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Home My WebLink About10-03-11COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1 7 1 28-0601 RECEIVED FROM: IRWIN & MCKNIGHT 60 WEST POMFRET ST CARLISLE, PA 17013 REV-1162 EX(11-96) PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT N0. CD 015028 ACN ASSESSMENT AMOUNT CONTROL NUMBER fold ESTATE INFORMATION: ssN: 204-oa-0259 FILE NUMBER: 211 1-0952 DECEDENT NAME: ADAMS ETHEL C DATE OF PAYMENT: 10/03/201 1 POSTMARK DATE: 10/03/201 1 couNTY: CUMBERLAND DATE OF DEATH: 05/26/2011 101 ~ 5183.70 TOTAL AMOUNT PAID: REMARKS: RECEIPT TO ATTY SEAL CHECK# 30932 $183.70 INITIALS: HMW RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS 15D5610140 -~ REV-1500 ~ (01-10) OFFICIAL USE ONLY County Code Year File Number PA Department of Revenue ~ I ~' of Individual Taxes INHERITANCE TAX RETURN Bureau Po Box 2aosol RESIDENT DECEDENT Harrisbur , PA 17128-0801 ENTER DECEDENT INFORMATION BELOW. Date of Death MMDDYYYY MMDDYYYY Date of Birth Socia- Security Number 0 5 2 6 2 0 1 1 0 9 2 4 1 9 2 D MI 2 0 4 0 3 0 2 5 9 Suffix Decedent's First Name ~ Decedent's Last Name E T H E L A D A M S MI Souse's Information Below Suffix Spouse's First Name licable) Enter Surviving P (If App Spouse's Last Name mber N ATE WITH THE TURN MUS I u Spouse's Social Security THIS RE WIL-I-S TER OF REGIS 3. Remainder Return (date of death FILL IN APPROPRIATE OVALS BELOW ~ 2 Supplemental Return prior to 12-13-82) 1. Original Return 5. Federal Estate Tax Return Required ^ romise (date of 4a. Future Interest Comp osit Boxes 4. Limited Estate death after 12-12-82) _- g_ Total Number of Safe Dep 7. Decedent Maintained a Living Trust s. Decedent Died Testate (Attach Copy of Trust) ~ 11. Election to tax under Sec. 9113(A) (Attach Copy of Will) ~ 10. Spousal Poverty Credit (date of death (Attach Sch. O) 9. Litigation Proceeds Received between 12-31-91 and 1-1-95) ST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIADL ~ l e Oel~hoOne NuOmberBE DIRECTED TO: CORRESPONDENT -THIS SECTION MU E S Q 7 1 7 2 4 9 2 3 5 3 Name U I R E REGISTER ~H-ILLS USE ONLY '~„~ R O G E R B I R W I N ~ W First line of address I R W I N & Second line of address 6 D W E S T City or Post Office C A R L I S L E M ~ K N I G H T P C- p O M F R E T S T R E E T State ZIP Code L P A 1 7 D 1 3 '' ~ " + ~ ~ - _..I ~ x7 ~ r " r ~ t - ` , --, r_~ _ _- E ~ILED ' - - ~ ~ ; ~;> : =T-, . knowledge and belief, Correspondents a-mail address: accompanying schedules and statements, and to thefeea~er has any knowledge. ersonal representative !s based on all information of whit p Under penalties of perjury, I declare that I have eeaa ereother than the p luding DA E it is true, cortect and complete. Declaration of p p RETURN t' d $ ! ~ ,.,...~wrl laF nF PERSON RESHO1jIS~BL~F, FOR FILI~I~ ADDRESS 384 LAKE MEADE DRIVE ..,i.w~eTi iR69F PREPARER OTHER TH REPRESENTATIVE i. IURCJV 0 WEST ~ FRET ST T BERLI CARLISLE T~USE ORIGINAL FORM ONLY Side 1 1505610140 pA 17316 D TE ~ 0~3~~, PA 17013 150561D140 Oh20'[9505'C Oh20'L9SOS'C Z ap!S 1N3WAtld213A0 Ntl d0 ONfi~321 tl ~JNI1S3f1D321 3?!tl fIOA dl ltln0 3H1 NI llld ~OZ 3f34 Xtll '6L ............... 0 z' E B 'I ............. '6l 5l~ X ales le~alelloo le ~gl. 0 0 Q algexel bl awl;o lunowy ~SL Q 0 ' 0 Z3• X ales 6ullgls le •~~ 0 0 Q algexel ql. aull;o lunowy 'LL 0 0 ' 0 540' X ales leaull 3e 'gl E 2 2 Q 0 h algexel 4l au!l bo lunowy 'gL Q~, E Q ,~ p' X (Z'l)(e) gl, Q p 0 gll,g •oaS aapun spa;sueal 0 0' 0 ~o 'ales xe} lesnods ayl le algexe3 4l au!l to lunowy 'S L S31tl?! 3l9tlOllddtl 2104 SN0110f3211SN133S - NOlltllflOltlO X'dl (83 awl snww Zl awl) xel of;aafgng amen 3aN ~Vl ...................... E 2 '2 Q O h .~I ue el of uoll ............... I.f alnPa4oS) spew uaaq lou sey x u ' • cJ ....... e £ l e £ l yolynn ~o} slsn~l £ L L6 oaS/slsanbag leluawwano pue alq 3. 40 ~ Zl ............................ (L L aull snww g aull) alels3;o amen ~aN E 2' 2 Q 0 h 'Z6 .............. (O L Pue 6 scull lelol) suol;anpa0 lelol ~ l l .............. 