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Home My WebLink About04-26-11J REV-1500 Ex (°'-'°' ~ 1505610143 OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Year - File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE PO 80X.280601 INHERITANCE TAX RETURN 2 1 10 0114 4 Harrisburg, PA 17128-0601 RESIDENT DECEDENT _ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 177 18 0189 10 04 2010 08 23 1921 Decedent's Last Name Suffix Decedent's First Name MI HART LOUISE S (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 Flt_! !!+: APPRQPRIA.TE O~~ALS BE4 Qll~~ ® 1. Original Return ^ 2. Supplemental Return ^ 4. Limited Estate ^ 4a. Future Interest Compromise (date of death after 12-12-82) ® g Decedent Died Testate ^ ~ Decedent Maintained a Living Trust (Attach Copy of WII) (Attach Copy of Trust) ^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) ^ 3, Remainder Return (date of death prior to 12-13-82) ^ 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes ^ 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ROBERT P KLINE 717 770 2540 First line of address 714 BRIDGE STREET Second line of address PO BOX 461 City or Post Office State ZIP Code NEW CUMBERLAND PA 17070 Correspondent's a-mail address: REGISTER OF WVII_LS USE ONLY ~~ r~ ~ _.. .._ -:~ . ~_,~ -.~ ,.., T, !'r' ~_r ~._ l ~- ~ n ~ . -r -a- ~'~ .-,, DATE ~.~~ _ __i ,~;-} -~-t ,; . ---, - i _ ._ ., .., .I ti.~ 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. SIGNATURE OF PERSON RESPONSI~ FOR FILING RETURN DATE ,,~~.,,11~ ~t`~r1~ ~ ,lL~,~,.L~-/ Patricia L. Blosser ~ ~ 2 b ~ `~ ~ ~rI.C L, ~r~ ~ `. ADDRESS ' 7003 Salem Park Circle, Mechanicsburg, PA 17050 SIGNA E 0 REPARER-~2~HER THAN REPRESENTATIVE DATE Robert P Kline ADDRESS 714 Bridge Street, New Cumberland, PA 17070 Side 1 L 1505610143 z_, V A,~,,.,1 2~,~ ~ 1505610143 J 1505610243 REV-1500 EX Decedent's Social ~~ecurity Number Decedents Name: HART , L O U I S E S. 17 7 18 CI 18 9 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. 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .............. .. 5. ~ , 7 0 0 5 4 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............ . 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ............ . 7, g. Total Gross Assets (total Lines 1-7) .................................................................. __ _ __ ..... g. h, 7 0 0 5 4 9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................................... .... 9. ~~ , 0 8 4 4 3 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................ .... 10. 3 2 , 8 8 5 7 4 11. Total Deductions (total Lines 9& 10) ................................................................. .....11. 4 1, 9 7 0 1 7 12. Net Value of Estate (Line 8 minus Line 11) ........................................................ .....12. - 3 5 , 2 6 9 6 3 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. - 3 5 , 2 6 9 6 3 TAX COMPUTATION -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 .00 15. 16. Amount of Line 14 taxable at lineal rate X .045 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. 0 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 L 1505610243 1505610243 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 - 10 - 01144 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. Check box 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) 0.00 Total Credits (A + B) (2) 0.00 (3) 0.00 (4) (5) 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 _i a. retain t e use or income of the property transferred :.................................................................................. _J ~ x b. retain the right to designate who shall use the property transferred or its income :............................ ~ `_--' c. retain a reversiona interest; or ............................................................................................................... I x d. receive the promise for life of either payments, benefits or care~ ..............................................................i _ I x j 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .....................................................................................................................'.. '' i x I ~~ _: 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? ................................................................................................................... --~ I~ z ~_ ~ ~ _~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND Fll_E IT AS PART OF THE RETUR 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 resquirements for disclosure of assets and filing a tax retturn 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 ears 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) (y.