Loading...
HomeMy WebLinkAbout04-13-11EX (01-10) REV-1500 PA Department of Revenue Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 1 7 1 28-0601 1505610148 OFFICIAL USE ONLY _ County Code Year File Number INHERITANCE TAX RETURN 2 ], 11 D 3 41 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY 561-54-3955 ~20520Q5 Decedent's Last Name Suffix CONCEPCION (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Social Security Number FILL IN APPROPRIATE BOXES BELOW ® 1. Original Return ^ 4 i i . L m ted Estate ^ 6. Decedent Died Testate (Attach Copy of Will) ^ 9. Litigation Proceeds Received ^ 3. Remainder Rel:urn (date of death prior to 12-13-t32) ^ 5. Federal Estate 'Tax Return Required 8. Total Number of Safe Deposit Boxes ^ 11. Election to tax under Sec. 9113(A) (Attach Sch. O) Date Of Birth MMDDYYYY 04051922 Decedent's First Name M I VINCENTE Spouse's First Name M I THIS RETURN MUST BE FILED IN DUPLICATE WITH 1'HE REGISTER OF WILLS ^ 2. Supplemental Return ^ 4a. Future Interest Compromise (date of death after 12-12-82) ^ 7. Decedent Maintained a Living Trust (Attach Copy of Trust) ^ 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number CRAIG A• HATCH, ESQUIRE 717-731-9600 First line of address 101,3 MUMMA RD, STE 100 Second line of address City or Post Office LEMOYNE State ZIP Code PA 1,7043 Correspondent'se-mail address: C - HATCHBGATESLAWFIRM • COM ` ~°r --~ -'j l .--, Under penalties of perjury, I declare that 1 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 represe tive is based on all information of which preparer has any knowledge. SIGNATURE nF PERSON RESPONSIBLE FOR FILING RETURN DAT MANUELA MELVILLE, ADMR . ~~ ~,~ ~ ~ ~' p~ ADDRESS 5251, MEADOWBROOK DRIVE MECHANICSBURG, PA 17050 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE 'DATE f_, CRAIG A • HATCH, ESQ • CJ ~~'~,~ (~~~ ADDRESS 101,3 MUMMA RD • , STE • ],00 LEMOYNE, PA 1,7043 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610148 1505610148 9M4647 4.000 ~~ REGISTER OF WnLLS USE ONLY n ~:: •--- ~~ ~.:? -~ - . ~~ ~.. . .., ,- .-->~ _ ;_,.~ D~l71: FILED . .. -: ~~ J 1505610248 REV-1500 EX Decedent's Social Security Number 561-54-3955 Decedent's Name: CONCEPCION VINC ENT E RECAPITULATION 1. Real Estate (Schedule A) 1 $ 0 • 0 0 2. Stocks and Bonds (Schedule B) . 2 $ 0 , 0 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) , 3 $ 0 • 0 0 4. Mortgages and Notes Receivable (Schedule D) , 4 $ 0 • 0 0 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) 5, $ 0 , 0 0 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested g, $ 0 , 0 0 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested 7. $ 0 • 0 0 8. Total Gross Assets (total Lines 1 through 7) 8 $ 0 • 0 0 9. Funeral Expenses and Administrative Costs (Schedule H) , , 9 $1 , 0 5 6.5 0 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) 10. $ 0 • 0 0 1 1. Total Deductions (total Lines 9 and 10) , 1 ~ $1, , 0 5 6 •5 0 12. Net Value of Estate (Line 8 minus Line 11) 12 ($ ], , 0 5 6.5 0 ) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) , , 13, $ 0 • 0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) , 14 ($ ], , 0 5 6 • 5 0 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES y 15. Amount of Line 14 taxable at the spousal tax rate, or transfers un~er Sec. 9116 (a)(1.2) x .o - $ 0.0 0 15. $ 0.0 0 16. Amount of Line 14 t xable at lineal at X 0 4 ~ r . e $ 0 • 0 0 16. $ 0 • 0 0 17. Amount of Line 14 taxable at sibling rate X .12 $ 0 . 