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Home My WebLink About10-05-111505610143 REV-1500 Ex(0,_,D> PA Department of Revenue Bureau of Individual Taxes oP~~M Sy~Ra~Na _OFFICIAL USE ONLY PO BOX.280601 County Code near Harrisburg, PA 17128.0601 INHERITANCE TAX RETURN File Number ENTER DECEDENT INFORMATION BELOW RESIDENT DECEDENT 2 ~' 11 Social Security Number ~ C~~ ~- 7 9 5 0 4 g 0 3 Date of Death Date of Birth 08 09 2011 Decedent's Last Name DUNIlK Suffix 12 22 1958 Decedent's First Name DENIS MI M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name DUMM Suffix Spouse's Social Security Number FILL IN APpROPR1ATE OVALS BELOW t. Original Return 4. Limited Estate ^~ g, Decedent Died Testate (Attach Copy of Will) L ^ 9. Litigation Proceeds Received Spouse's First Name ANDj MI M THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS ^ 2. Supplemental Return ^ 4a. Future Interest Compromise (date of death after 12 -12-82) ^ 7. Decedent Maintained a Living Trust (Attach Copy of Trust) ^ 10. batweeri P2 31 f de th 1 a d~t ~ a 8 n dagsj l ^ 3. Remainder Return (date of death prior to 12-13_g2) ^ :i. Federal Estate Tax Return Required - O 8. Total Number of Safe Deposit Boxes Name (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL Tt I Election to tax under Sec. 9113(A) GEORGE F DOUG AX INFORMATION SHOULD BE DIRECTED TO: LAS III E$Q Daytime Telephone Number 717 249 6333 n First line of address REGISTER OF ~ USE O N+,Y ..r ,I', ~.CCj r.. 354 ALEXANDER SPRING RO ~r~_.,-- ~'" - r-r-, Second line of address ' -47 r,~ - - _i -_ -.~ „*, ,,`..- City or Post Office ~ , ~,~~ - CARLISLE State DATE FILED - ~~ ~ ZIP Code Z'A 17015 Correspondent's a-mail address: gdOU IaS Under penalties of g @salzmannhughes.com pequry, I declare that I have examined this return, includin accom it is true, correct and complete. Declaration of preparer other than the personal representative is based on all infor SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN g \ panying schedules and statements, and to the best of m 1 m mation of which preparer has anowledge and belief, y knowledge. ADDRESS ~-- Ann M Dumm DATE ~Y ~ J ---- •-~Q~ ~arnsle PA 17013 SIGNATURE OrF~P,REPARER OTHER THAN REPRESENTATIVE '~-L ~r ADDRESS f-= George F Douglas, III Esq. 354 Alexander Sprin Road, Suite 1, Carlisle, Pq L Side 1 1505610143 DATE (1 1505610143 J .~ti~' 1505610243 REV-1500 EX Decedent's Name: Dumm, Denis M, Decedent's So i RECAPITULATION c al Security Number - 1 Real Estate (Sched l _1.79 50 4903 u e A) .............. ........... .......................................................... 1. 2. Stocks and Bonds (Schedule B) .......................... ................................................... 3. Closely Held Cor oration, Partnershi or Sole-Pro ri P p t 2 e orshi p p (Schedule C)......... 3 4. Mortgages & Notes Receivable S h ( c edule D).......... .. ......................... . 4 p 5 Cash, Bank De osits & Miscellaneous Personal P ro ert p Y (Schedule E) ............... 6• Jointly Owned Pr 5. o ert 7. Inter-Vivos Transfe ^ Separate Billing R l ) 1 r 500.00 rs & Miscel an equested.......... eou s (Schedule G) Probate Propert ~~ 6. y Separate Billing Requested............ 8. Total Gross Asset 7 s (total Lines 1-7)..., .... ... --- ..................... 21 ,000.00 ..... ---~- 8. 9. Funeral Expenses & Administrative Costs (Schedule H)....... -~ -~ 22,500.00 ... 10. Debts of Decedent, Mort a 9. 9 ge Liabilities, & Liens Sched l ( 5 ~ 015.0 0 u e I ............ ) 10. 11. Total Deductions (total Lines 9 & 10)........ ........... 8,000.00 .................................... 11. 12. Net Value of Estate (Line 8 minus Line 11)... 13. Charitable and G ........ 13 ~ 015 ' 0 0 ........................................ 12. overnmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J 9,485 00 ........... ~ 13. 14. Net Value Subject to Tax (Line 12 mi ) . nus Line 13 .....,...... ------ TAX COMPUTATION - ) ~~~~~~~~~~~~ ~ •~~'~ '~~' ~ ~~ •~~• 14. SEE INSTRUCTIO 15 . Amount of Line 14 taxable -- NS FOR APPLICABLE RATES 9 485 • OO at the spousal tax rate, or transfers under S ec. 9118 (a)(1.2) X .00 16. Amount of Line 14 taxable 9 ~ 485 • 00 15 . at lineal rate X 17~ Amount of Line 14 ta 0 00 0 • 00 . xable 1s. at sibling rate X .12 1 0 0 0 8. Amount of Line 14 taxable 0 • 0 0 17 . . at collateral rate X .15 0.00 0.00 1s. 19. Tax Due .. .............. .................. 