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Home My WebLink About05-04-11 1505610105 REV-1500°`i°Z-11't~' ~ PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes """"~"`"`°`"`~""` PO BOX z8o6oi INHERITANCE TAX RETURN Harrisbur , PA 17128-o6oi RESIDENT DECEDENT County Code Year ~ I ~~ File Number Q ~ ~ D ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 209-52-8481 08!24/2006 07/15!1973 Decedent's Last Name Suffix Decedent's First Name MI ROSWOG MICHELLE M (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 QD 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 Schedule O) ~vttrctsruNUeN f - THiS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONF~ENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number FRANCIS E ROSWOG (717) 432-2087 REGISTER OF WILLS USE ONLY First Line of Address 7 GALE ROAD Second Line of Address City or Post Office CAMP HILL State ZIP Code PA 17011 n __._ ~ t .'7 r~l 17.: ` ` ~ _;~ ` ?m > 1 try -~ ° ~ --, - - _ -_= ~ n ;ra ~ r s - ty ~, c~ p - ~ Correspondents e-mail address: hOpefrank@jUrtO.COm ~~ Under penalties of perjury, I declare that I have examined this return, inGuding axompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Dedamatkxm of preparer other than the personal representative is based on all information of which areuarer has anv krx»wla<in.. ~~~rvsu ant ~r rtrtavN IitSF'ONSIBLE FOR FILING RETURN /~--~ _ - DATE ADDRESS 7 GALE ROAD CAMP HILL PA 17011-2624 ctrructK UrFIER iHAN REPRESENTATIVE DATE PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610105 1505610105 J 1505610205 REV-1500 EX (FI) Decedent's Social Security Number Decedent's Name: MICHELLE M ROSWOG 209-52-8481 RECAPITULATION 1. Real Estate (Schedule A) .......................................... ... 1. 2. Stocks and Bonds (Schedule B) .................................... ... 2. 4,550.00 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. 21,014.00 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. 5,110.00 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. 30,674.00 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. 16,817.00 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............. .. 10. 4,460.00 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. 21,277.00 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 9,397.00 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. 9,397.00 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 5,497.00 16. 247.00 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate x .15 3,900.00 1 g 585.00 19. TAX DUE ....................................................... ..19. 832.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 J REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME MICHELLE M ROSWOG STREETADDRESS - - ---- 1768 CREEK VISTA DR CITY NEW CUMBERLAND - _. STATE Z~ - PA 17070 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments 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. (1) Total Credits (A + g) (2) (3) (4) 832.00 182.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 1,014.00 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 .................................................................................... ...... ^ ^ b. retain the right to designate who shall use the property transferred or its income ...................................... ...... ^ ^ c. retain a reversionary interest ........................................................................................................................ ...... ^ ^ 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 "intrust for" orpayable-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(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-1503 EX+ (egg) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MICHELLE M ROSWOG FILE NUMBER 2006-00787 All property jolothr-0wned With right of surviverahin moat ~ aie..l..e~ ,._ Q~L~J..~_ ~.. ,.....v ayow w t~vovw, n~pt GWIIIOfial SIIBC45 Or RIE SBRIe SZE) REV-1508 EX+ (1i-10) Pennsylvania SCFIEDI~LE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITgNCETAXRETURN PERSONAL PROPERTY RESIDENT DECEDENT C~IAIC VF: FILE NUMBER: MICHELLE M ROSWOG 2006-00787 Include the proceeds of litigation and the date the proceeds were received by the estate. Atl property jointly owned with right of survivorshia must be disclosed on srt~Pd~~ip F ,~ ~~~vrc aNa~e is neeaeD, use aoaiUOna~ sneers of paper of the same size. REV-iso9 EX+ (oi-io) j~i Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: MICHELLE M ROSWOG 2006-00787 If an asset became jointly owned within one year of the dec~ent's date of death, it must be reported on Schedule G. SCNEDI~LE F 70INTLY-OWNED PROPERTY SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A• FRANCIS E ROSWOG 7 GALE RD CAMP HILL PA 17011-2624 B' SCOTT WALKER C ]OINTLY OWNED PROPERTY: 1763 CREEK VISTA DR NEW CUMBERLAND PA 17070-2213 FATHER SIGNIFICANT OTHER ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR ]OINTLY HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S tNTEREST 1. A. 05/31/03 PSECU Member #8401138113 Regular Shares 207.00 50 104.00 2. A 05/31/03 PSECU Member#8401138113 Checking 2,193.00 50 1,096.00 3. A 04/25105 PSECU Member#8401138113 Money Market 3,728.00 50 1,864.00 4. B 03/28/06 FIDELITY INVESTMENTS #Z19-296465 Mutual Fund Fidelity Fifty (FFTYX) 122.070shs @ $21.130 2,579.00 50 1,290.00 Cash 1,511.00 50 756.00 TOTAL (Also enter on Line 6, Recapitulation) I $ 5,110.00 If more space is needed, use additional sheets of paper of the same size. REV-151 EX+ (08-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER MICHELLE M ROSWOG 2006-00787 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM DESCRIPTION OF PROPERTY NUMBE INCWDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSH[P TO DECEDENT AND R DATE OF DEATH °k OF DECD' S EXCLUSION TAXABLE THE DATE OF i AANSFER. ATTACH A COPY Of THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST ~~F APPUCAei E~ VALUE 1• Prudential Financial Group Life Alc 4352002667463 FRANCIS E ROSWOG 20,507.00 100 20,507.00 0.0( SCOTT WALKER 20,507.00 100 20,507.00 O.Of 2 Fidelity Investments Alc 73116 Hoiy Spirit Hospital 401k FRANCIS E ROSWOG 4,755.00 100 4,755.00 p.pp CHRISTINE M ROSWOG 4,755.00 100 4,755.00 0.00 3 PSECU IRA Share S20 - FRANCIS E ROSWOG 2,644.00 100 2,644.00 0.00 SCHEDULE G TOTAL (Also enter on Line 7, Recapitulation) $ I 0.00 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (1Q-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER MICHELLE M ROSWOG 2006-00787 Decedeirt's debts must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: I' Patrhemore Funeral Home Traditional Services and Merchandise 10,592.00 2. Office of Catholic Cemeteries Internment Space in Gate of Heaven 825.00 3. Office of Catholic Cemeteries Internment Fee in Gate of Heaven 800.00 4. Gingrich Memorials Bronze Memorial and Installation 1,850.00 e. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Names} of Personal Representative(s) Francis E ROSWOg Street Address 7 Gale Road ___ City Camp Hill state PA ZIP 17011 Year(s) Commission Paid: 2010 AND 2011 2• Attorney Fees: 3. Family Exemption: {If decedent's address is not the same as claimant's, attach explanation.) Claimant 4. 5. 6. 7. Street Address City State Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Preoarer Fees: ZIP 2,000.00 750.00 TOTAL (Also enter on Line 9, Recapitulation) I $ 16,817.00 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-OS} ,,. ~~ ` Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF MICHELLE M ROSWOG FILE NUMBER Report debts incurred br the deeedo~ ~ry,.~ •„ ae,....~._. ____. _ . _ 2006-00787