HomeMy WebLinkAbout10-12-11J 15D5610140
REV-1500 EX `°'-'°'
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
Po Box 2sosol INHERITANCE TAX RETURN
2 1 1 1
0 3 0 1
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Deat h MMDDYYYY Date of Birth MMDDYYYY
2 3 D 2 4 O D 3 7 0 1 3 0 2 0 1 1 0 6 3 0 1 9 2 5
Decedent's Last Name Suffix Decedent's First Name MI
K O V A C E V I C G O L D I E A
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WIl-H THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-E.2)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
QX 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 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 SIiOULD BE DIRECTED TO:
Name Daytime Telephone Number
M U R R E L W A L T E R S I I I E S Q 7 1 7 6 9 7 4 6 5 0
First line of address
5 4 E A S T
Second line of address
City or Post Office
M A I N S T R E E T
State ZIP Code
REGISTER Ot`D~'ILLS USE ONLS'
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DAZEt FILED
hl E C H A N I C S B U R G P A 1 7 0 5 5
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Correspondent's a-mail address:
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.
SIG T-U~1R~E OFD PERSON RESPONSIBLE FOR FILING RETURN )ATE
~L)~ u ll~~~i ~rs.~ hl rt ~ ~ ~i ~ ~r' l
ADDRESS
CONNIE M S VE~RINO,'~916 EMIL RIDGE DRf1ECHANICSBURG PA L7~,
SIGNATURE OF R A p, ER FIAN REPRESENTATIVE ~ ~~q~ iG ~~ /
v'
ADDRESS
MURREL R W LTERS, III ESQ 54 E• MAIN MECHANICSBURG PA 17055
PLEASE USE ORIGINAL FORM ONLY
Side 1
150561,0],40 1,505610140
1505610240
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: GOLDIE A• KOVACEVIC 2 3 0 2 4 0 0 3 7
RECAPITULATION
1. Real Estate (Schedule A) ........................................... 1. 1 6 D 7 ~ D . 3 4
2. Stocks and Bonds (Schedule B) ...................................... 2. 5 6 7 1 . 7 8
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. 1 2 9 9 9 8 , 4 8
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested . .... .. 6.
7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property
(Schedule G) ~ Separate Billing Requested . .... .. 7.
8. Total Gross Assets (total Lines 1 through 7) ..................... .... .. 8. 2 9 6 4 4 0 6 0
9. Funeral Expenses and Administrative Costs (Schedule H) ............ .... .. 9. 1 5 5 8 2 . 8 2
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... .... .. 10. 1 3 9 9 4 . 7 3
11. Total Deductions (total Lines 9 and 10) ......................... .... .. 11. 2 9 5 7 7 . 5 5
12. Net Value of Estate (Line 8 minus Line 11) ...................... .... .. 12. 2 6 6 8 6 3 . 0 5
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 Tax (Line 12 minus Line 13) ................ .... .. 14. 2 6 6 8 6 3 . 0 5
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) x .o _ 0 0 0 15. O. D 0
16. Amount of Line 14 taxable
at lineal rate X .045 2 6 6 8 6 3. 0 5 16. 1 2 0 0 8. 8 4
17. Amount of Line 14 taxable
at sibling rate X .12 D D D 17. D. D D
18. Amount of Line 14 taxable
at collateral rate X .15 D D D 1 g, D. D D
19. TAX DUE ................................................ .... ..19. 1 2 D D 8. 8 4
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
1505610240 15D561024CI J
REV-1500 EX Page 3
Decedent's Complete Address:
File Numher
21 11 0301
DECEDENT'S NAME
GOLDIE A. KOVACEVIC
STREET ADDRESS
6121 WERTZV ILLE ROAD
CITY
ENOLA STATE
PA ZIP
17025
Tax Payments and Credits:
~ Tax Due (Page 2, Line 19) (1) 12,008.84
2. Credits/Payments
A. Prior Payments 10,000.00
B. Discount 500.00
Total Credits (A + B) (2) 10,500.00
3. Interest
(3)
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. (4) 0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 1,508.84
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 : ............................................................. ......... ^ ^X
b. retain the right to designate who shall use the properly transferred or its income; ...................... ......... ^ ^X
c. retain a reversionary interest; or ....................................................................................... ......... ^ 0
d. receive the promise for life of either payments, benefits or care? .............................................. ......... ^ ^X
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................. ......... ^ ^X
3. Did decedent own an "intrust for" or payable-upon-death bank account or security at his or her death? ......... ^ ^X
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? ......................................................................................... ......... ^
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)]. Asibling 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-1502 EX+ (01-10)
pennsylvania ~ SCHEDULE A
DEPARTMENT OF REVENUE
REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
GOLDIE A. KOVACEVIC 21 11 0301
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knouvledge of the relevant facts.