0 . 0 0 ................................................. 19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUE STING A REFUND OF AN OVERPAYME NT. L 1505610243 Side 2 1505610243 REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME __ Dumm, Denis M. STREETA ERDD SS 932 Forbes Road CITY Carlisle Tax Payments and Credits: 1 Tax Due (Page 2, Line 19) 2 Credits/Payments A. Prior Payments B. Discount 0.00 3. Interest File Number 21-11 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. Check box on Page 2 Line 20 to request a efu tlPAYMENT. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. FATE ZIP PA 17013 (1) Total Credits (A + g) (2) (3) _~_ (4) (5) - Make Check Payable to REGISTER OF ;., ~ ~~ ,., ~; WILLS AGE e am the use or income of the property transferred :................ . b. retain the right to designate who shall use the property transferred or its income :.............. Yes No c. retain a reversionary interest; or....... ~ ~~ ~ ~ ^ .................... x d. receive the promise for life of either a .................................................................................................... P yments, benefits or care?....... 2. If death occurred after December 12, 1982, did decedent transfer ro ert ^ ^ receiving adequate consideration?....... ^ .............................. .p P y within one year of death without x 3. Did decedent own an "in tru t f " 0.00 0.00 ~.~Q PLEASE ANSWER THE FOLLOWING f ~ ~,+ rnti~.:yi,~,~f~ ,~,, NT a_;,..: w ,.;.~,~ ~ , ,_ QUESTIONS BY PLACING AN °' °~ ~ ~~~~~~ ~ ~ ~~ ~~~~ ~ ~~ 1. Did decedent make a transfer and: X IN THE AppROpRIATE BLOCKS a rt~ a rt contains a beneficia ya e u on death bank account or securit at Pis or her death?....... ^ ^ 4. Did decedent own an Individual Retirement Ac ount, annuit , or other non- roba y ^ ^ IF THE ANSWER TO ANY OF THE gBOVEignation?..... x r y P to pro e .... x ................................ Y whu:h - _ QUESTIONS IS YES YOU ................................................. ., , ---_ __ MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF ~E RETURN. For dates of death on or after July 1, 199q and before Jan j1, 199$, the tax rate imposed on spouse is 3 percent [72 P.S. §9116 a ~'" ~' ~`~'- -: - __ For dates of death on or after JanuaO (1 1) (f)j the net value of transfer o or for the use^of the survivor 72 P.S. § ry 1, 1995, the tax rate imposed on the net value of transfers to or for the use g [ 9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a survivin assets and filing a tax return are still applicable even if the survivin For dates of death on or after July 1, 2000: g spouse from tax, and the statutoryhequirements~or d sclosprercofnt g spouse is the only beneficiary. • The tax rate imposed on the net value of transfers from a deceased child 21 adoptive parent, or a ste 72 P.S. §9116 1.2 O (1.2)j. . The tax rate imposed on phe net voalue o transfers t or for the use of the dece years of age or younger at death to or for the use of a natural parent, an [72 P.S. §9116 (a) (1 dent's lineal beneficiaries is 4.5 percent, except as noted in . The tax rate imposed on the net value of transfers to or for the use of the decedent's sibling is defined under Section 9102, as an individual who has at least one siblings is 12 percent [72 P.S. 8116 (a) (1.3)j. A parent in common with the decedent, whether by blood or adoption. Rev-1508 EX+ (g_gg) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY Dumm, Denis M. FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the fastate. 21 _11 all property jointl -oevned with the ri ht of survivorshi Y 9 p must be disclosed on schedule F. ITEM NUMBER 1 1997 Chevrolet Blazer DESCRIPTION VALUE AT DATE OF DEATH 1, 500.00 TOTAL (Also enter on (If more space is needed, additional pages of the same size~Ltne 5, Recapitulation) Copyright (c) 2002 form software only The Lackner Group, Inc. 1,500.00 Form Pq-1500 Schedule E (Rev. 6-98) Rev-1510 EX+ (g_gg) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dumm, Denis M. SCHEDULE G INTER-VIVOS TRANSFERS ~ MISC. NON-PROggTE PROPERTY' FILE NUMB This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1 21 ~~ ~ ER 50~ COVER SHEET is yes. ITEM DESCRIPTION OF PROPERTY NUMBER THE DATE O MTR~NSFER SATTACN q COPY OF TIHE DEIED OR REAL ESTATE. DATE