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HomeMy WebLinkAbout01-26-11 (3)J REV-1500 ex ~°1-1°' 1505610101 PA Department of Revenue Pennsylvania Bureau of Individual Taxes ~""~~"`~~""INHERITANCE TAX RETURN PO BOX z8o6oi Harrisburg, PA 1128-o6oi RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year File Number Date of Birth MMDDYYYY 04/03/1965 _ ___ Decedent's First Name MI _ _ ,CATHY........ __ _ _ A Spouse's Social Security Number Spouse's First Name MI "~ """ 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 Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 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 -THIS SECTION MUST BE C OMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name _~ _ _.. .... _. _ .._.__ ~_ __ .... Daytime Telephone Number ...y 3 _. WILLIAM,P.,DOUGLAS - 717-243-1790x.,_..,...... ~, REGISTER First line of address _ _ _ 43 W SOUTH STREET Second line of address City or Post Office State ZIP Code _. _ _. CARLISLE _ _ _ _ _ . ! PA 170"13 ~ k_ 1 G_, is •~~ :%;. ~ .~ -rl ~; _-~ 2~ DATE FILED __, ~. . -r3 _~ _i_~) -, . :~ `+ J ~~ _~ Correspondent's a-mail address: oedela~aaw~par#ktlinlE nr~# Under penalties of perjury, 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. SIGN E OF PERSON R P NSIBLE FOR FILING ET RN . ~ S~ ~ ~_~ ~~~~- ~)A~ _ DATE ADDRESS Side 1 1505610101 1505610101 USE QNLY ~~ P ., J~ 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: ' 174548576 RECAPITULATION 1. Real Estate (Schedule A) ............................................. L '. 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 'ii 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. '. 47387.33 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. I 47387.33 9. Funeral Expenses and Administrative Costs (Schedule H) ........... ........ 9. 11392.15 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ...... ........ 10. 11. Total Deductions (total Lines 9 and 10) ......................... ........ 11. 11.392.15 12. Net Value of Estate (Line 8 minus Line 11) ...................... ........ 12. ' 35995 18 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. ', 35995 18 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 _ _ 16. ,...... ... ~....... .,..~ ~~, ~ ._-._ . ~e ~~ .~ Amount of Line 14 taxable .y -_ _ at lineal rate X .0q~ _ 16. ~ 1619.78'. 17. Amount of Line 14 taxable o, m. at sibling rate X .12 17. 18. .~.~ .. Amount of Line 14 taxable ..... ~ ~ . _R, at collateral rate X .15 18. 19. TAX DUE ................................................. ........ 19.i 1619.78 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 J REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENTS NAME CATHY A. MENTZER __ STREET ADDRESS CITY STATE ZIP Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 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. Total Credits (A+ B) (2) (3) (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 1596 56 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 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 .................................................................................................................... ...... ^ ^ 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? ........................................................................................................ ...... ^ ^ 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? .................................................................................................................. ...... ^ ^ 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 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) p2 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, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER Cathy A. Mentzer 577 Include the proceeds of litigation and the date the proceeds were received by the estate. All property loirrtiyowned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Maranatha-Carlisle Financial Management Service $40,157.33 Account Number 10519 2. I Hoffman Roth Funeral Home Pre-Paid Funeral $7,230.00 TOTAL (Also enter on line 5, Recapitulation) I $ 47, 387.33 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Cathy A. Mentzer 577 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: ~, Personal Representative's Commissions Name of Personal Representative (s) Russell Mentzer & Cathy Mentrer Social Security Number(s)IEIN Number of Personal Representative(s) 183-12-4709 street Address 37 Kenwood Ave city Carlisle state PA Z;p 17013 2. 3. Year(s) Commission Paid: Attorney Fees Douglas Law Office Family Exemption: (If decedents address is not the same as claimant's, attach explanation) Claimant Street Address City State _ Relationship of Claimant to Decedent 4. Probate Fees Grant of Letters 5 Accountant's Fees 6. Tax Return Preparers Fees $2,369.00 $168.50 7. Cumberland Law Journal $75.00 8. The Sentinel -Advertising $261.88 9. Cumberland Goodwill -Ambulance Bill $179.51 10. Stokan Opthamology $44.38 11. Hoffman Roth Funeral Home $7,692.97 12. First Lutheran Church -Pastor $100.00 13. Food $175.00 14 Flowers $159.00 15. The Sentinel -Obituary $83.20 16. Carlisle Memorial Service -Plaque $50.00 17. Oakwood Radiation Center $18.71 18. Filing Fee Inheritance Tax Return $15.00 TOTAL (Also enter on line 9, Recapitulation) E 11.392.15 Zip (If more space is needed, insert additional sheets of the same size) REV-1513 EX + (g-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Cath A. Mentzer 577 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 Uansfers under Sec. 9116 (a) (1.2)] 1. Russell Mentzer Lineal 507 37 Kenwood Ave Carlisle, PA 17013 2. Betty E. Mentzer Lineal 507 37 Kenwood AVe Carlisle, PA 17013 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 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 $ (If more space is needed, insert additional sheets of the same size) CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 248166 Fax: (717) 248-2883 July 16, 2010 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: William P. Douglas, Esquire Cathy Ann Mentzer Estate RE: Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. ------------------------------------------------------------------ ------------------------------------------------------------------ Advertisement inserted on the following dates: July 2, July 9 and July 16, 2010 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 0 .00 Total Amount Due $ 75.00 Payment received by ro b ~ ~ ~ ~~ ~ i ~ ~ o i c-r ct N I ~ ~ i J I ~ I w I (D wl rt ~ I n W trJ I f-' W 'Z I N- (D H I (D ~ N I ~ LTJ I t-t = ~ i z n7 I ~ I N H I N- ~C I ~ ~ I A~ O I ~ I c-r n I ~ 4 ~m I 1 11 I V I ~N,1' (~ ~ ' 1 i m n I Ci' ~, I (~ I ~ I i Q i ~ I I (* I C I (1 (~ I ~ 0 n I ~ ~ CrJ I c-r ~ ~ ct O I z ~ I ~ ~- I ~ (n ~ I I ~ ~ d I N• ( 1 I H 1 1 t ~ ~ I--' i N i n~nr~~ ~ w\tn N C~O~~ H• dHF-' cn O L~ \o trJ~~O roxcnn ~ H ~ x ~ ~ ~C 0 w O LTJ Z H N ~~nnn I--'- I--'- (D (D (D ~ ~ n x~xxx fl ~ ~ Q1 ~ fD (D ~ fD ~' ~ n ~i ~ ~ . A~ (D rt . ~¢ ~ ~ . . n. . ~, . 