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Home My WebLink About08-03-11J 1505610105 REV-1500Extoz_ii)(FI) '~ PA Department of Revenue penns~ ama Bureau of Indlvldual Taxes °°`""'"'"' PO BOX 280601 ~ qE~`"u` OFFICIgt_ USE ONLY ENTER DECEDENT INFORMATION BE 601 INHERITANCE T~ RETURN C°unty Code Year RESIDENT File Number Social Security Number LOW DECEDENT ~,~ / '.ten/ 313-12-2481 Date of Death MMDDYYYY / ~ / ''"" 02/11/2011 Date of Birth MMDDYYYY Decedent's Last Name 01/23/1922 SlfnpSOn Suffix Decedent's First Name (If Applicable) Enter Survivin Mary MI Spouse's Last Name 9 Spouse's Information Below R Suffix Spouse's First Name Spouse's Social Security Number MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE FILL IN APpROPR1ATE OVAt.g BELOW REGISTER OF ~ 1. Original Retum WILLS O 2. Supplemental Retum O 4. Limited Estate O 3. Remainder Return (Date of Death O 4a. Future Interest Compromise (date of Prior to 12.13-82) O 6. Decedent Died Testate death after 12-12-82) O 5. Federal Estate Tax Return (Attach Copy of Will) O 7. Decedent Maintained a Livin Required O g. Litigation Pro (Attach Co 9 Trust 8. Total Number of Safe De seeds Received PY of Trust.) O 10. Spousal Poverty Credit (Date o~' Death posit Boxes CORRESPONDENT- THIS SECTION MUST BE COMPLETED. Between 12 31 91 and 1-1_gs) O 11. Election to Tax under Sec. 9113(q) Name ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMA7 ON SHOULD BE D REC John M. Simpson Daytime Telephone Number TED TO: (717) 423-5505 First Line of Address REGISTER OF WILLS USE pytj. PO BOX 15 ~ - ~ .. ~~ Second Line of Address t J..~? "j 1 T~ 200 West Main Street ~~ `-~'' v` - z~ City or Post Office ~'~ -_ , Newburg state _'_' -'' ZIP Code DATE ~ --- D __ ;~.-t Pq 17240 •~ ~ _ `;~ C~ Correspondent's e-mail address: t "ri Under penalties of e ~~ f ~~ ~/~1 J ~S d ~/ ~ / it is true, p Oury, I declare that I have examined this return, includin ~~~n~ ~~' ~^ ' ~ ~' correct and complete. Declaration of preparer p ~ ~ SIGNATURE OypERSON RESPONSIB~ ~r wan the g aCCOmpanying schedules and statements, and to the best of m personal representative is based on all information of which FOR FILING RETURN y knowledge and belief, ADDRESS t ~( .J Pre arer has an p y knowledge. r~ / DATE SIGNATURE OF PREP RER OTHER T qN REPR SENTq~ Uf9G, ~~ / TIVE ~ ~ ~ 1~~ ADDRESS DATE L 1505610105 Slde 1 1505610105 15056:1,0205 REV-1500 EX (FI) Decedent's Name: RECAPITULATION Decedent's Social Security Number 313-12-2491 1 • Real Estate (Schedule A). • . . . .. ............... 2~ Stocks and Bonds S ) • ~ • ~ ~ ' ~ 1~ ( chedule B 3. Closely Held Corporation, p ~ .................... ........ 2. artnership or Sole-Proprietorshi p (Schedule C) . • 3 4. Mortgages and Notes Receivabl e (Schedule D) . • . . 4 5. Cash, Bank Deposits and Miscellaneous perso nal Pro ert p Y (Schedule E)..... . 6. Jointly Owned P 5 ro e P rtY (Schedule F ~ 7• Inter-Vivos Transfers & Miscellaneous Noon-p-p (Schedule G) 9 Requested . , , . 