HomeMy WebLinkAbout04-07-11 1505610140
REV-1500 EX (01-10)
PA Department of Revenue
Bureau of Individual Taxes
Po Box 2sosol
INHERITANCE TAX RETURN County Code Year File Number
Harrisburg, PA 17128-0601
RESIDENT DECEDENT 2 1 1 0 0 3 2 7
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
4 3 7 7 0 1 1 3 4 0 2 0 8 2 0 1 0 1 2 0 5 1 9 4 6
Decedent's Last Name Suffix Decedent's First Name MI
BERGERON J R ARTH UR
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
CAROL B E R G E R O N B
Spouse's Social Security Number
5 3 0 5 2 5 2 2 6 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
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)
^X 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 -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
J O E L R. Z U L L I N G E R 7 1 7 2 6 4 6 0 2 9
REGISTER OF WILLS USE ONLY
First line of address ~ C"? --- .._~.., ~..':
r -Z7 ~;o r 7
1 4 NORT H MAI N STREET ~' f -i'~~ } `__7
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Second line of address
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City or Post Office State ZIP Code ~ _ __ _ DR?.E~~FILED W -~'
CHAMBER S B URG PA 1 72 0 1 `1
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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 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.
SIGNAT ~ OF PERSO RESPON E FOR FILIN URN DA ~ /
/ '
ADDRESS
410 FREEDOM DRIVE SHIPPENSBURG PA 17257
SIG RE F PREP ER HER T N REPRESENTATIVE D TE
r/
ADS SS ~
1 ORTH MA TREET, ITE 200 CHAMBERSBURG PA 17201
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 150561014() J
J 1505610240
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: ARTHUR BERGERON , JR 4 3 7 7 0 1 1 3 4
RECAPITULATION
1. Real Estate (Schedule A)
........................................... 1. 0 • 0 0
2. Stocks and Bonds (Schedule B) ...................................... 2. •
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. •
4. Mortgages and Notes Receivable (Schedule D) .......................... 4. •
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 n-Probate Property
(Schedule G) ~ S
Billi
t
R
epara
e
ng
equested ....... 7.
8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 0 . 0 0
9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9• 3 7 4 . cJ 0
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. •
11. Total Deductions (total Lines 9 and 10) ............................... 11. 3 7 4 . cJ 0
12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. - ~ 7 4 . rJ 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. - ~ 7 4 . rJ 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 0 0 0 15.
16. Amount of Line 14 taxable
at lineal rate X •0 0 0 0 16.
17. Amount of Line 14 taxable
at sibling rate X .12 0 0 0 17.
18. Amount of Line 14 taxable
at collateral rate X .15 0 0 0 1 g.
19. TAX DUE ................................ ............... ...... .19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610240 1505610240
0. 0 0
0. 0 0
0. 0 0
0. 0 0
0. 0 0
J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 10 0327
DECEDENT'S NAME
ARTHURBERGERON,JR
TREET ADDRESS
410 Freedom Drive
CITY STATE ZIP
Shippensbur PA 17257
Tax Payments and Credits:
~ ~ 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.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
Total Credits (A + B) (2)
(3)
(4)
(5)
0.00
0.00
0.00
0.00
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 : ...................................................................... ^ Q
b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q
c. retain a reversionary interest; or ................................................................................................ ^
d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ^ Q
3. Did decedent own an "in trust 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? .................................................................................................. ^ ^X
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)J.
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) [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, 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+ (01-10)
pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ARTHUR BERGERON , JR 21 10 0327
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 property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of the settlement sheet if the property has been sold.
ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1. NOTATION - At the time of filing probate for this estate, the decedent's spouse and
executor, Carol B. Bergeron, understood that title to the real estate situate at 410
Freedom Drive, Shippensburg, was in the name of Arthur W. Bergeron, Jr., as sole
owner. When the deed records were checked it was discovered that title was vested in
Arthur W. Bergeron, Jr. and Carol B. Bergeron, his wife. A copy of the deed is attached.
All assets were held jointly between husband and wife. There are no assets to be
reported with the filing of this return. 0.00
TOTAL (Also enter on Line 1, Recapitulation.) I $ 0.00
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09}
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
ARTHUR BERGERON , JR 21 10 0327
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B.
2.
3.
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP
Year(s) Commission Paid:
Attorney Fees: Joel R. Zullinger
Family Exemption: (If decedent's address is not the same as claimants, attach explanation.)
Claimant
4
5.
6.
7
Street Address
City State ZIP
Relationship of Claimant to Decedent
Probate Fees: Register of Wills -JCS fee 23.50; automation 5.00; letters 20.00;
will 15.00; short certificates 16.00; renunciation 5.00; filing return 15.00
Accountant Fees:
Tax Return Preparer Fees:
275.00
99.50
TOTAL (Also enter on Line 9, Recapitulation) I $ 374.50
If more space is needed, use additional sheets of paper of the same size.
REV-1513 EX+ (01-10)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF: FILE NUMBER:
ARTHUR RFRC~FR(~N .IR ~~ ~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 outs' ht spousal distributions and transfers under
Sec. 9116 (a) (1.2).]
1. Carol B. Bergeron, formerly Carol Marchand Spousal
410 Freedom Drive residue
Shippensburg, PA 17257
NOTATION: The decedent's will dated May 15, 1996, directs
that his entire estate be distributed to his fiancee, Carol
Marchand. Arthur W. Bergeron, Jr. and Carol Marchand
were married June 6, 2010. All assets of the decedent were
titled jointly with his surviving spouse, Carol B. Bergeron.
