w ~ v. Name Daytime Telephone Number ~~ , ~ R O G E R B I R W I N ~I 2 ~_~ 5 3 7 1 7 ~, , ~ _ ` , REGISTER OFtNI1~l,~S USES ONLY `,_~ ~ r : , First line of address _ , .. ._. 6 0 W E S T P O M F R E T S T R E E T ~ ~~ - ~` ~ .~ ~-~ Second line of address r r. _ ~ ; ...~ . ~ ~-~~ ~: E ~ ~~ City or Post Office State ZIP Code , __ DATE FIt.ED_ C A R L. I S L E P A 1 7 D 1 3 Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowierdge ~rnd belief, it is true, correct and romplete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DNl E ADDRESS 612 WILSON STREET CARLISLE PA 1701,3 SIGNATURE F,h~REPARER OTHER T~N REPRESENTATIVE pA] E ADDRESS ~', 60 WEST P6MFRET STREET _ CARLISLE PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 150561,0140 _~.. J 1505610240 REV-1500 EX Decedent's Social Security Number 4 0 2 0 3 1 0 6 2 ~eceaent's Name: DALE L• F L O Y D __ RECAPITULATION 1. Real Estate (Schedule A) ......................................... .. 1 ~ • 2 1 6 2 t] ~ 4 . 3 0 2. ........................... Stocks and Bonds (Schedule B) _ .. , _ .. , _ . 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. • 4. Mortgages and Notes Receivable (Schedule D) ............... ........ .. 4. • E' ~~ ~J ' S 0 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. • 7. Inter-Vivos Transfers & Miscellaneous N Probate Property (Schedule G) ~ Separate Billing Requested ..... .. 7. • 8. Total Gross Assets (total Lines 1 through 7) ........................ ... 8. 1 6 2 ? 4 4 . 8 0 9. Funeral Expenses and Administrative Costs (Schedule H) ........ 9. 1 7 f3 ~ D . 9 9 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... 10. `j 1 D ' 1 1 11. Total Deductions (total Lines 9 and 10) ......................... ... . 11. 1 8 ~~ 4 1 • 1 D 12. Net Value of Estate (Line 8 minus Line 11) ...................... ... .. 12. 1 4 4 0 ® ~ . ~ 0 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 4 4 D 0 ~ . 7 0 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 D . D D 15. 16. Amount of Line 14 taxable 1 4 4 D D 3 7 ~ at lineal rate X •045 16. 17. Amount of Line 14 taxable D D D 17 at sibling rate X .12 . 18. Amount of Line 14 taxable 0 0 D at collateral rate X .15 18. 19. TAX DUE .. ........... ............................. ..... .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 150561D24D C I . 0 0 IO l'} 8 ^ C') e 1 I(~ a. o a D. D 0 6 4 ~8 0. 1 T 150561240 ti REV Page 3 'Decedent's Complete Address: File Number 21 10 1254 DECEDENT'S NAME ---- DALE L. FLOYD _ STREET ADDRESS ----- --- - ---- ----- 1000 WEST SOUTH STREET -----_-- CITY __ -~--- STATE --- _- j ZIP CARLISLE f'A ' 17013 LM Tax Payments and Credits: ~. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 324.01 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. (1) 6,480.17 324.01 (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) _N 6,156.16 Make check payable to: REGISTER OF UUIILLS, AGENT 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; ................................ ^ Q c, retain a reversionary interest; or ................................................................................................. ^ 0 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? ......... ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................ .......................................................................... ^ Q 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 tl'ie use of the surviving spouse 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 U 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 youncler 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, rioted 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)]. Asibling is defined, undE Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Total Credits (A + 13) (2) (3) REV-15('!3 E-:~~ + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OE FILE NUMBER DALE I_. FLOYD 21 10 1254 _w All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION ___ 01= DEATH 1. M&T INVESTMENT GROUP -ACCOUNT NUMBER 412870602 162,094.30 TOTAL (Also enter on line 2, Recapitulation) ~ 9~ 162,094.30 (If more space is needed, insert additional sheets of the same size) RE`,l-15(18 C}; -~- fr-9F' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY _ ESTATE OF FILE NUMBER DALE L. FLOYD 21 10 1254 _ Include the proceeds of litigation and the date the proceeds were received by the estate. N All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. M&T INVESTMENT GROUP -CASH -ACCOUNT NUMBER 412670602 650.50 TOTAL (Also enter on line 5, Recapitulation) I $_ 650.50 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-09) Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE ®F FILE NUMBER DALE L. FLOYD 21 10 1254 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A, FUNERAL EXPENSES: __ 1. HOFFMAN-ROTH FUNERAL HOME 5,233.49 2. FUNERAL LUNCHEON 150.00 B, ADMINISTRATIb'E COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State _ ZIP Year(s) Commission Paid: 2. Attorney Fees: IRWIN & McKNiGHT, P.C. 8,250.00 3. Family Exemptian: (If decedents address is not the same as claimant's, attach explanation.) 3, 500.00 Claimant VIRGINIA S. FLOYD Street Address 1 TODD CIRCLE City CARLISLE State PA _ ZIP 17013 Relatianship of Claimant to Decedent SPOUSE 4. Probate Fees: REGISTER OF WILLS 317.50 5 Accountant Fees; 6. Tax Return P~eparer Fees: PATRICIA A. ROSENDALE, CPA 350.00 7. REGISTER. OF WILLS -FILING FEE 30.00 TOTAL (Also enter on Line 9, Recapitulation} $ 17.830.99 If more space is needed, use additional sheets of paper of the same size. REV-151? EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER DALE L. FLOYD 21 10 1254 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed rriedical expenses. ITEM ~ VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. SARAH TODD -NURSING 890.11 2. IDR. ALAN HUFF -DENTAL ~ 20.00 TOTAL (Also enter on Line 10, Recapitulation; I $_ 910.11 If more space is needed, insert additional sheets of the same size. RE:V-1513 EX+ (01-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: FILE NUMBER: DALE L. FLOYD 21 10 1254 RELATIONSHIP TO DECEDENT _ ~ AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTp,TE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under _ M Sec. 9116 (a) (1.2).] 