6 Pfen 4,012.91 o ate Pro y 0 Separate Billi ng Requested.. . $~ Total Gross Assets (total Lin 7 es 1 throw 9h7).... ... 8 9. Funeral Expenses and Administrative Costs (Schedule H) . 4,012.91 . 10. Debts of Decedent, Mort a • ~ 9. 9 ge Liabilities and Liens (Schedule I 5,239.$6 ).... ~ • ~ ~ • 10. 11• Total Deductions (total Lines 9 and 10) ...... • .•.• 11 12~ Net Value of Estate (Line 8 min 149.71 us Line 11 13. Charitable and Governmental B 5,389.57 e an election to tax has not quests/Sec 9113 Trusts for which 12. been made (Sch d e ule J) ........ 14. Net Value Subject to Tax ~ ~ ~ ~ ~ ~ 13. (Li 0.00 ne 12 minus Line 13) • TAX CALCULATION _ SEE INSTRUCTIONS FOR • ~ • 15. Amount of Line 14 taxable APPLICABLE 14. RATES at th 0 00 e s transferspoundertS . ec. 911 g (a)(1.2) X .0 16• Amount of Line 14 taxable at lineal rate X .0 15. 1 ~~ Amount of Line 14 taxable at sibling rate X .12 16. 18• Amount of Line 14 taxable at collateral rate X .15 17~ 19. TAX DUE ..... . ........ ........ ... ....... ........... ......... 19. 20. FILL IN THE OVAL IF YOU ARE REQU 0.00 ESTING A REFUND OF qN OVERP AYM ENT C~ L 1505610205 Side 2 1505610205 REV-15oo EX (FI) Page 3 Decedent's Complete Address: DECEDENr~c ti,,..~ Mary Rose Simpson STREE DA DT RESS- -- 200 West Main Street PO BOX 15 CITY Newburg Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments 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 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. File Number STATE _---- PA zIP 17240 (1) 0.00 Total Credits (q + g) (2) (3) (4) (5) Make check payable to: REGISTER OF W[LLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING 1, Did decedent make a transfer and: AN "X" IN THE APPROPRIATE BLOCKS a. retain the use or income of the property transferred ............. ....................................................................... b, retain the right to designate who shalt use the property transferred or its income ..,. Yes No c. retain a reversionary interest ....... ... d. receive the promise for life of either a ............................................................................................. P Yments, benefits or care? ...................................................................... If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ............................................................... .. .... . 3. Did decedent own an "in trust for" or paya le-upon-death bank account or seairity at his or her death?.......... 4. Did decedent own an individual retirement account, annuity or other non-probate propert ^ • contains a beneficiary designations 0.00 ......... Y, which .................................. . IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST C For dates of death on or after July 1,1994, and before Jan. 1, 1995, the OMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. is 3 percent [72 P.S. §9116 (a) (1.1 I , tax rate imposed on the net value of transfers to or for (~)) For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value o [72 P,S. §9116 (a) (1.1) (ii)). The statute does