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HomeMy WebLinkAbout08-30-11 REV-1500 EX • OFFICIAL USE ONLY PA Department of Revenue Pennsylvania - DEPARTMENTOFREVENUE County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 28o6oi RESIDENT DECEDENT 4"l. ~ ~ Harrisburg, PA ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY / 9D DDS 6 pq`D~ ,~D ~ 9 0 2 Z / gZ Z Decedent's Last Name Suffix Decedent's First Name MI (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N/~ Spouse's Social Security Number - THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ Original Return ~ Supplemental Return O Remainder Return (date of death prior to O Limited Estate O 4a. Future Interest Compromise (date of O Federal Estate Tax Return Required death after ~ Decedent Died Testate O Decedent Maintained a Living Trust Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O Litigation Proceeds Received O Spousal Poverty Credit (date of death O Election to tax under Sec. 9113(A) between and (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number T....~ REGIST ~~E ILLS USE ONLY ~ r ~Z~ ' ~ r-- r ~ _ v,,..t, r First line of address p , : ~ t-7 , ~f - Second line of address T.._. -r-{ C,,, City or Post Office State ZIP Code DATE FILED ,~~e y,~-N t C s~ u ~G i ~ ~ ssw9 ~ ~s- Correspondent's a-mail address: l: Q grl ~ ~~c~5 3 ~ W/1~tCa.S~/1~ 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. SIGNATURE F PERSON RE ONSIBLE FOR FILING RETURN DATE ADDRESS ~L B• ,~2KN0 E S• ~h ~QX S" s ,~i! SIGNATURE OF PARER OTFj~R TH EPRESENTATIVE DATE 3 ADDRESS/~jl ~ ~d~Il i ,..~r t^ ~'l Q(,ISQ/' O l~l`7~T :.ZCJ C /yl P~hcvn res b~.~.?~ pi5~ l PLEASE USE ORIGINAL FORM ON Side 1 REV-1500 EX M Decedent's Social Security Number Decedenf's Name: Gt'.f~lt~t%t ~nC lQs~ j g U ~ ~ Q 6 RECAPITULATION Real Estate (Schedule A) D Stocks and Bonds {Schedule B) d a Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C} ~ O Mortgages and Notes Receivable (Schedule D) Q O Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... rp s 3 • s O Jointly Owned Property (Schedule F) p Separate Billing Requested C7 O Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested........ Total Gross Assets {total Lines 1 through ' ~p ~ ,~j , S-j~ Funeral Expenses and Administrative Costs (Schedule H) a 3 Q • ,~b Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) Q ~ Total Deductions (total Lines 9 and 3 O . S D Net Value of Estate (Line 8 minus Line L~ ~ 3 . D ~ Charitable and Governmental Bequests/Sec Trusts for which an election to tax has not been made (Schedule J} ' . ~ O Net Value Subject to Tax (Line minus Line ~ ~ 3 . © Q TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES Amount of Line taxable at the spousal tax rate, or transfers under Sec. (a)(1.2} X O Q O ~ O ~ Amount of Line taxable at lineal rate X . ~Q . D D Amount of Line taxable at sibling rate X ~ 3 . ~o ~ a 7 • ~ 3 Amount of Line taxable ' at collateral rate X ~ 9 ~ + 3 ~ ~ 8 . ,r~ TAX DUE ~l0 7 / FILL IN THE OVAL IF YOU ARE REQUEST{NG A REFUND OF AN OVERPAYMENT p Side 2 REV-1508 EX + i~-9~1 SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. iNHERfTANCE TAX RETURN PERSONAL PROPERTY RES{DENT DECEDENT ESTATE OF i Ae S5~ FILE NUMBER o2 I ^ O q ~ ~S~ Include the proceeds of 1'itigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH aXbvn~ l~~nnq. L,'~ S ~lea~f~t Trt slur: Cam. Asn. ~;,~g~'ax ~ay-~ ~ SD TOTAL (Also enter on line Recapitulation) $ ~p (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF ~ Ik MaSS+~. FILE NUMBER ut.n~ a I- 0 ~s~ Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: B. ADMINISTRATIVE COSTS: Persona{ Representative's Commissions l / Name of Personal Representative(s) V1 L~,y1Li t~ ~.s Street Address ~ 2 p~~ oaK City ~JOt ~~)'1Gi /IQS State A~ Zip Year(s) Commission Paid: _ L J, Attorney Fees C~a~Gs ~/71~t~5 ~ --nr~vtcw 11(1a.~7.#'~alS, d ~SG,tr7$r o?'t w' ~ ~So~ ~ ~~.n~aN.~'i PK,p Tdx ~Q~~trn~ ~u.~ Chet,~lS, pncp ee~r~esP. 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 Probate Fees Accountant's Fees Tax Return Preparer's Fees ~?~l;h ~ ~ ~ s~,r e~ GV~ Its o0 g• lQeirrtburSC,~ItvY1` r ~lo~~off'es ~ ,/~?