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN:
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
Ir more space is neeaea, use aaaltfonal sheets of paper of the same size.
~ ,
LAST WILL AND TESTAMENT
I, ~r~-~~,, ~ ~ ~~ r r- ~.~ ~~~~„ ,~Yo ,being of soL~nd mind and body, do IZereby
bequeath all my worldly possessions, including all retirement and insurance monies,
fiirniture and household goods, vehicles, bank accounts and any money or property
due from my divorce settlement to my fiancee, L_~. y ~ ( CYl ~ ~-~-t2a ~, A _____,
upon my death. This Will supercedes any and all previous Wills.
Signed,
C~~:,~._ ,.~.~ . ~ ~ e date s - ~ s'- ~ ~
-- 7..T -
~~
JRZ - 5.1 bergeron.f7
March 8, 2004
q ~ ~ 7 ~~~
March S, 2004
ISIS DEED
Tax Parcel No ..~ ~ ~ ~ `~ ~ ~~~ t ~~
MADE this ~ day of _ ~ ,
2 dG ,
Betweea
J. GARY RINE AND VIRGINIA B. RINE, his wife, and DARRIN G.
RINE AND LORETTA L . RINE, his wife, hereinafter whether one or more
referred to as "GRANTGIR."
Aad
ARTHUR W. BERGERON, JR., and CAROL B. BERGERON, his wife, of
Cheater, Virginia, hereinafter whether one or more referred to as
"C3RANTLE, "
WITNESSETH, that in consideration of the sum of One Hundred
Fifty-eight Thousand Nine Hundred ($158,900.00} Dollars, in hand
paid, the receipt whereof is hereby acknowledged, the said Grantor
does hereby grant and convey in fee simple to said Grantee
ALL the following described real estate, together with
improvements thereon erected, lying and being situate in
Southampton Township, Cumberland County, Pennsylvania, more
particularly described as follows:
BEGINNING at a point at the easterly edge of Freedom
Drive at corner of Lot F- 8 on the hereinafter referred to
plan of lots ; thence by said Lot F- 8 , North 7 9 degrees 3 9
minutes 0 seconds East 130 feet to an iron pin at corner
of other lands of the Grantor herein; thence by said
other lands of the Grantor herein, South 10 degrees 21
minutes 0 seconds East 90 feet to an iron pin at corner
of Lot F-6 on the hereinafter referred to plan of lots;
thence by said Lot F-6, South 79 degrees 39 minutes 0
seconds West 130 feet to an iron pin on the easterly edge
of Freedom Drive; thence with the easterly edge of
Freedom Drive, North 10 degrees 21 minutes 0 seconds West
90 feet to an iron pin the place of beginning, containing
11,700 square feet.
BEING Lot F-7 on subdivision plan prepared by Carl D.
Bert dated April 10, 2002, entitled "Land Subdivision for
Rine Estates, Phase VII," and recorded in Cumberland
County, Pa., Plan Book 86, Page 29.
P
THE above-described real estate is part of the same which
Richard E. Railing and Dorothy J. Railing, his wife, by
deed dated August 11, 1998, recorded in Cumberland
County, Pa . , Deed Book 183 , Page 607 , conveyed to J . Gary
Rine and Virginia B. Rine and Darrin G. Rine and Loretta
L. Rine, the Grantor herein.
SUBJECT to the provisions of the declaration of covenants
and restrictions for Rine Estates Subdivision, Phases I
and I I , dated October 2 , 1998 , and recorded in Cumberland
County, Pa., Deed Book 590, Page 1071.
SUBJECT FURTHER to the conditions, restrictions,
notations, and easements as shown on the aforementioned
plan of lots as fully as if written out at length herein.
AND the said Grantor hereby warrants specially the property
herein conveyed.
IN WITNESS ~R8OF, the said Grantor does hereby set his hand
and seal the day and year first above written.
Witness:
~..J ~ .
;Seal)
Seal)
(Seal)
STATR OF PSTTNSYLVANIA:
covNTx of ~~~~~~
On this the ~ day of , 25~~ before me the
undersigned officer, personally a eared J. Gary Riae aad Virginia
8. Rine, his wife, known to me (or satisfactorily proven) to be the
persons whose names are subscribed to the within instrument, and
acknowledged the foregoing deed to be their act and deed and
desired the same to be recorded as such.
_ I;Seal)
Gary ine
6aQf( G~;~ PACE &~9
M~
r
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Witness my hand and official seal the day and year first above
written.
COMMONWEALTH OF PENNSYLVANIA Not Pub 1 i c
No~arlal Seal
Nid~o~e,1. tce~e~ Nohary Public NI commission expires
~BaioE~C~Ctxx~ty I maintain my office in
MsmbK, Pennsylvenie Assodation Of Notsrfes
STATE OF PENNSYLVANIA:
COUNTY OF
On this the ~,~ay of 2 ~ before me
a notary public, personally app ared Darrixt d. Riae as Loretta L.
Riae, his wife, known to me o satisfactorily proven to be the
persons whose names are subscribed to the within instrument and
acknowledged that they executed the same for the purposes therein
contained.
In Witness Whereof,
COMMONWEALTH OF PENNSYLVANIA
Notartel Seal
t~d~cle J. Kellett, Notary Pubic
SNppe~~ebtxp Bav, C~mberlar>d County
My Cornnhelor+ Eycpirea Sept. 3, Z~QY
Member, PAnnevivanin Assodetion Of Noterie3
I hereby certify that Grantee's precise residence and post
office address is:
Dated:
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otary Public
My commission expires:
I maintain my office in:
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