2 0 '0 6 2 9 .13 ... .. ~ • • ~ ~ • • • ~ • • (I alnpayoS) suall pue 'salllllgell a6e6}~oIIV `luapaoaa }o slgaa 'OL . O h' h S E h 01 ue sasuadx3 le~aun~ '6 .................. (H alnPa4oS) slso~ anlle~lslulwpy P 2 9 ' S E 6 'C '6 (~ y6nwyl l scull lelol) slasstl sso~0 le3ol .E .......................... 5 2' 2 Z E O 'C .g {O alnpayoS) •~ ~ • • • ~ ~ • palsanba2l 6ugllg ale~edag ~ snoauepaoslW '8 spa;sued sonln-~alul 'L ad-u N e a d • } g ad ~a aunn0 Rllulof '9 alsanba~ 6ulpl8 aleaedag ~ (~ alnPa4oS) ~(}~adad P .. . • • g p • .......(3 alnpayoS) ~C~ado~d leuos~ad snoauepaosllN pue sllsodaa ~lue8'yse0 'S . 5 S 2 ~ 2 ~ E 0 ~ (O alnpayoS) algenlaoaa saloN pue sa6e6}~oW '4 .......................... .b • • • (O alnpayoS) dlys~olaudad-clog ~o dlys~au~ed 'uolle~od~o0 plaH ~lasol~ '£ ... . £ .......... (9 alnpayoS) sPuoB Pue s~loo3S 'Z ......................... ... .Z • ...................................... {y alnpayoS) alels3 lea2i ' L .... .} NOIltll1311dtl0321 S W y Q y '~ 13 H .L 3 :aweN s,luapaoaa 6 5 2 0 E 0 h 0 2 x3 005 ~-nla ~agwn-.I +~3!~noag leloog s,luapaoa4 Oh20'L9SOS'C REV-1500 EX Page 3 Decedent's Complete Address: DECEDENTS NAME ETHE_ L C_A~t STREET ADDRESS 700 WALNUT cITY CARLISLE 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 greatF'ti ~n ovlal on Page 2, Liner20 toirequest a refund.P OVERPAYMENT. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. File Number 0 0 STATE PA ZIP 17013 (1) 183.70 Total Credits (A + B) (2) (3) 0.00 (4) 0.00 (5) 183.70 Make check payable to: REGISTER OF WILLS, ~~GENT LOWING QUESTIONS BY PLACING AN "X" IN T'HE APPROPRIATE BLOCKS PLEASE ANSWER THE FOL Yes No Did decedent make a transfer and: .. •.•.• ^ 0 a. retain the use or income of the property transferred; nate who shall use the property transferred or its income; .••••••••••••••••••••••-•• desi t [] ••"' ^ X g o b. retain the right .......................................................................... ..... c. retain a reversionary interest or ............... d. receive the promise for life of either payments, benefits or care? nsfer property within one year of cieal.h t t ^ X ra 2. If death occurred after December 12,1982, did deceden ~ ^ ^ •. without receiving adequate consideration? • • • • • • • • • • • oath? n-death bank account or " ' l t ty ... • • • orpayable-upo 3. Did decedent own an "intrust for i ch rty, wf e ro o ate tirement account, annuity or other non pr P P l ^ re 4. Did decedent own an individua contains a beneficiary designa ion .................. 0 ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDIILE G AND FILE IT AS PART OF THE RETURN. IF THE ANSWER T ; 11 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 For dates of death on or after Ju y , 3 percent [72 P.S. §9116 (a) (1.1) (i)]. r dates of death on or after Jan.1,1995, the tax rate imposedson the net value of transfers to or for the ease of the surviving spouse is percen fer to a surviving spouse from tax, anti the statutory requirements for disclosure of assets and Fo [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a tran 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: x rate im osed on the net value of transfers from a deceased1 6 a21 2 ] rs of age or younger at death to or for the use of a natural paten , an Theta p adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9 ()( • 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)]. sed on the net value of transfers to or for the use of the dec eddecedentnwhether by blood o~ adoption16(a)(1.3)]. Asibling is defined, un • The tax rate Impo Section 9102, as an individual who has at least one parent in common with t REV-1506 EX + (6-98) SCHEDULE E COMMONWEALTIi OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY _ RESIDENT DECEDENT FILI= NUMBER ESTATE OF 0 0 ETHEL C. ADAMS Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned Huth right of survivorship must be disclosed on Schedule F. VALUE AT DATE ITEM DESCRIPTION _ OF DEATN NUMBER 10,372.25 ~. ORRSTOWN BANK -CHECKING ACCOUNT #146001845 TOTAL (Also enter on line 5 Recapitulation) I $ 10, 372.25 (If more space is needed, insert additional sheets of the same s ee) REV-1511 EX+ (10-09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITAN~~ETAXRETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT BILE: NUMBER ESTATE OF 0 0 ETHEL C. ADAMS _ Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION _ AMOUNT NUMBER A. FUNERAL EXPENSES: 662.12 ~. FUNERAL LUNCHEON - RILLOS g. ADMINISTRATIVE COSTS: ~, Personal Representative Commissions: Name(s) of Personal Representative(s) SVeet Address State ZVP _ City Year(s) Commission Paid: 1,200.00 2 Attorney Fees: IRWIN & McKNIGHT, P.C. 3 Family Exemption: (If decedents address is not the same as claimants, attach explanation.) Claimant Street Address State ;SIP City Relationship of Claimant to Decedent 4, Probate Fees: Accountant Fees: 5. g. Tax Return Preparer Fees: 30.00 7 REGISTER OF WILLS -FILING FEE -INHERITANCE TAX RETURP~ 43.50 g. REGISTER OF WILLS -FILING FEE -PETITION TO SETTLE Sti9Al_L ESTATE TOTAL (Also enter on Line 9, Recapitulation) I $ 1 If more space is needed, use additional sheets of paper of the same: size. REV-1512.EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE( DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8~ LIENS FILE NUMBER I) 0 ESTATE OF ETHEL C. AuHrvi~ Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. VALUE AT DATE OF DEATH ITEM DESCRIPTION _. NUMBER 4,060.98 ~. FOREST PARK HEALTH CENTER 2. (CAPITAL BLUE CROSS -APRIL AND MAY PREMIUM 293.42 TOTAL (Also eater on Line 10, Recapitulation) I $ If more space is needed, insert additional sheets of the same si~:e. .4f REV-1513 EX+ (01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ETHEL C. ADAMS ~~ 0 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. BARBARA L. NICKEL Lineal 2,041.11 384 LAKE MEADE DRIVE 1/2 REMAINDER EAST BERLIN, PA 17316 2. DOROTHY A. BECKER Lineal 2,041.12 48 DERBYSHIRE DRIVE 1/2 REMAINDER CARLISLE, PA 17015 I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF R,EV-1500 COVER SHEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT T~4KEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1;i00 COVER SHEET. I $ tf more space is needed, use additional sheets of paper of the same size. Q~sTOWIv B~ A Tradition of Excellence August 11, 2011 Law Offices Irwin & McKnight, P.C. West Pomfret Professional Building 60 West Pomfret St. Cazlisle, PA 17013 Fax: 249-6354 Re: Estate of Ethel C. Adams Social Security Number 204-03-0259 Date of Death 5/26/11 IT IS HEREBY CERTIFIED THATOT~HS OWN BANK D DECEDENT HAD THE FOLLOWING ACCOUNT WITH CHECKING ACCOUNT Account No.- 146001845 Account Type- 50+ Interest Checking Date Opened- 7/14/10 Joint Account (name/date)- No Balance_ $10,372.02 Accrued Interest- $0.23 Best Regards, `Q , ~ ~ J ~~~ J' R. Worthington Deposit Processing Clerk 2695 Philadelphia Avenus Chambersburg, PA 17201 1.888.ORRSTOWP STATEMENT Forest Park Health Center Resident: Adams, Ethel (22740) 700 Walnut Bottom Road Location: - Carlisle, PA 17013 Statement Date: 6/1/2011 (888) 880-7090 ALL TRANSACTIONS PROCESSED AFTER May 31, 2011 WILL APPEAR ON YOUR NEXT STATEMENT Barbara Nickel 384 Lake Meade Drive East Berlin, PA 17316 Amount Due $4,060.98 PLEASE DETACH AND RETURN WITH YOUR PAYMENT Amount Enclosed $ Forest Park Health Center Resident: Adams, Ethel (22740) 700 Walnut Bottom Road Location: - Carlisle, PA 17013 Statement Date: 6/1/2011 (888) 880-7090 Effective Date Description BALANCE FORWARD 5/5/2011 Payment - #115 5/16/2011 Payment - #TF 279 & Board charges May 1-24 2011 (STD) 5/1/2011 5!1/2011 Room "" Room & Board charges May 1-31 2011 (STD) "' 5/3/2011 Beauty/Barber 5/13/2011 Beauty/Barber 5/19/2011 Beauty/Barber 5/1/2011 thru 5/25/2011 Laundry Charges BALANCE DUE Units. Unit Amount Amount . $17,099.65 ($8,170.65) ($3,090.02) 24 $274.00 $6,576.00 -31 $274.00 ($8,494.00) 1 $20.00 $20.00 1 $50.00 $50.00 1 $20.00 $20.00 25 $2.00 $50.00 PLEASE CALL WITH ANY QUESTIONS: 888-880-7090 TRACT EXT. 872 $4,060.98