0 0 17. $ 0 • 0 0 18. Amount of Line 14 taxable at collateral rate X .15 $ 0 • 0 0 18. $ 0 • 0 0 19. TAX DUE 19. $ 0 • 0 0 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610248 1505610248 J 9M4648 4.000 REV-1500 EX Page 3 Decedent's Complete Address: File Number ai. i. i. n~u-I. DECEDENTS NAME CONCEPCION VINCENTE STREET ADDRESS MBER AN CITY MECHANICSBURG STATE PA ZIP 1,7050- Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments $ 0 - 0 0 B. Discount $ o . o 0 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) $o•oo $o.oo (3> $ 0.0 0 $o.oo (5) $ 0.0 0 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: 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? . Yes ^ ^ l rrNo'' ~~ L~.I~J L~-J L~J 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. X9116 (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. X9116(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. Total Credits (A + B) (2) 9Md671 2.000 REV-1502 EX+ (Ot-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF: FILE NUMBER: Vincente Concepcion 21 11 0341 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. swasss 2.00o 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 Vincente Concepcion 21 11 0341 Decedent's debts must be reported on Schedu{e I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~ . None B. 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Years} Commission Paid: 2. Attorney Fees: $1, 000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address 4 5 6 7 City State ZIP Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Preparer Fees: None $56.50 TOTAL (Also enter on Line 9, Recapitulation) ~ $ $1 , 056.50 swasAC 2.00o 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 ESTATE OF FILE NUMBER: vincente Conce cion 21 11 0341 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE 1 TAXABLE DISTRIBUTIONS [InGude outright spousal distributions and transfers under r Sec. 9116 (a) (1.2).] 1, Manuella Melville 5251 Meadowbrook Drive Mechanicsburg, PA 17050 Daughter $0.00 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 1 8 OF REV-1500 COVER SHEET, AS APP ROPRIATE. [[ NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET, $ $ 0.00 SCHEDULE J BENEFICIARIES Ir more space Is neeaea, use aooitlonal sheets of paper o1 the same size. 9W46A1 2.000 DEATH CERTIFICATE I tll~ IS To C('I-I]TV Tfl~l_l. II~I'~ `IL`t'I-1~~~1Tlol1 [1C~"( ~3~'C]l 15 CC31Tf'Clly CC)~~tl.t} Ill)lll ~tll C?1~1~~lil;tl CCIt)L1F'~itt' t~l Ul-:(ill ~tl(; jl 11~C-Ct iV/IU1 li~L ilk LOC3~ ~~~lti~t'ill-. 7 ~7t' oTi~'I'1~1~ C(7-liflCilte `Jt/ill ~1t'. TOl-WiU~C~t'C~ ~~~ 111 f' Still(' ~It~ll IiCCOI~~ t.~i~f,CC" ~(li~ ~lt:`I'IIl~Ittt~ll~ il~lli~f. V11A,~NING: It is illegal to duplicate this copy ~iy photostat cr photagr~(pl~. Fee for ti`~is certificate, $6.00 ~~,. H105 tai Rev 2lB7 TYPEIPRINT IN PERMANENT BLACK INN N Q a 2 O w U W O tL O w a (~, Local RcRisirart- c ~ ~~~ ~ ~- ~ ~~ ~.~ ~______~ ~<<te COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH NAME OF DECEDENT (First, Middle. Lest) SEX SOCIAL SECURITY NUMBER ! GATE OF DEATH (Month, Day, Year) ,, Vicente Concepcion 2. Mate ,. 