HomeMy WebLinkAbout05-16-11 (2)
1505610105
REV-1500 °`i~-11't~,1'~
PA Department of Revenue Pennsylvania OFFICIAL USE ONLY
Bureau of Individual Taxes °`""`"`"`"~`"°` Coun Code Year Fla Numt~
INHERITANCE TAX RETURN "'/ ty "' / " """
POSOxzsofioi pC ~ ` ~ U ~ ~ 5
Harrisburg. PA i7i28-o6oi RESIDENT DECEDENT
Spouse's Last Name Suffoc 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 Retum O 2. Supplemental Retum O 3. Remainder Retum (Date of Death
Prior to 12-1&82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required
death after 12-12-82)
t7p 8. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy d 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)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
'John M. Eakin (717) 766-3172 ~;
REGISTER Ot~l USE ONt~' ~i C~
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ne o
ress Z ~ z i
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Market Square Building , c~~~~ ~_-;
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~ c70 -n. a>b
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Second Line of Address
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4
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Clly Or POSt Office State ZIP Code DATE FILED C^
Mechanicsburg PA 17011
Comspondent's e-mail address:
Under penettles d~per)ury, I deckre that I have examined this return, Induding ecmmpanyirg schedules and statements, and to the best d my knowk+dge and belief,
It Is true, correct and eompleb. Declaration d preperer other than the personal representative is based on ali information d which preparer has any knowledge.
SIGNATURE O RS N NSIBLE FOR FILING RETURN PATE
fa~7~'~/
Market Squab Building, Mechanicsburg, PA 17055 ~
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 1505610105
15056102D5
REV-1500 EX (FI)
Decedent's Social Security Number
Decedent's Name: '. '.
RECAPITULATION
1. Real Estate (Schedule A) ........................................... .. L
2. Stocks and Bonds (Schedule B) ..................................... .. 2 ' 60,735.53
3. Closely Held Corporation, Partnership wSole-Proprietorship (Schedule C) ... .. 3. ' ',
4. Mortgages and Notes Receivable (Schedule D) ..............,.......... .. 4. ',
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. ', 284,039.01
6. Jointly C+wned Property (Schedule F) O Separate Billing Requested ..... .. 6. ',
7.
Inter-Vivos Trensfers & Miscellaneous Non-Probate Property _ .
',
(Schedule G) O Separate Billing Requested...... .. 7. !,
8. Total Gross Assets (total Lines 1 through 7) ............................ . 8. I 344,774.54 ',
9. Funeral Expenses and Administrative Costs (Schedule H) .................. . 9. ' 15,706.57
10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) .............. . 10. ', 2,448.86 '
11. Total Deductions (total Lines 9 and 10) ................................ . 11. ~' 18,155.43 ':
12.
Net Value of Estate (Line 8 minus Line 11) .............................
. 12. ', .,.
326,619.11 ',
13. CharifaWe and Governmental Bequests/Sec 9113 Trusts for which ` ~ ~' " °'° """ " """' "" "' "
an election to tax has not been made (Schedule J) ....................... . 13. 239,900.16
14. Net Value Subject to Taz (Line 12 minus Line 13) ....................... . 14. ', 86,718.95
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sac. 9116 _. __ _ _
16. Amount of Line 14 taxable
at lineal rate X .0 _ 16. I
17.
__. ~_- __
Amount of Line 14 taxable
at sibling rate X .12 17. ',
18. .,.. .~.... ,.. _~ . _~ m m .._,
Amount of Line 14 taxable _. ,.. _w._.. W r _ ...
90,000.00
at collateral rate x .15
_. __
1a.
13,500.00 '':
19. TAX DUE ........................................................ . 19.;
_ 1$,500.00
_
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
1505610205 1505610205 J
REV-1503 EX+ (8-88)
SCNEdULE B
COMMONWEALTH OF PENNSYLVANIA
STOCKS & BONDS
~'
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mildred A. Harrison 21-11-0015
All property Jointly-owned wkh right of survhronthip must ba disclosed on ScheduN F.
lT~ VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
t.