Real property that is jointlyowned with right of survivorship must be disclosed on Schedule F.
Attach a copy of the settlement sheet if the property has been sold.
ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1. 6121 WERTZ VILLE ROAD 160,770.34
ENOLA, PA 17025
NET SALE PRICE
TOTAL (Also enter on Line 1, Recapitulation.) I $ 160,770.34
If more space is needed, use additional sheets of paper of the same size.
OMB Approval No. 2502-0265
,';~II~~ A. Settlement Statement HUD-1
~; !~l;p.,~ ~ ~ FINAL
~=
~X FHA 2
~ Conv. Unins.
~ RHS 3
1 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number:
.
.
. 11-0556GC 0286551833 4460859596-703
4. ~ VA 5. Q Conv. Ins.
C. Note: This form Is furnished to glue you a statement of actual settlement costs. Amounts paid to and by the settlement agents are shown. Items marked
"(p.o.c)" were paid outside the closing; they are shown here for Informational purposes and are not inclutled In the totals.
D. Name & Address of Borrower: E. Name 8: Address of Seller F. Name. 8 Address of Lender:
Gary Gingrich, Beth M Winlermyer The Eslale of Goldie Kovacevic by her Executor Connie SunTrust IJlorigage, Inc.
209 N. Railroad St., Apl. 5, Palmyra, PA 17078 M. Severino 901 Semmes Avenue, Richmond, VA 23224
6121 Wertrville Road, Enola, PA 17025
G. Property Location: H. Settlement Agent: I. Settlement Date: 08/3'V2011
6121 Wertzville Road Guardian Transfer Corporation Disbursement Date: 08!31/2011
Enola, PA 17025 4075 Merkel St., Camp Hill, PA 17011
Hampden Township
717-614-4098
Place of Settlement: TitleExpress
4075 Market Slreel, Camp Hill, PA 17011 Printed 08!30/2011 at 3:51 pm
by JMG
100, Gross gmount Due from Borrower 400. Gross Amount bue to Seller
101. Contract sales price 172,000.00 401. Contract sales price 172,000.00
102 Personal properly 402. Personal property
103. Settlement charges to bonower (line 1400) 6,683.59 403.
104. 404.
105. 405.
Adjustments for Items paid b seller in advance Adjustments for items aid b seller in advance
106. City/town taxes l0 406. Cityllown taxes to
107. County taxes 08131!2011 to 12!3112011 164.07 407. County faxes 08/3112011 to 12/3112011 164.07
108. School taxes 0813112011 to 0613012012 1,579.73 408. School taxes 06!3112011 l0 0613012012 1,579.73
109. Sewer 06/31/2011 to 09/3012011 50.54 409. Sewer 08!3112011 to 09/3012011 50.54
110. 410.
111. 411.
112. 412.