¢•%iif s! ~l~S.st~ TOTAL (Also enter on line Recapitulations $ ~ 3 (If more space is needed, insert additional sheets of the same size) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER /j1 ~-ss~; 6'~i2~~ ~~n%~ a/moo ASS 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. (a) (1.2)j -SCN ~d tct E ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES THROUGH AS APPROPRIATE, ON REV-i COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE OF REV-1500 COVER SHEET $ (tf more space is needed, insert additional sheets of the same size) :.Ta.a~af Gu a.rd ~ _.v ~ - - _ _ _ . ___._..._o...,......__.__.s'dc~_.__ . ~ ---i_._ . _ _ _ - I s o ~ ~ 7 ~yo,-~ Sf: ~ ~ztr~n ~cir~.G~ _ t P~ 7a 3 . s rZ~.6.~ shields, s~sf~r ~ .___._.__-__I °fa %dte~..._._. y? z~ 6 sued G S ~m sthcd. . - , j o rz's;d~t~t y 7 ~ ~ H ~ 1 tw Ilat i~ Rd. _ . _ _ , _ . _ . _ _ _ - ~ . _ _ n.. . , _ _ _ ..._.._...._.__..._._______....~_.w _ . _ ~'Ylc~rca ll~, G. tv; l I,' am.~ s~s~ef-_ _.m _ ~ _ _ _ .......~,fD tes;d _ ~ Park ve ...d...~ ~ .....~_._._.._.w~.~.,~~... s._ e _t.. T . _ .._..___......~.~.._.___.._.,._._..o.....__ i o D jLSf Ke . . ~x ~_.___._._.r..~._._.,......,_. ` khan-ohS_ _ ~ _ . ~..~.m___.... y~ . , _ . _ _ _ - ..w.... _ ~rirf S . G _ ? 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L. ~ s 6c~rn ~?d- art:slc_,,_ ~A / S c ~_._...-.___._._...__._.____-------.-.._.__..__w___________..__.~._~_---._....________ _~_~..._..____..~.._...._..._.___----._._---.-------y-.---~--. - .~s~.r~e.~ ~ ~o L%sa cStu a2__ Z{~m I, st.J~r~f.Cs-~___ E /S7S cat/ear p~ _!~~i___.______ ' ks: d m~chael Koth _ ~'r~ und ..._._._..__~~o rct 4t s, f Ylan he. rvt t ~ S S~ ~g scJ~rl t. s~tof . ~ ~d ~~r ~ _ . - _____________w____________.__..__.~___ - _ ~ of Polar Aye • T~ ~ e~ C c~urnlacr-laNt.d . ~ ~ o? mangy rti~e ~~rn Stlitd. _ ~a i S.~S _ ~~.1c~r? ~2d. - - ha.rn~bwr~ _ _ - __._.___...____~_n _ . . _ ~ ~ri~ _ ~ flF G. x. A gs ~Y - Bs9 S CNFD co~~ _w_..___ . _ . .t . _ . _ _ . _ - - _ ; /y1~ra,?tdQ w_ niece Yd .~f~» r s~/~/ _.M_.,... . . _ ~ . , .~,.T~... - , . w~.~_ _ C: ~?a~.~__an c F wi//:am ~icun~r Sc&d G. ,~n~~1 x~tm _ _ _ _ ` T l~u mrr~Gl~{awn~Pi~ X70 3 ~ _ . _ _ _ - _ . _ . _ _ _ v,____._.__.___.___._..___._ _ rt _ 1 f ~.~.r..__: ..r..~....... .sew. •-vur - ~-n..- .,..w..~w~.v+..a .-r ~w~.~.:.-wr..~.s..wava..~w-.. .n ..h.. r~~. f ;v... _ _ ~:.~n+r.+.+.+-~_~..r~..e...u.-r..»e..~.-......- ....-..-H-~-~arsn~eu-nr..,~+.a~n~.-ia x~rt~...~Te~:~n:.r . y..~~.. ...r..: ~v+.~~-nv~.-lv~.~....~vr.rw~r~....n'-e .~:r.u.r If i i~ l i is } t: _ ; LAST TILL AND TES`TAIVIENT OF . ~ - GE~ZALDINE t7ASSE Y I, Geraldine K. Massey, of Hampden Township, Cumberland County, Pennsylvania; declare this to be my Last Will and Testament and revoke all Wills and Codicils previously made by me. ITEM I: I direct that all my legally .enforceable debts and funeral expenses, including all expenses of my last illness, shall ~be paid from my residuary estate as soon as practicable after my decease as a part of the expense of the administration of my estate: I direct that my funeral arrangements be handled by Ewing Brothers Funeral Home of Carlisle, Pennsylvania, that my burial service be conducted by a.Roman Catholic priest, and that my body be interred in the Cumberland Valley Memorial Gardens, Carlisle, Pennsylvania. Further, I authorize my personal representative(s) to expend funds from my estate, in such amount as my personal representative(s) shall consider necessary and desirable, for the purchase, erection and inscription of a suitable marker for my grave. ITEM II: I direct that all of my tangible personal property and all of my real property be sold at public or private sale by my personal representative(s), and I further direct that the net proceeds thereof shall be administered and distributed as a part of the residue of my estate. ITEM III: I devise and bequeath the residue of my estate of every nature and wherever situate, including any property over which I shall have any power of appointment, to the following named individuals in the percentages set forth herein: A. My sister, Janet J. Wickard, of Carlisle, Pennsylvania - B. My