561- 54 - 3955 ~ December 5, 2005 AGE (Last Birthday) UNDER 1 YEAR U DE R t DAY DATE OF BIRTH BIRTHPLACE (Clly and PLACE F DEATH C eck on o e - acs Inetrudbna o other aId Months Deys Hows Minutes lMonN, Day, Year) Stele or Foreign Country) NOSPRAL: OTHER: 83 Yra ~ Apr 5, 1922 Fort Stotsenberg, ..p•a.nt ^ GR/Ou~.a«.t ^ DUA ^ Nunbq ^ o„,a e. e. T. -. ... ea. ® ^ Home R••td•na• (sp•dgl ' COUNTY OF DEATH CITY. BORO, TWP OF DEATH FACILITY NAME (It not Inslltulion, glue etreal and number) WAS DECEDE NT OF HISPANIC ORIGIN? RACE - Arrlericen Indian, Blade, WNIe, etc Cumberland Hampden 5251 bleadowbrook Drive ® ^ c~~ Cubert, Ma T Ri YP l (SPAY) eb. ea. ed, x cen, uar o carL et e. Pacific tstander ,o. DECEDENT'S USUAL OCCUPATION KIND OF BUSINESS I INDUSTRY WAS DECEDENT EVER IN DECEDENT'S EDUCATION MARITAL STATUS -Monied, SURVIVING SPOUSE (Girs Irbil W work done eurhp mou U. S. ARMED FORCES? (Sp•°Ny Ord hghnt •d• campl•» Never Married, Widowed. (k wlf•, qM m•Wn name) of workbq kls; do not ua•r•&ed) Federal Government Yas® No^ ~'m•ntaryf8•con0ary CoNep• DIVOrtad (Specify) tt.. t,b.' ,2. „ (°^2j 12 (t-.°rs~) ~~ Marred 16 Eva Skorupinski DECEDENT'S MAILING ADDRESS (Street, Cily/Town, Stale, Zip Code) DECEDENT'S t7a. Stale Pa. atl Hampden tl ACTUAL d t G ed i ~ Y tT0 5251 Meadawbrook Drive es, BCa ert v n ~- trop ' decadent RESIDENCE Mechanicsbur , Pa. 17050 9 (see ktswdions Iwe ~ a No, decedent Nved Cumberland townshlp7 17d ^ ,~, . on other side) tTb. County wlthtn actual limits of cNy/boro c ei uEP~c !dAuc (F: _~, Mid•oe ~e r - s•) ~ u ruE ~i ,y, i ~ r iti ...0 P.'S A E ,F.:st, ,.tidd~, }fa an Susta.;ta; ,,. Antonio Concepcians ,e, Cresencia Abellia INFORMANT'S NAME (TypelPrintj Eva Conce cion INFORMANTS MAILING ADDRESS (SUeet, C' frown, Stele, Zfp Code) p 2oa. lob. 5251 Mea~iowbrook rive Mechanicsburg, Pa. 17050 ~ METHOD OF DISPOSITION ^ ~ ^ DATE OF DISPOSITION veer) (Monet Da PLACE OF DISPOSITION- Name of Cemetery, Crematory or Other PVaco LOCATION - CityrTowrt, State, Ztp Coda Burial Cremation Removal hom Stale Donatiort^ . y. C li othar(spa°iy) ^ ~ 27a. Dec 7, 2005 2tb. ono te Crematory 2ta. ;>chaefferstown, Pa. 17088 ltd. • SIGNATURE OF FUNERAL SERVICE LICENSEE OR PERSON ACTING AS SUCH LICENSE NUMBEr~ NAME ANDADDRE65 OF FACILITY . 2za z2b FD-012662-L 22a. Myers Funeral Home, Inc. 37 East Main Street Mechanicsburg, Pa. 17055 Gomplela Nems 23ac oNy when cartityin8 To the best of my knowledge, death occuned at the tune, date and place crated LICENSE NUMBER DATE SIGNED physidan is not evailaWe at tone of death to (Signalwe and Ti°e) (MOnOt. Day, Year) ' certiiy cause of death. 23a. 2]b. 230. Items 24-26 must be completed by person who pronounces death 71ME OF DEATH / s~ ' ~ DATE PRONOUNCED DEAD (Month, Day, Year) / •~ WAS CASE REFERRED TO A MEDICAL EXAMINER /CORONERS 1 • . 