not exempt a transfer to a survivi the use of the surviving spouse filing a tax return are still applicable even if the survivin s f transfers to or for the use of the surviving spouse is 0 percent For dates of death on or after Jul 1, g Douse is the only beneficiary. ng spouse from tax, and the statutory requirements for disclosure of assets and • The tax rate imposed on the net valOe of transfers from a deceased child 2 adoptive parent or a stepparent of the child is 0 percent [72 P,S. • 1 years of age or younger at death to or for the use of a natural parent, an The tax rate imposed on the net value of transfers to or for the use of the d(ecedent's lineal ben • The tax rate imposed on the net value of transfers to or for the use of the decedent's sibli under Section 9102, as an individual who has at least one parent in common with eficiaries is 4.5 percent, except as noted in ngs is 12 percent [72 P.S. [72 P.S. §9116(a)(1)). the decedent, whether by blood or adopt o(n.)(1 3))' A sibling is defined, REV-i5G8 E%+ (1-97) '' SCHEDULE E COMMONIh'EALTHOFFENNSYLVAN~A CASH, BANK DEPOSITS, ~ MSC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF ~- ~~~ ~. ~ ~~ ~'~~~,~ FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointtyowned with the right of survivorshi ITEM NUMBER p must be disclosed on Schedule F. DESCRIPTION VALUE AT DATE 1. -- ~~ ( `-l~-K OF DEATH i9c-ri ~ iSC~C ~Zi! L.~~/L~~'~/ ,/ Qom/,/ /~ /I G:~l~l'lC"~,.:h ~}CC: ~ i~ gi/s"~nC~c i~S C f~ ~7~/~t/ (D ,~t~~+ Y/.~ ~~~~ ~~,~ -~~;, ~ ~.~ f~;~c~, ,,~y ,Yz~~, - ~7y7 ~-~~rr~ g~~.~ ~ ~'Sy~J9c; ~` 3 ~ to .- Z v I TOTAL (Also enter on line 5, Recapitulation) g L~ ~ i Z+ 9 / "~ ~ or1 nrlr!(finn of choafc of fho camp ci~a) REV-1511 EX+ (10-06) ~~'~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ----- SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS __-___ /'(~"-r~ ~ ,` /{~~r~ FILE NUMBER Sin'/ ~ ITEh4 - Debts of decedent must be reported on Schedule I. NUMBER --- A. FUNERA NSES: DESCRIPTION 1. ~iJ~ :i?.~ ~r .vQ•iss~- /~C'+'~K l: s1'~.•~ /1'7'~~; ^J j ~: t. ~~ Z ~iLL t~y-ia-t-: ~ / "t ::t .v (.v rt t ~- T /'+~! .: - .i;;i ,cis .+.~J Gv ~ s r Lr,~,,,~,J ~ " ~-.~.r_T r~ .. 7s :, sue, .r-~_ B. I ADMINISTRATIVE COSTS: ~ Personal Representative's Comn'~ssicns I Name of Personal Representative(s) Street Address I City __ - ---- ----- - -- State -- Year(s) Commission Paid: Zip 4 5 6. 7. 2 Attorney Fees 3 Family Exemption: (If decedent's address is not the same as claimant s. attach explanationi Claimant Sheet Address I Cit;- - -- State _ Zip Re!at pnship o! C;faimant to Decedent Prcbate Fees I Accounlanfs Fees I Tax Return Preparers Fees AMOUNT _~,,` , t C~~~(~, 1 TOTAL (Also enter on line 9, Recapitulation) I S ~ ~ L'! (If more space is needed, insert additional sheets o` me same size) ~ ~ r G'4r REV-1512 EX+ (i2-03j CO!.'f:ION'•"~~EALTH OF PENNSYLVANIA is\'HERiTANCE TAX RETURN RESIDENT DECEDENT ESTATE nG SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ~-- ~~~n / ~~-- ~'/ ~~~~ ~~~~.1 FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical ex e ITEA -~- 1616ER p nses. DESCRIPTION VALUE AT DATE ~S LJ~//!