Treasury Bill
Prinrpal $10,000.00 Issued 71112010 Rate 2.18% Interest $185.15
10 185.15
,
2.' Treasury Bill Principal $10,000.00 Issued 8/05/2010 Rate 1.98% Interest $124.77 10,124.77
3. Treasury Bill Prinrpal $10,000.00 Issued 8126/2010 Rate 1.8590 Interest $25.34
__ __ 10,025.34
4.' !Treasury Bill Pnnttipal $10,000.00 Issued 1017/2010 Rate 1.85% Interest $121.64 10,121.64
5.' Treasury Bill Princpal $10,000.00 Issued 101712010 Rate 1.70% Interest $111.78 10,111.78
Q Treasury Bill Principal $10,000.00 Issued 12/0212010 Rate 2.1090 Interest $166.8ti 10
166
85
__ _ __ ,
.
__. __
TOTAL (Also enter on line 2, Recapitulation) S', 60,735.53
(If more space is needed, insert additional sheets of the same size)
I^
TD 5177 (Saptambar 2010)
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www.dvasu tydirvcLOov
1-800-722-2878
1-304-480-6464 (OUtsidvthv U.S.[' ..
MILDRED A HARRISON
1441 HILLCREST COURT X209
CAMP HILL PA 17011-8021
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_ .- --.- 19~l ...: ....:..:.. r 717) 761-3029
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-''~ - -- - - °-`{ No withholdin
TREASURY RETAIL SECURITIES SITE
P.O: BOX 567
PITTSBURGH PA 15230-0567
PHONE: {800) 722-2678
Payments made by direct deposit to:
PNC
Routing Number: 031312738
.N»ms ~n Account-hhiLflRE•D e+.-11A12ftISON
CHECKING Account Number: Confidential
ACCOUNT HOLDINGS
912795Xb5
sxLL
12/30/10 10,000
912795Y21
BILL
o2/ea/-xl-- la,ooo
912795204
BILL
02/24/11 10,000
912795VD0
sILL
04/07/11 10,000
9127952ND
BILL
04/20/11 10,000
O1 10,000 07/01/10 99.391306 0.218 0.215 1 26MK
Ol 10,000 08/05/10 99.901417 0.198 0.1951 2 26NK
O1 10,000 00/26/10 99.906472 0.188 O:lOb 02/24/11
Par
10,000.00
O1 10,000 10/07/10 99.906472 0.180 0.185 1 26NK
Ol 10,000 10/20/10 99.914056 0.173 0.170
04/20/11
Par
1A,000.00
IF YOU HAVE QUESTIONS CONCERNING THIS STATEMENT, PLEASE CONTACT YOUR TREASURY RETAIL
SECURITIES SITE AND PROVIDE YOUR ACCOUNT NUMBER
rD stn ~s.Pr«oe.r 2oto>
raaumg rvumoer: wtuuzeut
For 09/02/2010 to 12/03/2010
10/07/10 912795N23 BILL 10/07/10 R~dNption -10,000
10/07/10 912795VD0 BILL 04/07/11 R~inv~stttNnt Puroh>ts~ 110,000
Security Prior: 9,990.65
10/07/10 912795VD0 BILL 04/07/11 Refund PnyNnt 9.35
10/28/10 912795M49 BILL 10/28/10 Rnd~wptian -10,000
10/28/10 9127952ND BILL 04/28/11 R~inv~stNn4 Purdws~ ~ •10,000
Security Priem: 9,991.41
10/28/10 9127952ND BILL 04/28/11 Refund Pcyttunt 8.59
12/02/10 912795N98 BILL 12/02/10 Rcda~tion -10,000
OZ/~_ _912795NtW BILL J6/02/11 _ ~iinv0;~, Purohap _ •10,000
Security Prig: 9,189.
