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Home My WebLink About05-11-11' 1505610140 REV-1500 EX (01-10) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes Coun Code Year ~ File Number PO BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1, 1, 1, 0 2 8 9 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1, 7 4 1, 2 9 5 6 1 0 2 1, 4 2 0 1, L 0 L 1, 9 1, 9 L 7 Decedent's Last Name Suffix Decedent's Firs t Name MI W H I T L E Y N A N C Y ~1 (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 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder RE;turn (date of death prior to 12-13~-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal EstatE: T.ax Return Required death after 12-12-82) OX 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 ta>: 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 IVumber ~1 U R R E L W A L T E R S I I I E S Q 7 1, 7 6 9 '? 4 6 5 0 First line of address 5 4 E A S T f1 A I N S T R E E T Second line of address City or Post Office State ~1 E C H A N I C S B U R G P A Correspondent's a-mail address: REGISTER(OF 41VIL.LS USE:ONLY .--- _ . _ . _. ~ :~ .: i - ,-~ - ~, _,{~ ,.,r .__. . -`~ ___ - _-~- ,_., . - -r ___. . D$FE: FILED l-.,, ~' ZIP Code L 1, 7 0 5 5 ~. -;.~ -, "i -T1 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. Sj TURE OF PERSON RESPONSIBL OR FILIN TURN DATA , ._.____ _ Gam, ys ~:'..-.*~' ~ r `.. ~-,,,.._-~- ~ 5~/G'~ f/ ADDR S NANCY W GI EL I'NO 320 SOMERSET DRIVE SHIREMANSTOWN PA 1,7011, SIGNATURE OF A R HE HAN REPRESENTATIVE DATE ~`~,,, ADDRESS f MURREL WAL ERS~II, 54 E• MAIN ST MECHANICSBURG PA 1,7055 PLEASE USE ORIGINAL FORM ONLY Side 1 1,5056101,40 15056101,40 J J 1505610240 REV-1500 EX Decedent's Name: NANCY r1 • WHITLEY Decedent's Social :>ecurity Number 1, 7 4 L 2 9 5 6 L RECAPITULATION 1. Real Estate (Schedule A) ........................................... 1. • 2. Stocks and Bonds (Schedule B) ...................................... 2. 2 2 2 6. 4 0 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 8 4 0 . 6 4 6. Joint) Owned Pro ert Schedule F y p y ( ) ^ Separate Billing Requested ....... 6. 2 8 8 ? 9. 5 9 7. Inter-Vivos Transfers & Miscellaneous N -Probate Property (Schedule G) ~ S t Billi R t d 7 epara e ng eques ....... e . 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 3 7 9 4 6 . 6 3 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9• 2 7 9 2 • 1, 3 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. L 0 8 0 • 2 7 11. Total Deductions (total Lines 9 and 10) ............................... 11. 3 8 ~ 2 . 4 0 12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. ~ 4 D 7 4 . 2 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 4 ID ~ 4 . 2 3 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 .045 3 4 0 7 4 2 3 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 0. 0 0 1, .5 3 3. 3 4 0. 0 0 0. 0 0 1, 5 0 0. 3 4 Side 2 1505610240 1,50561,0240 J REV-1500 EX~age~ Decedent's Complete Address: Fire Number 21 11 0289 DECEDENT'S NAME NANCY M. WHITLEY _ ~___ STREET ADDRESS ~~ 320_ SOMERSET_DRIVE _ ~..._..y_. CITY SHIREMANSTOWN STATE ~ PA ZIP 17011 Tax Payments and Credits: ~ ~ Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 1,456.68 B, Discount 76.66 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) 1.533.34 (1) 1.533.34 (3) (5) (4) 0.00 Make check payable to: REGISTER OF WILLS, AGENT 0.00 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? ....................................................................................... ^ ^X 3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death? ......... ^ Q 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? .................................................................................................. ^ 0 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(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;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 + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER NANCY M. WHITLEY 21 11 0289 _ All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1, PRUDENTIAL 2,226.40 44 SHARES COMMON STOCK TOTAL (Also enter on line 2, Recapitulation) ~ $ 2,226.40 (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (6-Q8) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER NANCY M. WHITLEY 21 11 0289 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. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. WACHOVIA 4,323.29 SAVINGS 2. LOYALTON AT CREEKVIEW 1,492.00 PERSONAL CARE OVERPAYMENT 3. WACHOVIA 1,025.35 CHECKING TOTAL (Also enter on line 5, Recapitulation) $ 6 840.64 (If more space is needed, insert additional sheets of the same size) - _ -- REV-1509 EX+ (07-10 pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: NANCY M. WHITLEY 21 11 0289 SCHEDULE F JOINTLY-OWNED PROPERTY If an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. NANCY W. GIBELLINO 320 SOMERSET DRIVE SHIREMANSTOWN, PA 17011 B. C JOINTLY-OWNED PROPERTY: DAUGHTER 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 JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET °ro OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. 1994 WACHOVIA 12,267.05 50. 6,133.53 ACCESS FIFTY CHECKING 2. A. 1989 PSECU 1,853.95 50. 926.98 SAVINGS 3. A. 2001 PSECU 43,638.15 50. 21,819.08 CD TOTAL (Also enter on Line 6, Recapitulation) I $ 28,879.59 If more space is needed, use additional sheets of paper of the same size. R.EV-1511 EX+ (10-09` pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER NANCY M. WHITLEY 21 11 0289 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. MALPEZZI FUNERAL HOME 31.66 2. FUNERAL LUNCHEON 250.00 3. FUNERAL -CLOTHING 196.97 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) NANCY W. GIBELLINO (RENOUNCED) Street Address 320 SOMERSET DRIVE City SHIREMANSTOWN State PA ZIP 17011 Year(s) Commission Paid: 2, Attorney Fees; MURREL R. WALTERS, III 2,100.00 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: CUMBERLAND COUNTY REGISTER OF WILLS 213.50 5 Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL (Also enter on Line 9, Recapitulation) $ 2.792.13 If more space is needed, use additional sheets of paper of the same size REV-1512 EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER NANCY M. WHITLEY 21 11 0289 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1, OMNICARE 524.69 MEDICAL 2. ANGELS ON CALL PERSONAL CARE 3. HOLY SPIRIT HOSPITAL MEDICAL 4. MICHAEL LAWLER, NP MEDICAL 5. MOBILE X-RAY MEDICAL 6. QUANTUM IMAGING MEDICAL TOTAL (Also enter on Line 10, Recapitulation) $ If more space is needed, insert additional sheets of the same size. 91.25 27.90 415.43 10.46 10.54 1.080.27 REV-1513 EX+ (~ 1-1 ^! pennsylvania ~ SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURPJ RESIDENT DECEDENT ESTATE OF: FILE NUMBER: NANCY M. WHITLEY 21 11 0289 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 outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. NANCY W. GIBELLINO Lineal 320 SOMERSET DRIVE SHIREMANSTOWN, PA 17011 2. JOSEPH E. WHITLEY Lineal 1400 4TH STREET MONONGAHELA, PA 15063 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 TAX IS 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. $ If more space is needed, use additional sheets of paper of the same size,