120. Gross Amount Dua from Borrower 180,477.93 420. Gross Amcunt Due to Seller 173,794.34
200;- Amounts.Pald by or in Behalf of Boi7ower 500. Raductlona lniAmount.DUe to Seller
201. Deposit or earnest money 3,000.00 501. Excess deposit (see instructions)
202. Principal amount of new loan(s) 167,639.00 5D2. Settlement charges to seller (line 140C) 13,024.00
203. Existing loan(s) taken subject to 503. Existing loan(s) taken subject to
204. 504. Payoff of first mortgage loan
205. _
505. Payoff of second mortgage loan
206. 506.
207. 507.
208. 508.
209. 509.
Adjustments far items unpaid by seller Adjustments for items unpaid by seller
210. Cityltowntexes to 510. City/towntexes to
211. County taxes to 511. County taxes to
212. Schooltexes to 512. Schooltexes to
213. 513.
214. 514.
215. 515.
216. _
516.
217. _
517.
218. _
518.
219. 519.
220 Total Paid b Ifor Borrower 170,639.00 520. Total Reduction Amount Due Seller 13,024.00
300. -.Cash at Sektl.erilent (ronyto'Borrower 600. Cash at Settlement tdfrom Seller
301. Gross amount due from borrower (line 120) 180,477.93 601. Gross amount due to seller (line 420) 173,794.34
302. Less amounts paid bylfor borrower (line 220) 170,639.00 602. Less reductions in amount due seller (line 520) 13,024.00
303. Cash nX From ~ ToBorrower
•Re 9,838.93 603. Cash QX To ~ FromSeller 160,770.34
o+ e
eflk ~~~c.`emsp+y+•cvrenry wea OrABCWrd n+roer. NO COneE+N1e11Ylee+sueq lNe Eledoeue l+m+Ma1vY.TJ+Ia Eeslgr,eE la O~aNEelee Oerlle+loa RESRACOVe~eEtnnsacllon Mlf, Inlorm+Ilon tlurlny lM
Previous editions are obsolete Page 1 of 4 HUD-1
700, TotarRearEstateBrdker Fees S 1Ds15.DO - Peid From ': Paid; From'
Division ofeommissiori(Iine700)osfdllows- 13brrower'S SE?Iler'S
701. $5,355.00 fo ERA-NRT, LLC. I FUndS dt: FundS dt
702. $5,160.00 to Coldwell Banker Homestead Group ~ie1:i;IP_rilellt:. SECt12I712111:
703. Commission paid et settlement 10,515.OD
704. Broker Fee to Coldwell Banker Homestead Group 350.00
__
800. - Items Pa stile In Connection with. Loan
801. Our origination charge (Includes Origination Point 2.500% or $4,190.98) $4,749.50 (from GFE #1) ~-
602. Your credit or charge (points) for the specific interest tale chosen $-4,619.62 (from GFE #2)
603. Your adjusted origination charges (from GFE A) 70.12
804. Appraisal fee to Rid a Marketin Assoc (from GFE #3) 425.00
805. Credit report to Credco (from GFE #3) 25.00
BO6. Tex service to (from GFE #3
807. Flood certification to Corelo is Flood Serv. (from GFE #3) 6.00
BOB. Final Inspectien to Ridge Marketin Assoc. (from GFE #3) 110.00
900. rrltems Required by Lender to be Paidih Advance
901. Deily interest charges from tram 0813112011 to 0910112011 @ $20.670D/day (from GFE #10) 20.67
902. Mortgage insurance premium for months to (from GFE #3)
903. Homeowners insurance for 1 years to State Ferm $635.D0 P.O.C.(B')(from GFE #11)
904. UFMIP for months to Dept of HUD (from GFE #3) 1,659.80
1000.'Reserves:De osited.witb Lender
1001. Initial deposit for your escrow account (from GFE #9) 754.49
1002, Homeowner's insurance 3 months $ 52.911month $158.73
1003. Mortgage insurance months $ 157.901monlh $
1004. Property taxes months $ 0.00/month $
1005. County taxes 7 months $ 40.571monlh $283.99