12/02/10 91279SMi4 BILL Oi/02/11 Refund Paytwnt 10.62
IF YOU HAVE QUESTIONS CONCERNINt3 THIS STATEMENT, PLEASE CONTACT YOUR TREASURY RETAIL
SECURfT1ES SITE AND PROVIDE YOUR ACCOUNT NUMBER
REV->,5o8 EX+ (11-io)
pennsylvarria
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCMEpULE E
CASH, BANK DEPOSITS 8t MISC.
PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
Indude the proceeds of litigation and the date the proceeds were received by the estate.
Ali P~oP~Y j~~Y owned with right of survivorship must be dbdoaed on Schedule F.
ITEM VALUE AT DATE
NI IMCC4
DESCRIPTION OF DEATH
1. Desert Grove Inc. subscription refund 24.90
2.' Cash
54.88
3, PNC Bank checking account#4024-8034 104,861.62
4. PNC Bank money market account #62-7762 177,762.17
5, Miscellaneous furnishings 965.00
g, Verizon refund
1.04
7. Miscellaneous jewelry
355.50
g Comcast refund
, 4.51
g, Neil Funeral Home refund for prepaid funerel bill 9.39
TOTAL (Also enter on Line 5, Recapitulation) ~ 284,039.01
If more space is needed, use additional sheets of paper of the same size.
Account 1'r~nsactian Detail Report
Il/22/2U30 11/22/2010 ;10.00 5302,467.29 D N 083919230 CHECK 4472
083919230
12/01/2010 12/01/2010 S3,058.68 5105,500.97 C N A 1524601 0 CSA CIVIL SERVO
5 TREASURY 3120001033001306358
9
12/03/2010 12/03/2010 ;211.00 5105,722.59 C N
12/06/2010 12/06/2010
525.00 5105,711.62 D N
Page 3 of
184079489A SSA 50C SEC U
S TREASURY 3030001033400407354
6
CALCULATED SERVICE CHARGE
TYPE lD
12/07/2010 12/07/2010 5875.00 5104,861.62 D N 086254739 CHECK 447
_-
086254739
01/03/2011 01/U3/2011 ;3,058.68 6107,931.67 C N A 1524601 0 CSA CIVIL SERVO
S TREASURY 3120001036300870578
• 8
+....--„---------.___t__~__...._/....:......./..1./Q..:~.f~,.,.....eCe...isf9Q(1TTD!`R_!'~I7AATI~TRT=TTNYC 1/S/7(111
Account Transaction Detail Report Page 1 of 1
https://www. cct.pncbank. com/eaimsg/sb/EaiMessageServlet?SOURCE-CHANNEL=UNK... 1 /5/2011
REV-1511 EX+ (10-09)
pennsylvania
DEPARTMEN70F REVENUE
[NNERRANCE TAX RENRN
RESIDENT dECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Midred A. Harrison 21-11-0015
Decedent's debts must be reported on Schedule I.
B. __
ADMINISTRATIVE COSTS
1. Personal Representative Commissions:
'i 0,000.00
Name(s) of Personal Representative(s) Jghn M. Eakin -
street address Market Square Building
~;ty Mechanicsburg state PA zIP 17055
Year(s) Commission Paid: 2011
Z• Attorney Fees: 5,000.00
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:
377.50
5• Accountant Fees:
6• Tax Return Preparer fees:
Z __ _ _
The Sentinel, estate notice _.
174.07
a• The Cumberland Law Journal, estate notice
_ 75.00
9• Kim Potteiger
Personal Prope
t
A
raisal
,
r
y
pp
. _ 50.00 ,
t o• Register of Wills -Filing Fee inheritance tax and inventory
30.00
If more space is needed, use additional sheets of paper of the same size.
