HomeMy WebLinkAbout05-18-11 (2)1505610140
1500 EX `°'_'°'
REV
- OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
Po Box 2sosol INHERITANCE TAX RETURN 2 1 1 1 0 3 4 0
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
1 9 8 1 0 3 3 1 6 0 2 2 5 2 0 1 1 0 1 2 1 1 9 2 0
Decedent's Last Name Suffix Decedent's First Name MI
STA V E R L OU I S E V
(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 Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax 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 tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
(:UKKtSF'UNUtN I - 11115 St(:I IUN MUJI tit I:VMF'Lt 1 tU. ALL I:UKKtSt'UNUtNI:t AMU I:VNt1UtN I IAL I H1~ INtVKMAI IVN JFIVULU tSt UIKtI, l tU I V:
Name Daytime Telephone Number
H ANTHONY ADAMS 7 1 7 5 3 2 3 2 7 0
First line of address
4 9 WEST ORANGE STREET
Second line of address
S U I T E 3
City or Post Office State
S H I P P E N S B U R G P A
REGISTER OF~ILLS USE ONLY
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Correspondent's a-mail address: htadamslaw@embargmail.com
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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.
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ADDRESS O
986 RIDGE ROAD_ SHIPPENSBURG PA 17257
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
49 WEST ORANGE STREET, SUITE 3 SHIPPENSBURG PA 17257
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140 J
J 1505610240
REV-1500 EX
Decedents Name: LO U I S E V. STAVE R
Decedent's Social Security Number
1 9 8 1 0 3 3 1 6
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 and Notes Receivable (Schedule D) .......................... 4. •
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 3 4 5 5 5. 9 0
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. •
7. Inter-Vivos Transfers 8~ Miscellaneous N~-Probate Property
(Schedule G) Separate Billing Requested ....... 7.
8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 3 4 5 5 5 , 9 0
9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 4 4 9 1 4 0
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. 3 4 4 • 0 9
11. Total Deductions (total Lines 9 and 10) ............................... 11. 4 8 3 5 . 4 9
12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. 2 9 7 2 0. 4 1
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. 2 9 7 2 0. 4 1
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 .045 2 9 7 2 0. 4 1 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
1505610290
1 3 3 7. 4 2
1 3 3 7. 4 2
1505610240 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 11 0340
DECEDENT'S NAME
LOUISE V. STAYER
STREET ADDRESS
101 NORTH PRINCE STREET
CITY
SHIPPENSBURG STATE
PA ZIP
17257
Tax Payments and Credits:
~. Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments 1,274.00
B, Discount 63.70
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, 337.70
(1) 1,337.42
(3)
(5)
(4)
0.28
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
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? ....................................................................................... ^ Q
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? .................................................................................................. ^ 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
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)(1.3)]. Asibling is defined, unde
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1508 EX + (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
LOUISE V. STAYER 21 11 0340
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. HIGHMARK REFUND 417.37
2. EPICOPAL TOWERS SECURITY DEP 124.09
3. REFUND OF RENT 59.00
4. PERSONAL PROPERTY SOLD AT AUCTION 1,828.01
5. COMCAST REFUND 24.84
6. CENTURY LINK REFUND 13.13
7. CITIZENS BANK CD# 6140898048 17,500.00
8. CITIZENS BANK CD# 6140897785 1,075.69
9. CITIZENS BANK CD# 6140898021 10,010.00
10. CITIZENS BANK CD#6140877415 2,500.00
11. CITIZENS CHECKING 6100795373 1,003.77
TOTAL (Also enter on line 5, Recapitulation) I $ 34,555 90
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (10-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
LOUISE V. STAVER 21 11 0340
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. FOGELSONGER-BRICKER FUNERAL HOME 3,565.90
B.
1
2
3
4,
5.
6.
7.
City State ZIP
Relationship of Claimant to Decedent
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State
Year(s) Commission Paid:
Attorney Fees: H. ANTHONY ADAMS
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant
Street Address
Probate Fees:
Accountant Fees:
Tax Return Preparer Fees:
750.00
175.50
TOTAL (Also enter on Line 9, Recapitulation) I $ 4,491 40
If more space is needed, use additional sheets of paper of the same size.
ZIP
s
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
LOUISE V. STAYER 21 11 0340
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. COMCAST 21.24
2. CENTURY LINK 25.23
3. VAPOR JET (APARTMENT CLEANING) 135.62
4. DR. KEVIN LORENTSEN 162.00
TOTAL (Also enter on Line 10, Recapitulation) I $ 344 09
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+ (01-10)
Pennsylvania ~ SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
LOUISE V. STAYER 21 11 0340
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).j
1. BRENDA K CUMMINGS Lineal 100.00
986 RIDGE ROAD
SHIPPENSBURG PA
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 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.
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I, LOUISE V. STAVER, also known as V. LOUISE STAVER, of the
Borough of Shippensburg, Cumberland County, Pennsylvania, do make and
publish this as and for my last will and testament, hereby revoking
any and all wills heretofore made by me.
1. I direct my executrix to pay all of my debts, funeral and
administrative expenses as soon as convenient after my decease.
2. I authorize and empower my executrix to sell any realty and/
or personalty owned by me at my death, at either public or private
sale or sales and to give good and sufficient deeds and/or bills of
sale therefor, in fee simple, as I could do if living. My executrix
is authorized and empowered to continue to engage in any business in
which I may be engaged at my death, for such period as seems expedient
to said executrix.
3. All the rest, residue and remainder of my property, real and
personal, I give, devise and bequeath to my dawgiiier, Brenda Kay St aver
4. I nominate and appoint Brenda Kay St aver to be the executrix
of this my last will and testament without the filing of any bond.
5. I suggest that my personal representative retain the services
of Irwin, Irwin & Irwin, Carlisle, Pennsylvania, as attorneys in the
settlement of my estate.
WITNESS my hand and seal this ~~ ~ day of December, 1974.
(SEAL)
LOUISE V. STAVER
Signed, sealed, published and declared by the within named
testatrix as and for her last will and testament, in our presence, who
at her request, and in her presence and in the presence of each other,
(have hereunto set our names as subscribing witnesses.
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CODICIL
I, Louise V. Staver. also known as V. Louise Staver, of the
Borough of Shippensburg, Cumberland County, Pennsylvania, being of
sound mind, memory and understanding, do make, publish and declare
this a codicil to my Last Will and Testament dated December, 30th,
1974.
FIRST: I hereby nullify, revoke and cancel Paragraph 5 of the said
Last Will and Testament with the same effect as if the said paragraph
had never been a part the
SECOND: It is my desire
remain in full force and
IN WITNESS WHEREOF,
Last Will and Testament,
1980.
~reof .
that the rest and residue of the said document
effect.
I, Louise V. Staver, to this a codicil to my
set my hand and seal this/6~ day of February,
~ ~ SEAL)
Signed, sealed published and declared by Louise V. Staver as a codicil
to her Last Will and Testament and so done in the presence of we the
witnesses who sign at her request and in her presence and in the presence
of each other.
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