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:, e:KCept 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)1. 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. I SCHEDULE E ' ~ CASH, BANK DEPOSITS, & MISC. COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT I - - _ _ _ -- 1 -------- __ _- ---- -_ -- _ _ rFILE NUMBER ESTATE OF Hart, Louise S. 21 - 10 - 01'144 __ __ -___ Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-ov~vned with the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE OF NUMBER DESCRIPTION DEATH 1 Citizens Bank #6100705722 1,365.94 2 Citizens Bank #6243929782 4,455.10 3 Messiah Village Trust Account refund 559.51 4 Highmark refund 319.99 -- _ ___ -- TOTAL (Also enter on Line 5, Recapitulation) 6,700.54 i SCHEDULE H II ' ~~ FUNERAL DCf~ENSES & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN er~l~'~e~ RESIDENT DECEDENT /-~~~ ~V , , v"~ FILE NUMBER ESTATE OF Hart, Louise S. ' 21 - 10 - 01144 Debts of decedent must be reported on Schedule I. ITEM -- ---- - -- - -- NUMBER FUNERAL EXPENSES: DESCRIPTION ~ AMOUNT A. 1 I, Myers Funeral Home, Inc.37 E. Main St., Mechanicsburg, PA 17055 7,395.00 2 ' Rolling Green Cemetary, Camp Hill, PA 17011 285.00 i, B. ;ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Patricia L. Blosser -- ~'I street Address 7003 Salem Park Circle i 'i city Mechanicsburg state PA zip 17050 Year(s) Commission paid 2011 2. Attorney's Fees Kline Law Office 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. I Probate Fees Register of Wills i 5. Accountant's Fees 6. I Tax Return Preparer's Fees 7. II Other Administrative Costs 1 292.93 1,000.00 111.50 __ _ -- TOTAL (Also enter on line 9, Recapitulation) 9,084.43 SCHEDULE I ' ~ DEBTS OF DECEDENT, MORTGAGE it COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN LIABILITIES, & LIENS RESIDENT DECEDENT z - - _ ~ _ _ -- ---- __ __ _ _ __ -- __ - _ __ ESTATE OF FILE NUMBER Hart, Louise S. 21 - 10 - 01144 _. _ __ _ , Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. - - -- __ __ ----- __ M NUMBER DESCRIPTION - -------------------- - _-_-- PA Department of Public Welfare Estate Recovery Program 2 Messiah Village -_---- TOTAL (Also enter on Line 10, Recapitulation) AMOUNT 32, 835.74 50.00 32,885.74 q :.i 1 '~ TAT ~ n ~ i'1 " 'r ~ ~r 7t'~ (~ L~ ?" T T _~ .-1 :J '~~ _~. ~ 11.1_ 1l n ~. ~ ~ _~, :'J 1.~ .~ r4~"_ w.- 1~' 1 l,~.C' J..l :J ~~,I 1.. h`.. 'J ~ t"~ i ,!-~ f ; t ~~~~ _, '. %~ , .--~- _ - _:r:- L._ i - i^ -~ `- . -; 1'.. 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L s COMMONWEALTH OF PENNSYLVANIA COUNTY OF .CUMBERLAND s SS. ) T I, i,~J',~IS ~ S. l-?h-~"' the testat S~3_X .~__ whose name is signed to the attached or foregoing instrument, having been duly qualiiied aCC6rding to i&w, uL~ heicby 8~kiavwicdg~ that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and volun- tary act and deed, for the purposes therein contained. Sworn and affirmed to and acknowledged before me by _._ OLJI~}~ ~,• ~L~~ L TT ~ ~~' ~ '~^~T the testat i~ this _ =` day of rgaT,~ A. D, 1~9~ r ~. f 1~; ~~ 13.~Gri r~, of ~:..-:4, _'_;~, C 1 / '~ '~ C ~~ f' { ~ ~, ~'?t'C ' ~:a~.iC1•.^..`:i};~il ~?l!`L{)i8i'~a;3S~6, ~ ~. --L :Y..~..~~ a ..~.~~.~~.~ ~...~ ~~ ~ . '` COMMONWEALTH OF PENNSYLVANIA ) SS. COUNTY OF CUtriBERLAND ) We, the undersigned, ~ . OB~PT Sry~~UFrE~ ~. and GI~~DYS .?. P~~rI~ the witne:~~°s whose names are eigrted to the attached or foregoing instrument, ;~g d~.;'v quali`ied according to law, depose and say that we were present an- testatrl_:~ r ~Tj ~'F' ~-' ~ '~?~r~:~ , sig cute the instrument as ~ .-her Last Will and Testament; that the said te8tat riy LOUISE S. ~l!.RT executed it as ~'s/her free and vcluntary act fer the purposes therein expressed; that each of us, in the hearing and sight of the teatat~_, signed the Will as witnesses; and that to the best of our knowledge, the te8tat ri~c was, at the time, eighteen (18) or more years of age, of Bound mind, and under no constraint, duress or undue influence, Sworn and subscribed to before me Chis .~ ~ day of ~- ~ .. ...._._, ,~~ . -r ~ ,~ zt A f ,,. 1.._..r" ~~ r ~ (r''. 4 /i /' aJ w~~ ~~ ;,~ ~,~ yy~~~ey' ~t..<., ~~ i jr4-~:. :~ .: t ~ ~a., t pSi}1'~ ~r'SA'~Lf'-5.:....,.: ei~. ,,.'„ ~i,, [`:.o =' ; J. ~ vJ.7.