1. VIRGINIA S. FLOYD Spousal 1 TODD CIRCLE CARLISLE, PA 17013 DISCLAIMED IN WHOLE ALL OF HER INTEREST IN THE ESTATE TO CAROL A. ZEIGLER AND NANCY K. BENNETT 2. CAROL A. ZEIGLER Lineal 72,001.85 612 WILSON STREET 1/2 REMAINDER CARLISLE PA 17013 3. NANCY K. BENNETT Lineal 72,001.85 11 DUNCAN DRIVE 1/2 REMAINDER HOLMDEL, NJ 07733 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HE:E:T~, ,AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN: 1. 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ;p Ir more space Is neeoeo, use aoaltlonai sheets of paper of the same size. ~. r-- c~ Z ~ ~~ Q ~ t.~ f-- Q C~ r o_ w~ ~~ w ~, Qo ~.- --+ N ~ ~It C1- V ~ t- a "~ m d Z t-W~ ~ ~~~ G~ ate, F.. Q .- N c!7 ~ r ~ ~ a 4 ~ ~~ , ot5 C~ 4 u.i Z "'°z~ =~ ~~~ cy r w ~', a.. ~ N ~ Z~ d r3 r ~~ Z `" 7 O i'- © ~,y T- >" "~ ,4 o ~a "- v w J -~ p M WQd --~ t^ 4 ~.-tJ 0 ~~ ~~ c°~ --- V N p N .-- Q~ N~ 7 ~' c'- ~J ~~ d t~ V H ti ~ O 4 Z H~ Ny ~ O y ~ vy -. r- 0 <r r~ N N O O Q U? c~ d' f a 0 N N 0 0 0 O N O O Q c3 C] co CO t- O O .- ~~ ~_ ~~ "'" ;' ~_ ...~ r~ r v~ co rn T 0 0 N N O O O O N O O O O O cD rn O O T f f ~___ ~ ~ ' ~ ~ r '~ r' ~ ~ pp ~ r ~r ' ~ •. . r a .. ': ~ = . k- z _,,, N o r- ~ t,, ~ - 0 o z ~~ ' ~ . oQ . -_ - . - ~' ~• ~- ~. • t!) - ~ >" ~ Ems,,. .~-! 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O : p G to ~ ~" c3' ~ ~•.,~ C ° v ~ f z ''"' rn ~``}~~` ~ l? . .,~ O o ~ ~ ou o a r o ~- ~ ~ .~- 4 ~ r` ; ~C1 d ~ ~ ~ T' t~C) d' Z N "r { ~ a0 tC c4 CL r 7 Q Z O --~ Q H r-{ U Z U LL1 ty J Q. 7 Y w ~. --a 5 W a i cc 0 d ~ i~ .~ ~~ u.~ y' ~~ Q ~~ ~z off, Y o ~; ti ~ ~ 2 ~ 4 ~ S ~ a = v ~. . ~ 2 N ~ d ~ J c~ ~ r -- z cn ~ °~ m a Q ~ a ~ yyi ~ ~ Q Y i3 ~ ~ O ~ t m -- QUALIFIED DISCLAIMER In accordance with Internal Revenue Code Section 2518 (b) and pursuant to Section 62,01 of the Pennsylvania Probate Estate and Fiduciaries Code, (20 PA.C.S.A. Section 6201), this Qualified Disclaimer is being executed by the undersigned beneficiary, VIRGINIA S. FI~O~'D, in order to disclaim in whole all of her interest in the ESTATE OF DALE L. FLOYI): The undersigned, as one of the beneficiaries in the above-referenced Estate is 1herE;by disclaiming her interest in the estate in favor of the Decedent's children., CAROL A.:ZEIIsL1~R and NANCY K. BENNETT, as evidenced by the undersigned's execution hereof. S~ This disclaimer is executed as of this ~_ da;y of January, 2011, the same being effective as of the date of death of the decedent, Dale L. Floyd on November 4, 2010. WITNESS: r ) VIRGIN .. S. FLOYD COMMONWEALTH OF PENNSYLVANIA SS COUNTY OFCUMBERLAND S ~" C}n this, the 3 f day of January, 2011, before me, t:he undersigned officer, personally appeared Virginia S. Floyd, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. Iri witness whereof, I hereunto set my hand and official seal. ~, - n COMMC7i~~lV~E=l~LT~Fi JF PENNSYLVANIA, --~ ~`'~~~~' ~Y~" ~ ~'L"''SEAL) _.. ~~ ivotar~a. Seal Notary Public Jessica i_. Pc~ese, lVciary public ~Cariisle Boro, Cumberiand bounty My CammissiQn expires ~`~ral 26, 2011 N~,iamb~~, F~c~rzn ,~~#v~z7i~z ,~ sraait~tion of fdotaries Sarah A Todd Memorial Home 1000 West South Street Carlisle, PA 17013 Telephone: (7~_7) 245-2187 Dale Floyd 1 Todd Circle, Apt. B Carlisle, PA 17013 STA,T E N1 E N T Statement Date: 12/10/2010 Due Date: 12/25/2010 Amount Enclosed $ Account. #: 101676 RE: Dale L Floyd .. -Date E ~Y, -_..