1006. Schoel taxes 3 months $ 157.97/month $473.91
1007. Aggregate Adjustment $-162.14
1100: Title Chap es -
1101. Title services end lender's title insurance from GFE #14 1,510.75 30.00
1102. Settlement or closing fee to $
1103. Owner's title insurance -Title Resources Guaranty Company from GFE #5) 20.00
1104. Lenders title insurance -Title Resources Guaranty Company $1,423.75
1105. Lender's title policy limit $167,639.00 Lenders Policy
1106. Owners title policy limit $172,000.00 Owners Policy
1107. Agent's portion of the total title insurance premium $1,163.44
to Guardian Transfer Co oration
1108. Underwriters portion of the total title insurance premium $280.31
to Title Resources Guaran Com en
1109. -
1200. Government Recording and TragsfecCharges
1201. Government recording charges $ (from GFE #7) 152.00
1202. Deed $62.00 Mort a e $90.00 Release $
1203. Transfer taxes $ (from GFE #8) 1,720.00
1204. CitylCountytax/stemps Deed $1,720.00 Mortgage$
1205. SteteTex/stamps Deed $1,720.00 Mortgage$ 1,720.00
1206. Deed $ Mort age $
1207. $ -
1300. AdditlonaLSettlemenLCtiarges-"
1301. Required services that you can shop for (from GFE #6)
1302. Survey to $
1303. to -
1304. Deed Prep Fee to ERA-NRT, LLC. 100
00
1305. Home Warranty to American Home Shield _ .
659.00
fifer ~ '~ - ' r - 6,683.59 13,024.00
'Paid outside of closing by (B)orrower, (S)eller, (L)ender, (I)nvestor, Bro(f()er. ''Credit by lender shown on page 1. "'Credit by seller shoam on page 1.
Previous editions are obsolete Page 2 of 4 HUD-7
Com arlson of Gddd Falth`Estlmate (GE and HUD•1 Char es Good Faith Estimate c HUD-1
Char esTfiat;Cannotlncrease HUD-1 Line Number
Our origination charge. # 801 4,749.50 4
749.50
Your credit or charge (points) for the specific interest rate chosen f{ 802 -4,819.62 ,
-4,(119.62
Your adjusted origination charges y .803 -70.12 -70
12
Transfer taxes N 1203 1,720.00 .
1,720.00
char es That In Total Canhot Increase More Than 1D%
Government recording charges rE 1201 Good Faith Estimate
175.00 :HUD-1
152 00
AppraisaPfee p 804 400.00 425
00
Credit report g 805 ' 25.00 .
25
00
Flood cerluicalion p 807 - 6.00 .
00
6
rival Irispection y 808 150.00 .
110
00
UFMIP y 904
Title services end lender's Lille insurance g `1101
Owner's title insurance-Title Resources Guaranty Company p 1103 1 fi59.8D
1 748.75
500.00 .
1,659.80
1,510.75
20.OG
4,664.55 3,908.55
r ~ :: $ -756.00 a r -16.2074
Char ee That Can Cfian a
Inltialdepi)sitloryourescroweccoun( d 1001 Good Faith Estimate
2,800.00 HUD•1
754
49
Dailyinterest charges from p 901 $20.6700/da 20.67 .
20
67
Homeowner's Insurance g 903 600.00 .
635.00
d
f# --
~ --
Loan Terms
Yourihitial lbah amount is $167,fi39.00
Your loan term is 30. years
Your inltlal Interest rate is 4.5000°
Your Initial monthly amount owed for principal, interest, end any mortgage $1,007.31 includes
Insurance is
QX Principal
- - ^X Interest
~X Mortgage Insurance
Can your interest rate rise? ^X No. ~ Yes, it can rise to a maximum of %. The first change
will be on I I end can change again every years alter 1 I .Every change
date, your interest rate can increase or decrease by %. Over the life of the loan, your
interest rate is guaranteed to never be lower than % or higher than °/ .
