HomeMy WebLinkAbout10-20-11 (2)1505610143
REV-1500 Ex (01.1°'
PA De artment of Revenue OFFICIAL USE ONLY
p Pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO 60X.280601 INHERITANCE TAX RETURN 21 10 0 933
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
197 03 0642 09 04 2010
Decedent's Last Name Suffix
HENDERSON -
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
1. Original Return
4. Limited Estate
I-~ g Decedent Died Testate
'-I (Attach Copy of Will)
9. Litigation Proceeds Received
Date of Birth
10 14 1916
Decedent's First Name MI
WILLIAM L
Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
2. Supplemental Return ^ 3. Remainder Return (date of death
prior to 12-13-82)
^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required
(date of death after 12-12-52)
~ Decedent Maintained a Living Trust ~ 8. Total Number of Safe De osit Boxes
^ (Attach Copy of Trust) P
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 SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
FOREST N MYERS 717 532 9046
First line of address
137 PARK PLACE WEST
Second line of address
City or Post Office
SHIPPENSBURG
State ZIP Code
PA
,,
REGISTER f7F_!CI~ILLS USE ONLY _~_
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DATE FILED
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Correspondent's a-mail address: fnmyers@lawofficeforestmyers.com
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 ' rue, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATUR FpE SON RESP LE FOR FILING RETURN DATE
Orrstown Bank
77 E King Street P O Box 250, Shippensburg, PA 17257
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
~-r-*~._. Forest N Myers ~ _ t _ -Za~~
ADDRESS v
137 Park Place West, Shippensburg, PA
Side 1
1505610143 1505610143 J ~q
1505610243
REV-1500 EX
Decedent's Social Security Number
~e~edent'SName: HENDERSON -Supplemental, William L. 197 03 0642
RECAPITULATION
1. Real Estate (Schedule A) ....................................................................................... 1.
1,458.54
2. Stocks and Bonds (Schedule B) ............................................................................. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3.
4. Mortgages & Notes Receivable (Schedule D) ........................................................ 4.
2,434.54
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billinq Requested............ 6.
7. Inter-Vivos Transfers & Miscellaneous Noq Probate Property
(Schedule G) a Separate Billing Requested............ 7.
g. Total Gross Assets (total Lines 1-7) .................................................................... . g.
3,893.08
533.08
9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10.
11. Total Deductions (total Lines 9 & 10) ................................................................... 11.
533.08
12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12.
3,360.00
13. Charitable and Governmental Bequests/Sec 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.
3,360.00
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
15
0
0 0
(a)(1.2) X .00 . .
16. Amount of Line 14 taxable
840
00
16
37.80
.
at lineal rate x .045 .
17. Amount of Line 14 taxable
0
0 0
17
0
0 0
.
at sibling rate X .12 . .
18. Amount of Line 14 taxable
2
5 2 0. 0 0
18.
3 7 8. 0 0
,
at collateral rate x .15
19. Tax Due ................................................................................................................. . 19. 415.8 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-10-0933
DECEDENT'S NAME
HENDERSON -supplemental, William L.
STREET ADDRESS
210 Big Spring Road
CITY STATE
Newville PA ZIP
17241
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.
Check box 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.
Make Check Payable to: REGISTER OF WILLS, AGENT.
(3)
(4)
(5) 415.80
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 :..................................
^ --
c. retain a reversionary interest; or ............................................................................................................... ^ '^
d. receive the promise for life of either payments, benefits or care? ............................................................ ^ ^'
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ................. ^ ^
3. Did decedent own an "in trust for" or payable 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? ..................................................................................................................
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 January 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.
(1) 415.80
Total Credits (A + B) (2)
Rev-1503 EX+ (6-98)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF (FILE NUMBER
HENDERSON -supplemental, William L. 21-10-0933
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER CUSIP
NUMBER
DESCRIPTION
UNIT VALUE VALUE AT DATE
OF DEATH
1 591568108 37 shares of Metlife Inc - Com 39.42 1,458.54
TOTAL (Also enter on Line 2, Recapitulation) 1,458.54
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98)
Rev-1508 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
HENDERSON -supplemental, William L. ~
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with the right of survivorship must be disclosed on schedule F.
ITEM
NUMBER
DESCRIPTION VALUE AT DATE
OF DEATH
1 Adams Electric -Capital Retirement refund 48.25
2 Appalachian Orthopedic Center LTD -refund 266.67
3 Blue Mountain Anesthesia Assoc -refund 23.34
4 Carlisle Regional Medical Center -refund 43.98
5 Commonwealth of Pennsylvania -refund 130.00
6 Highmark -refund of unrealized premium 513.42
7 Presbyterian Homes -refund 408.88
8 Union Labor Life Ins Co. -funeral benefit payable to estate 1,000.00
FILE NUMBER
21-10-0933
TOTAL (Also enter on Line 5, Recapitulation) I 2,434.54
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98)
REV-1151 EX+(10-06)
COMMNHERITANCE~ AX RETURNANIA
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF I FILE NUMBER
HENDERSON -supplemental, William L. 21-10-0933
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A, FUNERAL EXPENSES:
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Orrstown Bank
Street Address 77 E King Street P O Box 250
city Shippensburg state PA zip 17257
Year(sl Commission paid 2011
2. Attorney's Fees Law Office Forest N Myers
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. I Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. I Other Administrative Costs
68.08
150.00
15.00
300.00
TOTAL (Also enter on line 9, Recapitulation) I 533.08
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06)
REV-1513 EX+(11-OS)
LE J
SCHEDU
COMMN
~ RETURNANIA
TANC
D
ER BENEFICIARIES
E
T
H
I
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
HENDERSON - su plemental, William L. ~ 21-10-09 33
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not List Tr tee s
I TAXABLE DISTRIBUTIONS [include outright spousal
~ distributions, and transfers
under Sec. 9116 a 1.2
Betty J HANCOCK Sister-in-Law 3/4 share of net
pA distributable
estate
James SHERMAN Jr Grandson 1/4 share of net
pq distributable
estate
Total
Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 15 00 cover sheet, as a ro riate.
NON-TAXABLE DISTRIBUTIONS:
II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-OS)
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