OF DEATH % OF DECD'S 1 Quietside Cor VALUE OF ASSET INTEREST EXCLUSION poration -401(k); beneficia (IF APPLICABLE) Dumm, spouse rY Ann M. 21,000.00 100.000% TOTAL (Also enter on Line 7, I Recapitulation) Copyright (c) 2002 form software only The Lackner Groups Inced, additional pages of the same size) TAXABLE VALUE 21~ 21,000.00 Fonrl Pq_~500 Schedule G (Rev. 6-98) REV•1151 EX+(10.06) SCHE COMMONWREALT~EOF PENNSUUYLVANIA D~~E H IN RESIDENT DE~ DENTRN FUNERAL EXPENSES ~ ESTATE OF ADMINISTRATIVE COSTS Dumm, Denis M. FILE NUMBER ITEM Debts of decedent must be reported on Schedule I. 2111 N MBER DESCRIPTION '4• FUNERAL EXPENSES: AMOUNT B• ADMINISTRATIVE COSTS: 1 Personal Representative's Commissions Name of Personal Representative(s) Street Address ~- City Year(s) Commission paid State Zip ---'-. 2 Attorney's Fees Salzmann Hughe P s, .C. 3. Family Exemption: (If decedent's addr 1,500.00 ess is not the same as claimant's, attach explanati Claimant Ann M. Dumm on) Street Address 932 Forbes Road 3,500.00 city Carlisle Relationship of Claimant to Decedent State Pq Zip 17013 S ~- pouse ~__ ~-~ 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees ~ Other Administrative Costs See continuation schedule(s) attached 15.00 TOTAL (Also enter on line 9, Recapitulation) Copyright (c) 2009 f orm software only The Lackner Group, Inc. 5,015.00 Form PA_1500 Sched ule H (Rev. 10-06) FUNERAL EXPENSES~AND VLE H ADMINISTRATIVE COSTS continued ESTATE OF -- Dumm, Denis M. ITEM NUMBER Qther Adrttinict..• 1 Resister of Wills -filing fee Copyright (c) 2002 form software only The Lackner Group, Inc. DESCRIPTION FILE NUMBER 21-11 AMOUNT H-B7 Four PA-1500 Schedule H (Rev. 6-98) 15.00 15.00 Rev-1512 EX+ (12.08) COMMON WEALTH OF PENNSYLVANIA INHERITANCE 7qX RETURN RESIDENT DECEDENT ESTATE OF Dumm, Denis M. SCHEDULE ~ DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21-11 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical ITEM NUMBER expenses DESCRIPTION 1 Philip Cohen -balance due on Sears credit card VALUE AT DATE OF DEATH 8, 000.00 TOTAL (Also enter on Line 10, Re tion) Copyright (c) 2009 form software only The Lackner Groupn Inced, additional pages of the same size) 8,000.00 Form PA-1500 Schedule I (Rev. 12.Og~ REV-1513 EX+ (11-09) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dumm, Denis M. NUMBER NAME AND ADDRESS OF PERSON(Sl RECEIVING PROPERTY j, TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers 1 under Sec. 9116 a 1.2 Ann M. Dumm 932 Forbes Road Carlisle, PA 17013 FILE NUMBER RELATIONSHIP TO 21'11 DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE t (Words) ($$$) SpouseEntire- Cn[er tlollar amounts for distributions shown above on lines 15 throw h 18 on Rev 15 IO cover sheet, as a I NON-T Total II. A. SPOU8AB pIgTRIBUT ONSNUNDER SECTION 9113 FOR WHICH AN ELECTION TO TA,'K IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS .. ~ ~~ ur PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright (c) 2009 form software only The Lackner Group, Inc. Forrn Pq_1500 Schedule J (Rev. 11-08) SCHEDULE J BENEFICIARIES '`~==_---- - Corporation 8750 Pioneer Boulevard Santa Fe Springs CA 90670 Tel :562 699 6066 Fax :562 699 4351 Web : www.quietside.com Denis Dumm -Survivor Benefits -Ann rt. Dumm Survivor/Ber.~eficiary In light of the tragic accident that Denis has suffered, we are prepared to offer the following to help you transition through these difficult times. Quietside will pay all Funeral expenses Quietside will pay regular salary on 8/15, plus accrued vacation o~f 15 days Quietside will continue to pay Denis's regular salary until 12/31/2C~11(Tax will have be paid as this will count as income). Payments will made on a monthly basis. ~iC 401(k) can be rolled over or taken as a lump sum, there is approximately $21,000 in this ~! account. There is no penalty for early withdrawal of the fund valuE~ or it can be rolled into another contributing fund. Quietside will make COBRA payments until 12/31/2011 to ensure health benefits are maintained until the end of the calendar year. Unfortunately we have no record of any life insurance policy held b~y the company on Denis, the only policies we have cover death or disfigurement on company premises during working f yours. Again let me on behalf of Quietside extend our heartfelt sympathies and condolences. John Miles Vice President