~I'[ ~ OF DEATH ~i~!'r~~l)~ZC CMG"si>( %~.I~S ~' li ~, TOTAL (Also enter on line 10, Recapitulation) $ I (If more space is needed, insert additional sheets of the same s¢e) + ~ ~ .~ fUl i Linglestown Road Harrisburg, P.~ 17112 (717 j 652-8888 warr~ti R_ HOO~'t;l', Jr., ~Crrl~ert:isvr• ~- ~. __ii t ~--~ ~- ---V-~ _---- oov~r Funen] f3"owes & Ctamatory, dnc. "Uur Family Sensing li~aer Faniilti. fit. Fi»e Gerretutians" tivwtiv.hooverfuneralhome. com John M. Simpson 200 W. Main Street, P O Box 15 Newburg, PA 17240 Funeral Expenses for Mary Rose Simpson Professional Services, Use of Facilities, Automotive Equipment and Necessary Documents ~ 1,625.00 Merchandise Selected Riverstone Gray cultured marble urn (engraved) TOTAL FUNERAL HOME CHARGES ~ 325.00 Cash Advanced Items Coroner Authorization Fee ]2 Death Certificates @ $6 ea S 25.00 TOTAL CASH ADVANCED CHARGES ~ 72.00 TOTAL FUNERAL & CASH ADVANCED CHARGES BALANCE DUE: I_ f ,,C ~~ ~~~~=- _.~ - Route 422 & Lucy Avenue P.G. Box 475 Hershey, P.A 17Q33 (717) 53;-7700 Sheldon K. Hoover, ~'rrpe~ risor ~~ ~a ~- ,..~ _ . February 18, 2011 ~1,950.Oo ~ 97.00 ~ a,oa~.oo ORIGINATING ~ EMPLOYEE NUMBER °DST DEBIT WIP TRANSACTION CENTER AUTHORIZATION ____ _ SUB PRODUCT ACCOUNT # _ ~' ~ ~ ~ r I I` ~ I ~ I I CUSTOMER NAME (PRIN"~ DESCRIPTION I J- ~.~--- i GF-269 (8/07) DATE ________ ' j Original -Processing Work ---"-~'`- {' .---- CopY -Branch ; , i,. ~ I - CU OMER S((,,~NATURE G/L NO. POSTING COST CTR. JULIAN DATE ORIGINATING COST CENTER SEQ. NO. z , 9 0 ~ , -$ ,~ ~ i , ~~ ~r- -I~ A~ ORIGINATING _ EMPLOYEE NUMBER CENTER ~' 1, I cOST DEBIT WIP TRANSACTION AUTHORIZATION __ ~F zF9 `e'°'' SUB PRODUCT ACCOUNT # ~ ~ ' ,. ------- -_ DATE - ~ ," ,' DESCRIPTION ~ ~ ~ ~ I I r `+ I i - CUSTOf~1ER NAME (PRjN~ ~- ~ ~". i - i . ---'--t-_ ~ , ..__ ! _ Original -Processing Work ~--~---' ' Copy -Branch `~ ~ ~------ ~ ~ ~ + I I t . -- CUS7~OMER SIGNATURE _ G/L }VO. POSTING COST _CTR. ORIGINATING 2 1 JULIAN DATE COST CENTER `--~--L_J ~ 7 $ ~ I i r, SEQ. NO. ~' ° ~~ [~ ~I AMOUNT / ~~ I __~ __ _ __ _.. __ _ __ ((~~ _ _ . _ ORIGINATING ~~ EI I I ENU~~___l DEBIT WIP TRANSACTION COST ~1 W CENTER GF-zss Is.~o71 AUTHORIZATION - --------------_ DATE ~_ SUB PRODUCT ACCOUNT # _ ~' ~ ~ ~ r ~ ~ ' ~ ~ ~ I CUSTOMER NAME (PRINT) DESCRIPTION _I _._t ~ ------_-~---- - j Original -Processing Work ~ ~' -7` - `~- Copy -Branch ~.- ~ ~ ~,~ l ~ \ CU` OMER S{GNATURE G/L NO. POSTING COST GTR. JULIAN DATE ORIGINATING ( COST CENTER SEQ. NO. 2 1 9 0 7 8 71 ,' 1- JJ AMOUNT _.. ORIGINATING EMPLOYEE NUMBER j CENTER ~ CDST DEBIT Wip TRANSACTION I ~ AUTHORIZATION ._ ~ GF-26s1e~°" SUB PRODUCT ACCOUNT # ,.~ --------_ DATE=i - ~ 'f DESCRIPTION ! GUSTO -~- ! ~~ (ryIER NAM----- E ~pR~N~ ' ` r. _...._ ij ~ ~ - ~ Original -Processing Work - _-___- ~ ~ Copy -Branch ~ -r , "; r F -~ ~ CUS R IGNATURE G/L "NO. POSTING COST ~^ ~ ORIGINATING TR. JULIAN DATE `2 1 9 0 7 $~ (' COST CENTER O- (~, - (, SEQ. NO. L _ AMOUNT ~~ j