sister, Deborah S. Shields, of Mt. Union, Pennsylvania - l C. My brother, Barry R. Covert, of Orbisonia, Pennsylvania - D. My sister, Marcella B. Williams, of Chambersburg, Pennsylvania E. My sister, Dorothy A. Bock, of Fannettsburg, Pennsylvania - F. My niece, Sharon S. Spencer, of Marysville, Pennsylvania - l G. My niece, Ginine Jordon, of Gettysburg, Pennsylvania - H. My niece, Monda Wickard, of Carlisle, Pennsylvania - I. My nephew, Brian Wickard, of Carlisle, Pennsylvania - J. My great-niece; Gracie Stayman, of Chambersburg, Pennsylvania - 1 K. My friend, Michael D. Koth, of Manheim, Pennsylvania - S% With regard to the foregoing bequests and devises, should any of the above named persons, with the exception of Michael D. Koth, predecease me, I devise and bequeath his or her share of my estate to his or her issue, per stirpes, surviving me, and in default of any such issue, his or her share of my estate shall be added to the shares for the other named persons, or their issue. In the event Michael D. Koth predeceases me, his share of my estate shall lapse and be distributed proportionately to the other named persons, or their issue. ITEM IV: I appoint Citizens Bank, of Carlisle, Pennsylvania, guardian of any property which passes, either under this Will or otherwise, to a minor and with respect to which I am authorized to appoint a guardian and have not otherwise, specifically done so, provided that this appointment of a guardian shall not supersede the right of any fiduciary in its discretion to distribute a share where possible to the minor or to another for the minor's benef t. Such guardian shall have the power to use principal, as well as income, from time to time for the minor's support, health and medical care, and education (including college education, both undergraduate and graduate), or to make payment for these purposes, without further responsibility to the minor or to any person taking care of the minor. ITEM V: Ail federal, state and other death taxes payable because of my death, with respect to the property forming my gross estate for tax purposes, whether passing under this Will or otherwise, including any interest or penalty imposed in connection with such taxes, shall be considered a part of the expense of the administration of. my estate and shall be paid out of the principal of my residuary estate without apportionment or right: of reimbursement. ITEM VI: I appoint Ellen B. Rundle of Boiling Springs, Pennsylvania Executrix of this my Last Will. ITEM VII: I direct that all fiduciaries acting under this Will, whether or not named herein, shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal, this Zg~ day of , c'. [SEAL] Th.e preceding instrument, consisting of this and two other typewritten pages, each identified by the signature of the Testatrix, was on the date thereof, signed, published and declared by Geraldine K. Massey, the Testatrix therein named, as and for her Last Will, in the presence of us, who at her request, in her presence and in the presence of each other, have subscribed our names as witnesses hereto. f . ~ ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND We, Geraldine K: Massy, Michael R. Rundle and ~ ~ ~ ~M~y the Testatrix and the witnesses, respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and that she has signed willingly, and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as .witness and that to the best of his/her knowledge the Testatrix was at that time eighteen (I8) years of~age or older, of sound mind and under no constraint or undue influence. Testatrix Witness i ess Subscribed, sworn to and acknowledged before me by Geraldine K. Massey, the Testatrix, and subscribed and sworn to before me by Michael R. Rundle and . ~ ~ v~sav~, the witnesses, this 2 ~ day of ~ , NOTARIAL S Staci L. Snyder, No lie Carliste Bora., Cumberland County My commission expires July I5, W ~ ~ ~ ° J ~ r _ • ~ CL 'r O W .cam' - Z ~ _ ~ ~ z ~ M ~ ~ Q ~a ~ ~ U c1) ~ a o~ ~ C? ~ o ~c° W N cd ? r- J ~ d N~ i3 r ~ la1 W tr N O'C3N m ~ ~ ~ Cfl7 J cA ~ ~ r' Q fl u+ ~ ~ ~ U o ~ a=~N r c1~t~U ~ N a ~ Qov s sU~ ~ U ~ c•~ i.S Sr f U~ l`. .r ~f