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Home My WebLink About02-09-111505610143 REV-1500 Ex(ot-1o> ~ OFFICIAL USE ONLY County Code Year File Number PA Department of Revenue Pennsylvania Bureau of Individual Taxes ~""""r'"ENTOFRE1EN1E Po Box.28oso~ INHERITANCE TAX RETURN 21 0 9 7 58 Harrisburg, PA 17128-o6ot RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Date of Birth Social Security Number Date of Death 197 09 6180 07 31 2009 09 29 1917 Suffix Decedent's First Name MI Decedent's Last Name W THOMAS ~~ (If Applicable) Enter Surviving Spouse's Information Below MI Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ^ 3, Remainder Retum (date of death rn l R t 1. Original Return ^ u e 2. Supplementa prior to 12-13-82) ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required 82 12 ^ 4. Limited Estate ) . (date of death after 12- B Decedent Died Testate f Wilq ^ 7• ~gtt~e~opy of~rust)a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy o ^ 9. Litigation Proceeds Received ^ 10~ betweenP2=3i ~J1 a d~t~(dacaesadeath ^ 11. Attach Sch O) nder Sec. 9113(A) BE DIRECTED TO: rrNe AX T CTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL CORRESPONDENT -THIS SE tt D y Telephone Numbe Name 717 691 9808 WAYNE M PECHT ESQ ~•., REGISTERILLS US)~~NLY~ ~~ r ~ _ First line of address r `rm I ~~} ~ w ~, ~, :, `_~ 1205 MANOR DRIVE t `~: %c7 `- r ' Second line of address t } r~~ ~ _-i ,~ ~ _ ~ ~ _~ ~ ` SUITE 200 `' DATE FILED r' ' `"'~ -~~ City or Post Office State ZIP Code MECHANICSBURG PA 17055 w ech echtlaw.com Correspondent's a-mail address: p ~p it s true correct and complete~Demclahation of prepares ottrler tfian the personal re~poresentaytive Is based oral d inforrnation~of which prepares has any knowledge.~iief, DATE GNATURE OF PERSON R SPONSIBLE FOR FILING RETURN e+ ~ ~~~ Donna M Schle el ADDRESS 61 Hella Drive M anicsbur PA 17055 DATE SIGNA RE PREPARER OTHE HAN EPRESENTATIVE ,~ /( ,, ~ ~,~~ Wayne M. Pecht Esq ,~~ 7~ j 1205 Manor Drive, Suite 200, Mechanicsbur , PA 17055 1505610143 Side 1 1505610143 J 1505610243 REV-1500 EX Decedent's Social Security Number oecedenYsName: Thomas, Adam W 197 09 6180 RECAPITULATION 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 & Notes Receivable (Schedule D) ....................................................... . 4. 238,341.08 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .............. . 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous I~oq Probate Property (Schedule G) u Separate Billing Requested............ 7. 8. Total Gross Assets (total Lines 1-7) .................................................................... . g, 238 , 341.08 26,735.16 9. Funeral Expenses 8~ Administrative Costs (Schedule H) ...................................... . 9. 1,278.33 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................. . 10. 28,013.49 11. Total Deductions (total Lines 9 & 10) .................................................................. . 11. 12. Net Value of Estate (Line 8 minus Line 11) ......................................................... . 12. 210,327.59 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .............................................. . 13. 210 , 32 7 . 5 9 14. Net Value Subject to Tax (Line 12 minus Line 13) ............................................. .. 14. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15 (a)(1.2) X .00 . 16. Amount of Line 14 taxable 210 , 32 7 . 5 9 16. at lineal rate X .045 17. Amount of Line 14 taxable 0 00 17 at sibling rate X .12 . . 18. Amount of Line 14 taxable 0 0 0 18 at collateral rate X .15 . . 19. Tax Due ................................................. ................................................................ . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 1505610243 0.00 9,464.74 0.00 0.00 9,464.74 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-09-758 DECEDENT'S NAME Thomas, Adam W STREET ADDRESS 61 Hellam Drive CITY Mechanicsburg STATE ZIP PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 9,464.74 B. Discount 0.00 3. Interest (1) 9,464.74 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 Line 20 to request a refund g, If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. Total Credits (A + g) (2) 9,464.74 (3) (4) (5) ~.~~ Make Check Pa able 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 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 :.................................. ^ ^x . ..... ........................................................................... ~ x c. retain a reversionary interest; or ............................. ^ ^ 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 "intrust for' or payable upon death bank account or security at his or her death?....... ^ ^x 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, 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 January 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 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 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 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, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-7508 EXt (8-98) SCHEDULE E CASH, BANK DEPOSITS, i& MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF - (FILE NUMBER Thomas, Adam W 21-09-758 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with the right of survivormhip must be disclosed on schedule F. (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) REV-1151 EX+ (10-05) COMM_QNEWRF~g4Ttl Q~p,P~F~N~IT~RNANIA nnRESIIID EnN4~DEC EDF~N SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Thomas. Adam W 21-09-758 Debts of decedent must be reported on Schedule 1. ITEM DESCRIPTION AMOUNT N R A, FUNERAL EXPENSES: 7,625.59 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Donna M. Schlegel Street Address 61 Hellem Drive city Mechanicsburg state PA zio 17050 Year(sl Commission oaid 2009 10,000.00 2, Attorney's Fees Pecht 8 Associates,PC 8,000.00 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, Cumberland County 360.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 425.00 7. Other Administrative Costs 324.57 TOTAL (Also enter on line 9, Recapitulation) 26,735.16 Copyright (c) 2009 form software only The Lackner Group, Inc. Forth PA-1500 Schedule H (Rev. 10-06) Rev-1512 EX+(12A8) gCNEDULE ~ DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF 21-09-758 Thomas, Adam W Repoli debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbunsed medical ezpenaes. VALUE AT DATE ITEM DESCRIPTION OF DEATH NUMBER Meadows Association - t C Assisted Living Residential Community 866.20 ry oun 1 40.00 2 Darren Barbecci -Podiatrist 12.13 3 Veizon -Telephone Service 360.00 4 Visiting Angels -Caregivers l TOTAL (Also enter on Line 10, Recapitulation) 1,278.33 (If more space is needed, additional pages of the same size) Form PA-1500 Schedule 1 (Rev. 12-08) Copyright (c) 2009 form software only The Lackner Group, Inc.