Eveh if you mike payments on lime, can your loan balance rise? QX No. ~ Yes, it can rise to a maximum of $
Even d you makepeyments on time, can your monthly amount owed for ^X No. ~ Yes, the first increase can be on ! / and the monthly
principal, inf Brest, and mortgage insurance rise? amount owed can rise to $
. The maximum it can ever rise to is $
Does your loon have a prepayment penalty? QX No. ~ Yes, your maximum prepayment penalty is $
Does your loan have e balloon payment? QX No ~ Yes, you have a balloon payment of $ due in
years on I I
Total monthly amount owed including escrow account payments ~ You do not have a monthly escrow payment for items, such as property taxes
end homeowner's insurance. You must pay these items directly yourself.
^X You have an additional monthly escrow payment or $251.45
that results in a total initial monthly amount owed of $1,254.76 This includes principal, interest, a'
mortgage insurance end any items checked below:
QX Property Lazes QX Homeowner's insurance
Flood insurance ~ School Taxes
^_ ^
Nate: If you have any questions about the Settlement Charges and Loan Terms listed on this corm, please contact your lender.
Previous editions are obsolete Page 3 of 4 HUD-7
HUD CERTIFICATION OF BUYER AND SELLER
1 have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, it is a true and accurate statement of all receipts and
disbursements made on my account or by me In this transaction. 1 further certify that I have received a copy of the HUD-t Settlc:menl Statement.
Gary Gingrich
Beth M. Wintermyer
Lev / v u~e. ~ • C~ f~,[r{/4.(.f~l.l1
The Estate of Goldie Kovecevic by her Executor Connie M. Severino
The HUD-1 Settlement Statement which I have prepared is a true and accurate account of this transaction. I have caused or will cause the funds to be
disbursed In accordance with this statement.
~V
r
S ~Ty MENT ~ T DATE
bNARNING IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPOfJ
CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE iB'. U.S. CODE SECTION 1001 AND SECTION 1010.
Previous editions are obsolete Page 4 of a HUD-]
a ! r
Name of Borrower.
Gary Gingrich
Beth M Wintermyer
Name of Seller
The Estafe of Goldie Kovacevic by her Executor Connie
M. Severino
File Number
i t-OSS6GC
Prepared 08!3012011 at 3:51 pm
Note: This page displays an itemization of the charges shown on line 1101 of the HUD-1 Settlement S1:atement This page
accompanies but Is not a part of the HUD-1 Settlement Statement If a discrepancy exists, the information on the HUD-1 Settlement
Statem ant applies.
1100. Title Charges Total Gharge - Borrower Seller -
1101, Title services end lender's title insurance to
Wire In to Guardian Transfer Corporation $ 12.00 12.00
Notary Fee- Purchasers to Guardian Transfer Corporation $ 25.00 25.00
Courier Fee-Purchase to Guardian Transfer Corporation $ 15.00 15.00
Electronic Document Fee to Guardian Transfer Co oration $ 35.00 35.00
Notary Fee- Sellers to Guardian Transfer Co oration $ 20.00 20.00
Tax Cert Reimbursement Fee to Guardian Transfer Corporation $ 10.00 10.00
1102. Settlement or closing fee to $ 0.00
1104. Lender's title insurance -Title Resources Gto Title Resources Guaranty Comp;$ 1,423.75 1,423.75
Totals: 1,540.75 0.00 1,510.75 30.00
SellerlLander credits shownon page 1 '~- POC =.Paid OutsideCldsirig CR-=lender Credit-
Previous editions are obsolete Page 1 of 1 HUD-7
