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Home My WebLink About08-01-11J 1505610140 REV-1500 EX (01-10) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 1 1 0 2 7 4 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 2 0 7 3 4 6 7 2 1 0 2 2 2 2 0 1 1 0 9 1 3 1 9 4 4 Decedent's Last Name Suffix Decedent's First Name MI S P O T T S KENN ETH E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death prior to 12-13-$2) ^ 4. Limited Estate ^ 4a. Future Interest Compromise (date of ^ 5. Federal Estate Tax Return Required death after 12-12-82) ^ 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) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number J A M E S H TURNER E S QU I R E REGISTER OF WILLS USE~ONLY First line of address 4 7 0 1 N O R T H Second line of address City or Post Office H A R R I S B U R G F R O N T S T R E E T State ZIP Code P A 1 7 1 1 0 C7 :: :z:= .~? -~~ ~. ~ -`3 t ~ - .--i U - . ~ `-- _ - ~,_ ._.. , l7AT LED .. T7 ~-' -%: ,~ :: Correspondent's a-mail address: jht@tUrflef811d000nneII.COfn unoer 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 o^ all information of which preparer has any knowledge. SIG l~E OF PERSOf~I Fi~ESPONS~F~OR FILING RETURN DATE ~.e _ V a n ADDRESS 24 Presb SIGNATU&E'C Side 1 1505610140 1505610140 J 4701 North Front Street Harrisbura PA 17110 PLEASE USE ORIGINAL FORM ONLY 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: KENNETH E. SPOTTS 2 0 7 3 4 6 7 2 1 RE CAPITULATION 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. 2 2 2 6 0 . 5 9 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested . .. ... 6. 2 5 0 • 0 0 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested .... ... 7. 3 7 0 2 0 , 2 2 8. Total Gross Assets (total Lines 1 through 7) ........................ ... 8. 5 9 5 3 0 , 8 1 9. Funeral Expenses and Administrative Costs (Schedule H) ............. ... 9. 7 2 8 1 5 0 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .......... ... 10. 1 6 0 9 6 . 8 4 11. Total Deductions (total Lines 9 and 10) ............................ ... 11. 2 3 3 7 8 . 3 4 12. Net Value of Estate (Line 8 minus Line 11) .......................... .. 12. 3 6 1 5 2 . 4 7 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 6 1 5 2 . 4 7 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 6 1 5 2 4 7 1s. 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 6 2 6. 8 6 0. 0 0 0. 0 0 1 6 2 6. 8 6 Side 2 1505610240 1505610240 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 11 0274 DECEDENT'S NAME KENNETH E. SPOTTS STREET ADDRESS 1101 YVERDON DRIVE, APT. A6 CITY STATE ZIP CAMP HILL PA 17011 Tax Payments and Credits: ~ Tax Due (Page 2, Line 19) (1) 1,626.86 2. CreditslPayments A. Prior Payments B. Discount Total Credits (A + B) (2) 0.00 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3) Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 1,626.86 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; ........................ ...... ...... ^ ^X c. retain a reversionary interest; or .................................................................................... ^ ^X ...... 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? .................................................................................. ..... ^ 0 3. Did decedent own an "in trust for" or payable-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? ............................................................................................. ..... ^X ^ 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)(1.3)]. 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-1508 EX + (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, Sc MSC. IN R SI DENTEDECEDEN TN PERSONAL PROPERTY ESTATE OF FILE NUMBER KENNETH E. SPOTTS 21 11 0274 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. Balance from personal checking account 4,423.42 2. Balance from savings account 1,321.23 3. Vacation payment from employer Dura-Bond Pipe 1,058.23 4. Worker's compensation benefit check 1,274.80 5. Reimbursement from Donegal Mutual auto insurance policy 74.00 6. Pennsylvania state income tax refund 49.91 7. Federal income tax refund 59.00 8. 1992 Firebird-inoperable 100.00 9. 2007 Buick 13,900.00 TOTAL (Also enter on line 5 Recapitulation) I $ 22 260 59 (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY tJ lql t UF: FILE NUMBER: KENNETH E. SPOTTS 21 11 0274 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. Dawn L. Miller 24 Presbyterian Drive daughter Mechanicsburg, PA 17050 e C JOINTLY•OWNED PROPERTY: 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 % OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTERESI 1. A. 2003 Oldsmobile Alero-90,000+ miles very poor condition; 500.00 50. 250.00 no lien on title TOTAL (Also enter on Line 6, Recapitulation) I $ 250 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+ (08-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY t51ATE OF FILE NUMBER KENNETH E. SPOTTS 21 11 0274 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 NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION pF nPPUCAe~e) TAXABLE VALUE 1. Retirement savings plan through employer; Dawn L. Miller 37,020.22 100.00 0.00 37,020.22 beneficiary TOTAL (Also enter on Line 7 Recapitulation) I $ 37 020 22 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF KENNETH E. SPOTTS SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS FILE NUMBER 21 11 0274 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: 1. KM Knight Funeral Home 2~ Crypt Plate-Rolling Green Cemtery 3. Funeral luncheon-Eberly's Church of God B. 1 State Zip Year(s) Commission Paid: ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City 2, attorney Fees: Turner and O'Connell 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 ZIP Relationship of Claimant to Decedent Probate Fees: Register of Wills Accountant Fees: Tax Return Preparer Fees: TOTAL (Also enter on Line 9 Recapitulation) I $ If more space is needed, use additional sheets of paper of the same size. AMOUNT 6,318.00 535.00 100.00 250.00 78.50 7,281. 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 KENNETH E. SPOTTS 21 11 0274 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. PPL Electric Company 319.67 2. Roadside Rescue-towing of car from location of death 125.00 3. VISA credit card balance 1,316.04 4. Verizon Phone/Cable 73.03 5. Cindy Rowe Auto Glass-repair of window broken by EMS to access decedent 100.00 6. Wells Fargo-lien on 2007 Buick 14,163.10 TOTAL (Also enter on Line 10, Recapitulation) $ 16 096.84 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-t0) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: KENNETH E. SPOTTS 21 11 0274 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. Dawn Miller Lineal 24 Presbyterian Drive Mechanicsburg, PA 17050 36,152.47 I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS 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 ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ If more space Is needed, use additional sheets of paper of the same size.