21. ~O " / ~ M. s, 26. / ~ / - D a~ Yas ^ ~ , ^ t'~ 2C. X L 2T. PART t: Enter rh. dls••s•a, In)urt•s or eomplieaNon• w hloh e•ua•d the death. Do not •n4r tlr • mode of dyMp, such •• osrdb• or nsplrat•ry •n•a~ shocY or h••n hllun. ~ Approxirtwle PART U' Otnef spnlGeaM conditions eonlntxltmg to death but Llat ony on. cau•• on .ach Nnw ~ Intervet ltetween , not resulting in the untledyktg cause given N PART I IMMEDIATE CAUSE (Final ~ :onset end death disease or conditio ~ ~ /1 / 1 ~~ 1~~~~~/ p / ~~ G ~ ~ n a resulting in death) -- -~ '1 L~ r i - -_ DU E TO (SAS A CONSEQUENCE OF): Saquenkelly list conditions b _ _ ' if any, leading to Immediate DUE TO (OR AS A CONSEQUENCE OF)~ rouse. Enter UNDERLYING CAUSE (Oisaase ar injury c NHt ktNialed events DUE To (OR AS A CONSEQUENCE OF): -_- ~ recutting an aeaUt }LAST • d WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH DATE OF INJURY TIME OF INJURY INJURY AT WORK? DESCRIBE FIOW INJURY OCCURRED. PERFORMED? AVAILABLE PRIOR TO COMPLETION OF CAUSE Natural © Homiuda ^ (Abner, D•y. Y•u) OF DEATH? Accident ^ Pendin tnvastl ation ^ Yes ^ No ^ Yes ^ No a Yea ^ No © g g 5uiutle ^ Could not be determined ^ SOa. 70b. M~ 30a. 30d. PLACE OF INJURY At ho f l f K OCA7 0N S T tea. zeb. 2e- - me, arm, cVee , actory, o ~ce L 1 ( treet, City/ own, State) buidna. etc. (Sp•d1Y) So•. Sof. CERTIFIER (Check ordy one) _ SIGNATURE TITLE FIER V 'CERTIFYING PHYSICIAN (Physician cerutying cause of death when annlher physician has pprroonnounced tleatn antl completed item 23) To th. b•q of my knovvladpa, death occumd du. to the causas(s) and manner as atabtl . .................................................................. ^ - 31b. >/j /ty 'PRONOUNCING AND CERTIFYING PHYSICIAN (Physician Doth pronotutctrtg death end certifying to cause of death) NSE NUMBER - M 63 E DATE SIGNED ( nut, ey, Year) 7 To fh• beat of my knoyvl•dp•, death occumd at the tlma, dal., and place, and dw to the aua•a(c) and manner as stabd . ....................... ^ ]ta. Yfd. , NAME AND ADDRESS OF PERSON WHO COMPLETED CA SE O DEATH 'MEDICAL EXAMINERICORONER - (Item 27) Type or Pant ' On Ina baala of aaaminadon andlor InvaaUgatlon, In my oplnlon death occumd st w• tlma, dot., and plan, and du. to the eaunae(a) and l d John P. Zornosa manner ac s ate ..... .... ..... -~~~-~-~~~~ ~---~~~--~-~~~~~~~~~-~ - ~~~~~~~-~~-~--_n 7L. __. - ~. 12. y_. y IOL7Q ~V Urlll l'IUrll JIrCCI VVUIIIIIC~ Jr1U1 r'r't I(U'+J REGISTRA 'S I NATU A~,D NU BE DATE FILE Month, Day, Year) CERTIFICATE of GRANT of LETTERS REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA CEF;TIFIC_;ATE OF GRANT OF LETTERS ADMINISTRATION No . 201 ~ - 0034 ~ PA No . 21- ~ 1- 0341 Estate Of : VINCENTE CDNCEPCION (First, Middle, Last) Late Of : HA/1/IPGEN TO VVNSHIP CUMBERLAND COUNTY Deceased Soci a1 Security No : 561-54-3955 WHEREAS, VINCENTE CONCEPCION (First, Middle, Last) late of HAMPDEN TOWNSHIP CUMBERLAND COUNTY died on the 5th day of December 2005 and, WHEREAS, the grant of Letters of Administration is required for the administration of the estate. THEREFORE, I , GLENDA EARNER STRASBAUGH Register of Wi 11 s in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, have th s daI% ~~ran ted Letters of Admin i s tra t i nn to MA NUEL A MEL VlL L E who has d1~1y qualified as ADMINISTRATOR (RIX) of the estate of the ai~ove named decedent and has agreed to aaminister the Estate ac;~ording to 1 aw, all of which fu11y appears of record in my office a t CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA, IN TESTIMONY WHEREOF, I have hereunto set my hand and affi~~ed the seal ~~f m ~,; ~ ff ?_ ~ ~ ~,~~~ the 16th day of Mare't~ ''01 1. G '; ~ ' "` RPg/s ter o f I11/i//s , / , Deputy * *NOTE* * ALL NAMES AB05IE APPEAR (FIRST, MIDDLE, LAS`T') *** END OF ATTACHMENTS ***