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HomeMy WebLinkAbout09-21-11 1505610101 REV-1500 ex(°, _1°' PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes ~F~^^T«F~~~°Wt~~«~r County Code Year File Number INHERITANCE TAX RETURN PO BOX 280601 Harrisburg. PA 1'7128-0601 RESIDENT DECEDENT °Z I ~ ~ ' ©~~~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY ! ~ ~- 1 ~ - i ~ ~ Y 03/27/2009 ~a~d~/.l 9aa ........................ Decedent's Last Name Suffix Decedent's First Name MI :Clem S. Ray (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Clem Martha A Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 177-24-6239 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ® 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of 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 Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number Andrew C. Sheely, Esquire ' 717-697-7050 First line of address 127 South Market Street Second line of address P.O. Box 95 City or Post Office State ZIP Code Mechanicsburg PA '17055 Correspondent's a-mail address:andrewc.sheely@verizon.net REGISTER CtF jNILLS USE ONL-Y "-o ;:: _r~ =`'~ -,, ~~ rn :- , ~'. ~... D,~~ FILED "" _~_, ~= J L_) . -.. ~ 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 OF PERSON RESPONSIBLE FOR FILING RETURN r1ATC pnnRF~S Martha Ann Clem, Executrix, 61 Longwood Drive, Mechanicsburg, PA 17050 SIGNA E O PREP~RL R TH REPRESENTATIVE _ DATF CL/ ~' ~'` 4~1 blll pnnr~FCc Andrew C. Sheely, Esquire 7 South Market St., P.O. Box 95, Mechanicsburg, PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 7 1505610101 1505610101 J J 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: CI@fll, S. R8y /. ? "'7 y /~ _ /~ r1 ~ / L ! 6 7 7 REC APITULATION 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. $861.03' 6. Jointly Owned Property (Schedule F} O Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property - - (Schedule G) O Separate Billing Requested..... ... 7. 8. Total Gross Assets (total Lines 1 through 7) .......................... ... 8. $861.03' 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. $286.50 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........... ... 10. 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. $286.50'. 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. $574.53 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... .. 13. 14. Net Value Subject to Taz (Line 12 minus Line 13) ...................... .. 14. ' $574.53 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers undo cec. 9116 (a)(1.2) x .00 $574.53 15. $0.00 16. Amount of Line 14 r~~gble at lineal rate X .0 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. _..........$0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L, 1505610105 1505610105 J REV-1500 ~X Page 3 Decedent's Complete Address: File Number ~ ~ _ /~ - ~ ~ / / DF(:Fr1FNTC NAAAF S. Ray Clem STDCCT Ar1r1DCCC _ - ..- -.- --__._.__-..__ 61 Longwood Drive Mechanicsburg srarlpA ' Z117050 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments _ B. Discount 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 2Q 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} (3) (4) (5) 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 : ..................................... ....... ^ (~f c. retain a reversionary interest; or ................................................................................................................... ....... ^ [~ d. receive the promise for life of either payments, benefits or care? .............................................................. ....... ^ [~ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of dea#h without receiving adequate consideration? ........................................................................................................ ...... ^ [~ 3. Did decedent own an "in trust for" orpayable-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? .................................................................................................................. ...... ^ ~]! $0.00 $0.00 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)]. A sibling 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} ~' _. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDVLE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF S. Ray Clem 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. FILE NUMBER 21-11-0911 (If more space is needed, insert additional sheets of the same size) ti .a m i^ W O a m r u-t O :. Q' ti O to r ti LJ'1 r o ~ ,b ~ ~ o ' ri ri ~ ° ~ mrn < ~ ~ . ~M ~~--~yy L-.1 L-J H (,~ o' 'a ~ d o ~ , ~ d ~ ! ~> _ ~ f ~ ~ x ~ H ~ ~ _ r-3 k-' J ~ ~ i O N", ~ ~ o '3 ~ d • 0 ~ ~ O `;` C c o ° '~ ~ ~ m ~ ~1 Ct~ p ~; ~ O ~ ~ z ~ ~ ` 1 ~ Z ~ i; ~ v - o Z, ~: ~`. f: ~ N : N w 4 { < m ~ o d l I7~v-1; it ex+ rio-oy> v~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF S. Ray Clem FILE NUMBER 2.1-11-0911 Decedent's debts must be reported on Schedule I. )0 )0 i0 .p 50 Ir more space is needed, use additional sheets of paper of the same size. RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 CLEM S RAY Receipt Date: 8/29/2011. Receipt Time: 10:41:44 Receipt No.: 106679 Estate File No.: 2011-00911 Paid By Remarks: MARTHA ANN CLEM DB ------------------- ----- Receipt Distribution ----- -------- ------- ---_ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 20.00 CUMBERLAND COUNTY GENERAL FUN WILL SHORT CERTIFICATE 15.00 8.00 CUMBERLAND CUMBERLAND COUNTY COUNTY GENERAL GENERAL FUN FUN JCS FEE AUTOMATION FEE 23.50 5.00 ------ BUREAU OF RECEIPTS CUMBERLAND COUNTY & CNTR GENERAL M.D FUN Check# 2313 ---------- $71.50 Total Received..... .... $71.50 REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER S. Ray Clem 21-11-0911 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. Martha Ann Clem, 61 Longwood Drive, Mechanicsburg, PA 17050 Spouse 100°!o Rest, Residue of FGtatp ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART I) -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ (If more space is needed, insert additional sheets of the same size) .~ LAST RILL I, S. Ray Clem, of 414 Orr's Bridge Road, Camp Hill, Cumberland County, Pennsylvania, declare this to be my Last Will, hereby revoking all prior Wills and Codicils. FIRST: I direct that the expenses of my last illness and funeral be paid out of my estate as soon after my death as is convenient and expeditious in the judgment of my Executrix, hereinafter named. SECOND: I give, devise and bequeath my entire estate to my beloved wife, Martha Ann Clem, provided she survive me by a period of thirty days. THIRD: Should my wife, Martha Ann Clem, predecease me or die on or before the thirtieth day following my death, then and in that event, I give, devise and bequeath my entire estate to my son, Ray Eugene Clem. FOURTH: I have made no provision in this my Last Will for my natural born daughter, Patricia E. Fike, as I do not wish her to receive any share of my estate. FIFTH: I have made no provision in this my Last Will for my two adopted daughters, Stephanie L. Fisher and Kimberly A. Clem a/k/a Kimberly A. Dworchak, as I do not wish them to receive any share of my estate. SIXTH: I have made no provision in this my Last Will for my two step-daughters, Belinda L. Dellinger and Rebecca A. Hench, as I do not wish them to receive any share of my estate. SEVENTH: I hereby nominate, constitute and appoint my wife, Martha Ann Clem, Executrix of this my Last Will. Should my wife, Martha Ann Clem, be unable to so serve for any reason whatsoever, then and in that event, I nominate, constitute and appoint my son, Ray Eugene Clem, Executor of this my Last Will. I further direct that they shall not be required to post any bond to secure the faithful performance of their duties in the Commonwealth of Pennsylvania or in any other jurisdiction. R. SCOTT CRAMER Attorney at Law 5 S. Market St. P.O. Box 159 )uncannon, PA 17020 IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will, which consists of two (2} sheets of paper, dated this day of , 2003. (SEAL ) . Ra Clem The writing contained on this and the one preceding page was signed and sealed by S. Ray Clem, and by him published and declared as his Last Will, in the presence of us, who have hereunto subscribed our names as witnesses at his request, in his presence, and in the presence of each other.. R. SCOTT CRAMER Attorney at Law 5 S. Market St. P.O. Box 159 )uncannon,PA 17020