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Home My WebLink About04-18-111505610101 REV-1500 Ex ~°1.1°' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Count Code Year File Number Bureau of Individual Taxes °E°"R,ME".oFRE~E""E y Po BOX 280601 INHERITANCE TAX RETURN ,~ __ Harrisburg, PA 1128-0601 RESIDENT DECEDENT ~ ` ~ ~} (~ ~:~ ENTER DECEDENT INFORMATION BELOW -` Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 156-38-0721 11 /10/2010 08/17/1949 Decedent's Last Name Suffix Decedent's First Name MI Pszczolkowski Thomas C (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW C!~ 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 oaf ;;afe 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 COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD E3E DIRECTED TO: Name Daytime Telephone N!urnber C'~ . . Andrew Pszczolkowski (610) 704-358~~: ~-~,, .. vw.. ~, _ ~...7 First line of address 1883 Aster Rd Second line of address City or Post Office State ZIP Code Macungie PA 18062 Correspondent's a-mail address: badandy2t~verizon.net - ~~~~ REGISTER OF.~V`f}~L.~I~SE ONL` rY --' - ,e.,. ~~1:) ,; , ._~ _ r~ - . . i-a , ~. __' DATE !FILED ~~ ~ _, ~. ~~.'-~ r~ 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 PERSON RESPONSIBLE FOR FILING RETURN A'TE ~ c~ ~ ~ ADDRES ~1 , ~) ,(~ ~I p 1~ ~tSf-P_t- 'j2~_ /VlGC~y~/1G.~ t"fit ~~J~~DoZ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS -- PLEASE USE ORIGINAL FORM ONLY Side 1 150561010], 1505610101 J J 1505610105 REV-1500 EX Decedent's Name: ThOmaS C. PsZCZOIkOWSki Decedent's Social SE:curity Number 156-38-0721 RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 0.00 2. Stocks and Bonds (Schedule B) ....................................... 2. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 15,067.98 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 0.00 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G} O Separate Billing Requested........ 7. 0.00 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 15,067.98 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 7,488.92 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 5,291.09 11. Total Deductions (total Lines 9 and 10) ................................. 11. 12,780.01 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 2,287 97 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 2,287.97 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_ 15. 16. Amount of Line 14 taxable at lineal rate x .0 45 102.95 16.. 17. Amount of Line 14 taxable at sibling rate X .12 17 18. Amount of Line 14 taxable 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 1505610105 1505610105 102.95 102.95 O J REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME -- Thomas C. Pszczolkowski STREETADDRESS ---------- 615Thrush Court CITY STATE Zip Mechanicsburg PA 17050 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments __ ___ _ 0.00 B. Discount 0.00 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 (1) 102.95 Total Credits (A + g) (2) 0.00 (3) 0.00 (4) 0.00 (5) 102.95 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 : ............................................ ^ 0 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 requiremenl:s 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)j. • 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-i5o8 EX+ (il-io) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Thomas C. Pszczolkowski Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ~~ rnure space is neeaea, use aaoitional sheets of paper of the same size. REV-1511 EX+ (10-0~~) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Thomas C. Pszczolkowski _ Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION A• FUNERAL EXPENSES: i' Professional Expenses - Malpezzi Funeral Home, Mechanicsburg, PA 2 Rental Casket 3 Wood Urn 4 Memorial Flowers 5 Religious Service Fee s Newspaper Obituary B. 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Andrew PSZCZOIkowski Street Address 1883 Aster Rd city -Macungie_ Year(s) Commission Paid: N/A state PA ZIP 18062 2• Attorney Fees: 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: 5• Accountant Fees: 6• Tax Return Preparer Fees: ~• PA County Estate and Notice Fees $ Expenses for administering proprety TOTAL (Also enter on Line 9, Recapitulation) I $ If more space is needed, use additional sheets of paper of the same size. AMOUNT 4,875.00 975.00 425.00 40.00 100.00 270.17 0.00 0.00 0.00 0.00 0.00 0.00 208.02 594.73 7,488.92 REV-1512 EX+ (12-08) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER Thomas C. Pszczolkowski Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimburse~i medical eYnenspc Ir more space is needed, insert additional sheets of the same size.