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CARLISLE, PA 17013 717-243-1790 AD NUMBER PAGE NO. 385908 1 of 1 BILL DATE SALESPERSON 07/14/10 wolfs START DATE STOP DATE 06/30/10 07/14/10 AD NUMBER AD DESCRIPTION CLASS LINES 385908 ADMINISTRATOR'S NOTICE LETTERS OF 10 PUBLIC NOTICES 48 2 cols Publication Insertions Rate Net Amount Gross Amount 3 THE SENTINEL -LEGAL 3 LGL $254.88 TOTAL AD CHARGE $254.88 3 PROOF OF PUBLICATION 01PRF $7.00 Purchase Order Est. C.MentZer PAY THIS AMOUNT ~261.'?8 ~d ~~* i w.... ..~.. *AFTER 08/08/10 Thank you for advertising with The Sentinel! Deadline for in-column legal ads is 4:00 p.m. two business days prior to date of insertion. For questions, call (717) 240-7130. THE SENTINEL c/o LEE NEWSPAPERS PO BOX 540 WATERLOO IA 50704-0540 ~~~vl.~ ~~ a~~-~~ -cerurn rms poruon wnn your payment Check # ~ Credit Card ^ ®^ vt~ ^ ^ Acct #: Ems. Date: m m Name on credit card Signature Please make checks oavable to: THE SENTINEL c/o LEE NEWSPAPERS PO BOX 540 WATERLOO IA 50704-0540 Legal Ad Number 385908 Billing Date 07/i4/10 Amount Due $ 261.88 AuNleiunt Enclosed $ W~yykk ooosoz THE SENTINEL I'~ DOUGLAS LAW OFFICE c/o LEE NEWSPAPERS 43 W. SOUTH ST. PO BOX 742548 CARLISLE, PA 17013 CINCINNATI OH 45274-2548 ~r~n~r~t~nt~t~~ur~r~n~n~r~i~r~n~u~~n~u~n~~n~r~n~~~ 21540200000003859080000000000000003142600000261880 !05!2010 11:31 ~: 7175301338 I-RDLLAR AVE CumbeNand-Goodwill FireRescue Pfl BQX 9291(1 PHtLA, PA 19176-d91d phone #: (800 36T-0512 ~ederai Tax ID: 23-22gg~Z2 'ATIENT NAME: ~-I-~ MENTZEft ~suRAricE_ ~~fl~~~~ CATHI( MENTZER 7 E ORANGE ST SHIPPENSI9URG, PA 47257-4tifl9 PATIEi~T NUMBER. CALL NUMBER. DATE CIF CALL: TIME C~1"~ CALL: GALLE;i~ FRC)M: r©: REAS{3N(Sj FQR TRpNSP(TRT flit VC?tCE 11820 rii~~ i0122I20G8 PAGE 03 ~" ~~ f i ., ~~ NMCI SUP2 CARLf3LE REGIQNAL MEDICAL CTR MEADQWS PSYCHIATRIC CENTER PSYCHIATRIC DISOR[~ER/REtQI; DESCRIPTit)N OF CHARGE LiuANTITY UNfT PRICE gp~p},fhiT BLS NON EMERGENCY A0428 1.p 4pp_0{~ 400 ~ MILEAGE CHARGE A0425 94.4 _ ii_5D 1048,50 ~~~ ~~ _ ,;, .~ . ~ ~~ ~ ~ ~ c7 ~1,,~0 ~' ~ ~ ,S ~ ~~ DE$C:R#PTiC)N pF PAYMENT RECEIPT PAYMENT DATE AMOUNT Med~re Rssignment Adjustmerrk ~ t 1/18!,2409 _ 54$.9a Medicare Bark B Payment 109688879 i 1/78/2009 Tf>D.04 PLEASE PAY TIiIS AMOUNT ~- 17 .57 X5/2010 11:31 7175301338 I-IOLLAR AVE PRGE 02 STOKEN UPHTHALMOLOG'~ 33$ ALHXANDER SPRING RD_ CARLxSI.E, PA 1701.5 /14 I 36979 Return Service i4eguestad _ 2$646 CATHY A MENT2ER 7 EAST oRANCE ST SHIPPENSHITRG PA 17257-1909 44.38* • _ISC _VISA Diac Securitq Cards ~ ~„~ ~ Code _ Sign p f ST4fCEN €~PHTHALISOLOGY 338 A1.ExAAmE$ S~RZNG RD. CARLISLE, PA 17015 .L-- _ .: *** Pa Account Ha1a5~je7l~ed~ietel tb Avoid Coliectioa eia ttttli B/14/49 1 1 t. COMP NP 924f14 3dZ.04 175.Op q/ag~p9 Hedicars Pay~esnt, 97.53: gf08f09 Accept Asaian Add. -53.t]~S't 24.3$* B/14/49 1 1 REFRACTI(?N 92(115 362.134 20:.04 24.(}4* ~'v «_.~;,, ~ D ~ t'~~ ~ ~ ~~ ~~ , ~~ V