___-~ v g~ .D scr~ :fia "::s3 ~.r ~~ '~. . .. .,_n. ~ ~ uan# ~ . ~~~ Rate q u .;,__,. Car es ._._.. .__. .. ~~ ~hmen#s .._.__._ Bala ces ,...~._T _tl.__.. Balance B/F 874.80 874.80 11/03/1.0 Incontinence Supplies 1 8.88 8.88 883.68 11/03/].0 Medical Supplies 1 6.'43 6.43 890.11 ! (~ I ~ ~f , ~V ~- ^ ~ I v i i Currenlt 1-30 Days 31-60 Days 61-90 Days wer 90 Days Amount Due .00 __~ 15.31 874.80 _ _ .00 .00 °y. ~0, ~ ~ _~~~ IVV I t: "°""T F'HT I~ItIV I 15 UUt UF'UIV Ktl.t1F' I TT~'"^' tSU I IVV W I tK THE 25TH OF TFiE MONTH ***** Please remit the LAST AMOUNT your statement. Include the ACCT# from the statement on the MEMO Statement Date: 1;?/10/2010 of your check. Payrrlents after 12/08/10 do not reflect on statement. NOTE: ** LATE PAYMENTS ARE SUBJECT TO A 1.25% LATE CHARGE PER Due Date: 12/25/2010 A $10.00 FEE W:[LL BE CHARGED for RETURNED CHECKS ** Dale LFloyd -Account # : 101676 Sarah A Todd Memorial Home 1000 West South Street Carlisle, PA 17013 Telephone: (717) 245-2187 ALAN C. HUFF, DDS 6780 Lehigh Ave. Harrisburg, PA 17111 1-866-807-7161 (Toll Free) r ~~,le ~Ioy~l ~~Gh~"5 ~---- Date Services Rendered Fee ULiI (~ V C{ I Vl/- J' ~ ~S~Ga ~ ~~ ~ ~®ta~ ~.- ::,;;~, S~ ~~ 'Y`~' Carlisle brethren In Christ Church } ~ ~ 1155 WaMnut Bottom Road Phone: 717-243-1363 Cnrlisle, PA 17015 Invoice 11/9/201() Bill To: Carol Zeigler Funeral Service: Please make check payable to: Dale Floyd Carlisle BIC Kitchen Fund ~ Dnte Description # of people Payment Balance I ----f ------- -- - - -------- -- 11/9/2010 Luncheon 50 $3.00/Person $150.00 Hnm & Cheese Sandwiches Chicken Salad Sandwiches ---- ---------- Pasta/Potnto Salad --- Chips -- ~ , /; ~, ~ ~ ~ -- --- -------- -~ _ l `--- ~-.-___- Pickles - - ~ , -~ ~ -------- --- Coffee/Ice Tea/Wnter Cake L-- ----- -- --- - ---- ------ Total ---- $150.00 Carlisle BIC Kitchen Committee __ _ _ ~ t~ ~~~ ~ ~ Z / ~ FUNERAL HOME & CREMATORY, INC. Mrs. Virginia Floyd 'I Todd Circle Carlisle, PA 17013 Statement of Funeral Expenses for: Dale L. Floyd :? 19 Nc~rth Nanover Street Ca~iisle, PE~nnsywania 17013 717.243.4511 toll fre+= 1.8+56.451.4511 fax 717.243.3723 wvnN.hoffmanroth.com infoQhoff'~anroth.com November 15, 2010 Date of Death: November 4, 2010 Account Id: 16080-257 PACKAGE: Traditional Funera{ Service TRADITIONAL FUNERAL SERVICE PACKAGE $ 4,550.00 Sub Total: $ 4,550.00 TOTAL FUNERAL HOME CHARGES: $ ----- 4,550.00 CASH ADVANCES: 4 Certified Death Certificates at $ 6.00 each $ 24.00 Newspaper Notice -Sentinel $ 163.77 Additional Death Certs $ 24.00 Clergy 2 @100 Ea $ 200.00 Flowers $ 171.72 Organist $ 100.00 Sound Tech $ 100.00 Sub Total: $ 783.49 Total Funeral Expense: $ 5,333.49 Total Payments Made: $ 759.49 Payments Made: Virginia Floyd Check 235 Nov 15, 2010 759.49 Balance: Please return this portion with your Remittance. ,,,~,~.c.-~-~,,~,z~~-~._ ,~rv~ ~.~~,~~~«~ $ Amount Enclosed ('_c~.~ (~ i~ r~O~~_~~ ij Dale L. Floyd c~ ~/ ~"~ ~~% -~-- Service ID#: 16080-257 / ~=~-_ SERVING OUR COMMUNITY SINCE 1 907