TOTAL (Also enter on Line 9, Recapitulation) I;;'
15,706.57
REV-1512 EX+ (12-OB)
~pennsylvania SCHEDULE I
OEPARTNENT Of REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mildred A. Harrison 21-11-0015
Report dabtt incurred by the decedent prior to death that remained unpaid at the date of death, includine unraimhureed m~diol wxn.n~e
REV-1513 EX+ (O1-10)
~pennsylvania SCHEDULE 7
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE f7F: FILE NUMBER:
Mildred A. Harrison 21-11-0015
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Lot Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).]
__
1• Angie Bowers, 6598 Rio Dorado Ct., La Mesa, New Mexico 68044 Friend 30,000.00
2. Camib Arbalaez, 3850 Rio Road #4, Carmel, CA 93923 'Friend 60,000.00
_.
ENTER DOLLAR AMOUNTS FOR DISTR18UT10NS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECRON TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTR1BUTi0NS:
1. _ __. _ _ _ _ _
The Church of The Good Shepherd, 3435 Trindle Road, Camp Hill, PA 17011 Residue of Estate
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S
IF more space is needed, use additional sheets of paper of the same size.
~.~~t ~irY ~~~ ~o~t~rmc~~t
of
MILDRED A. HARRISON
I, MILDRED A. HARRISON, of Lower Allen Township, Cumberland County,
_._.. --
Pennsylvania, being of sound and disposing mind, memory and understanding, do'hereby
make, publish and declare this my Last Will and Testament, hereby revoking and making
void any and all prior Wills by me at any time heretofore made.
1.
I direct the payment of all my just debts and funeral expenses as soon after my
decease as. the same can conveniently be done. I direct that I be interred in Gate of
Heaven Cemetery, Silver Spring, Maryland.
~ 2.
I direct that there shall be paid out of my residuary estate all estate; inheritance and
like taxes together with any interest or penalty thereon imposed by the Government of the
United States, or any state or territory thereof, or by any foreign government or political
subdivision thereof, in respect to all property required to be included in my gross estate ,_,
..,__:,
for estate, inheritance or like tax purposes by any of such governments, whether the
property passes under this will or otherwise.
3.
I give and bequeath Thirty Thousand ($30,000.00) Dollars to my friend ANGIE
BLOWERS, wife of Timothy Blowers of La Masa, New Mexico to be used in her sole
discretion for the benefit of her children JAMES BLOWERS, JOSHUA BLOWERS
and NATHAN BLOWERS. In the event she should predecease me the gift shall lapse
-1-
each of said children, viz JAMES BLOWERS, JOSHUA BLOWERS and NATHAN
BLOWERS in lieu of the gift to their mother.
4.
I give, devise and bequeath the sum of Sixty Thousand ($60,000.00) Dollars to my
friend, CAMILO ARBELAEZ, and in the event he predeceases me the gift shall ~~;
4 ~lrti
~a~:1
`• .. r::.
A11 the rest, residue and rem~inder-of my estate, of whatsoever raatpre .~i
wheresoever situate, I give, de~is~~ and bequeath to THE CHURCH (~~'~ >' Gt~D'
SHEPHERD, Camp Hill, Pennsylvania to be used at the discretion ofthe-Pastor.
6.
Lastly, I nominate, constitute and appoint, JOHN M. EAKIN, to be the Executor
of this my Last Will and Testament and direct that no bond or other security be required
of my personal representative to guarantee faithful performance of his duties.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this day of
May, 2009. ~ "'`~G.~`'•( ~ . '~~ (SE~v~
~.
~~
r~yX>
Signed, sealed, published and declared by the above-named Mildred A. I=larri~~ii~'as arid~
for her Last Will and Testament, inthe presence of us who have subscribed our names
hereto as witnesses at the request of said testatrix, in her presence and in the presence of
each other. /~,
1 i
=2-
and in that event I give and bequeath the sum of Ten Thousand ($10,000.00) Dollars to ~ L