REV-1503 EX + (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
GOLDIE A. KOVACEVIC 21 11 0301
All property jointlyowned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
PRUDENTIAL
COMMON STOCK
5,671.78
TOTAL (Also enter on line 2, Recapitulation) I $
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
GOLDIE A. KOVACEVIC 21 11 0301
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointlyowned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. PRUDENTIAL 43,783.55
ANNUITY
2. PRUDENTIAL
ANNUITY
3. PERSONAL PROPERTY
PER APPRAISAL BY JEFFREY A. NOAKER
4. SUSQUEHANNA
CHECKING
66,629.24
3,400.00
16,185.69
TOTAL (Also enter on line 5, Recapitulation) I $ 1
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+(10-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
GOLDIE A. KOVACEVIC 21 11 0301
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. MALPEZZI FUNERAL HOME, MECHANICSBURG, PA 9,888.32
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s) CONNIE M. SEVERING (RENOUNCED)
Street Address 3916 EMIL RIDGE DRIVE
City MECHANICSBURG State PA Zlp 17050
Year(s) Commission Paid:
z, Attorney Fees: MURREL R. WALTERS, III
3. 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
4• Probate Fees: CUMBERLAND COUNTY REGISTER OF WILLS
5 Accountant Fees:
6. Tax Return PreparerFees:
7. JEFFREY A. NOAKER, PERSONAL PROPERTY APPRAISAL
TOTAL (Also enter on Line 9, Recapitulation)
If more space is needed, use additional sheets of paper of the same size.
5,250.00
384.50
60.00
REV-1512 EX+ (12-08)
pennsylvania SCHEDULE
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
GOLOIE A. KOVACEVIC 21 11 0301
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. SARAH TODD HOME 149.77
RESIDENTIAL CARE
2. MILLENIUM PHARMACY 1,302.89
PRESCRIPTIONS
3. U.S. TREASURY 28.00
INCOME TAX
4. MICHAEL LANGAN, TAX COLLECTOR 477.13
COUNTY/TOWNSHIP REAL ESTATE TAX
5. MICHAEL LANGAN, TOWNSHIP TAX COLLECTOR 1,857.77
SCHOOL REAL ESTATE TAX
6. HARTMANISCHEUCHENZUBER 250.00
TAX PREPARATION
7. NATIONWIDE 864.00
HOMEOWNERS INSURANCE
8. HAMPDEN TOWNSHIP 270.00
SEWER AND REFUSE
9. VERIZON 23,87
TELEPHONE
10. H.D. McCLURE 334.00
FURNACE SERVICE
11. PPL 880.73
ELECTRIC
12. BARRY HAKE 800.00
LAWN CARE
13. DON LENK 200.00
TREE REMOVAL
14. GENE LAKIN 400.00
PLASTER REPAIR
15. BRUNO REMODELING 1,678.51
REPAIRS TO HOUSE
TOTAL (Also enter on Line 10, Recapitulation) I $ 13
If more space is needed, insert additional sheets of the same size. ~
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
GOLDIE A. KOVACEVIC 21 11 0301
Decedent's Name Page 1 File Number
Schedule I -Debts of Decedent, Mortgage Liabilities, 8~ Liens
ITEM
NUMBER DESCRIPTION AMOUNT
16. HEMPT BROS., INC. 124.61
DRIVEWAY STONE
17. NB MECHANICAL 60.00
HOME INSPECTION REPAIR
18. WRIGHTSTONE 1,403.91
ELECTRICAL REPAIR
19. DAN WHITE'S PLUMBING 172.00
REPAIRS
20. EICHELBERGERS, INC. 609.50
WELL WATER REPAIR
21. ANDERSON'S CHIMNEY SWEEPS, INC. 2,107.94
FIREPLACE INSPECTION & REPAIR
SUBTOTAL SCHEDULE I 4,477.96
GRAND TOTAL SCHEDULE I $ 13,994.73
REV-1513 EX+ (01-10)
pennsylvania ~ SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
GOLDIE A. KOVACEVIC 21 11 0301
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. CONNIE M. SEVERING Lineal 266,863.05
3916 EMIL RIDGE ROAD
MECHANICSBURG, PA 17050
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ;i
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