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Home My WebLink About10-21-111505610143 REV-1500 Ex(°'-'°' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Year File Number Bureau of Individual Taxes OEPRRTMENT OF REVENUE PO 60X.280601 INHERITANCE TAX RETURN 21 0 9 0 953 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death 197 68 7518 09 09 2009 Decedent's Last Name Suffix AYERS (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Social Security Number Date of Birth 06 10 1978 Decedent's First Name MI JEREMY L Spouse's First Name MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return ~ 2. Supplemental Return 4. Limited Estate ~ 4a. Future Interest Compromise (date of death after 12-12-82) g Decedent Died Testate (Attach Copy of Will) C1 ~~ (AtlacheCo alof Trusd a Living Trust PY ) 9. Litigation Proceeds Received 10. S ousal Poverty Credit date of deatn b~tween 12-31 91 and 1<-1-95) prior to 12-13-82) 5. Federal Estate Tax Return Required _ 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. 0) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number PATRICIA R BROWN ESQ 717 249 6333 First line of address 354 ALEXANDER SPRING RO Second line of address City or Post Office CARLISLE Correspondent's a-mail address: State ZIP Code PA 17015 REGISTER OF S USE ONLY '.:x ~1, ,; ,, ,_._ I, __ i-r, ; , - -r~ 4' DAT~ILED ' _~ ,~ J ~.~ _,_~ 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. ADDRESS YILIN(i Kt I UKN ~. A 1 224 B Street. Carlisle. PA 17013 hanie SIGNATURE OF EPARER OTHER THAN REPRESENTATIVE DATE a~2~.~_-.._.~ ~~(" . i~-~--T..~~,~,~ Patricia R. Brown Esq. i ~~ ~ ~ ~, ~ z- o ~ i _ ADDRESS 354 Alexander Spring Road, Suite 1, Carlisle, PA 17015 3. Remainder Return (date of death Side 1 1505610143 1505610143 J PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF I FILE NUMBER Ayers, Jeremy L. 21-09-0953 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. Signature #2 ^~~ ~~~ ~~ ~ ~E;~~ac~` Name Address1 Address2 City, State, Zip Date Staci L Hair 169 E. North St. Carlisle, PA 17013 / (~-o~(~-l/ REV-1500 EX Decedent's Name: Ayers, Jeremy L. Decedent's Social Security Number 197 68 7518 RECAPITULATION 1. Real Estate (Schedule A) ...................................................................................... . 1. 81 , 748 . O1 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. 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .............. . 5. 9 , 368.00 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested........... . 6. 7. Inter-Vivos Transfers & Miscellaneous i nn,-Probate Property (Schedule G) a Separate Billing Requested........... . 7, 8. Total Gross Assets (total Lines 1-7) ................................................................... .. 8. 91 , 116.01 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ..................... 9. 8 , 621.00 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ......... ..................... 10. 90 , 0 95.0 9 11. Total Deductions (total Lines 9 8~ 10) .............................................. .................... . 11. 98 , 716.0 9 12. Net Value of Estate (Line 8 minus Line 11) ..................................... ..................... 12. - 7 , 60 0 . 0 $ 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. -7 , 600.08 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 0 0 0 15 0. 0 0 (a)(1.2) x .o0 . . 16. Amount of Line 14 taxable 0 00 16 0.00 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 0 00 18 0.00 at collateral rate X .15 . . 19. Tax Due ............................................................................................ ..................... . 19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 1505610243 1505610243 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-09-0953 DECEDENT'S NAME Ayers, Jeremy L. STREET ADDRESS 29 Mountain Street CITY Mount Holly Springs STATE PA ZIP 17065 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount 0.00 (1) 0.00 Total Credits (A + g) (2) 0.00 3. Interest (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) 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. (5) x,00 e Check Pa able to: REGISTER OF WILLS, AGENT. ..a~~ . r ~~~° { 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 property transferred or its income :.................................. ^ ^x c. retain a reversionary interest; or ............................................................................................................... ^ 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 "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? .................................................................................................................. ^ ^x IF THE ANSWER TO ANY OF THE ABOVE QUEST,IIONS IS YES, YOU Ma,,UST ~CiOMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ~ ;•!i '., ~ . ,'~; .'-di ~~, ;. ~'i•. i+,. ~;t>'k rJ~Gt!!G~'ti«~~}~14~L7cS~riPSh~~i~i~:ih~r~++~{'~iPY~Sy~`•~ I:i,t-,+G~, a. .~•+i±d;'`rv~~~v~J~. a{ 's~':~~', .Mi ~ '==i~~ ~. ~"is',~ir l 4~ .;~ ---- - Fordates 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. Rev-1502 EX+ (f t-08) SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Ayers, Jeremy L. 21-09-0953 All real property owned solely or as a tenant in common must be reported at Tait 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 knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on schedule F. Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 11-08) (If more space is needed, additional pages of the same size) Rev-7508 EX+(6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Ayers, Jeremy L. 21-09-0953 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Members 1st -Savings Account No. 228826-00 5.00 2 2000 Ford Truck -VIN 1 FTRX18WXYNC09164 6,000.00 3 Household goods - at proceeds of sale 293.00 4 U.S. Treasury - 2009, 1040 income tax refund (will not receive due to debt owed to the IRS of 3,070.00 $6,779.23) TOTAL (Also enter on Line 5, Recapitulation) I 9,368.00 (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~ gCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANC~ETAXRETURN ADMINISTRATIVE COSTS RE3SIDEN DECCEDENTT ESTATE OF I FILE NUMBER Ayers, Jeremy L. 21-09-0953 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT N MBER . A, FUNERAL EXPENSES: See continuation schedule(s) attached B. 1 2 3 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Stephanie Ayers Staci L Hair Street Address 224 B Street city Carlisle State PA zip 17013 Year(sl Commission paid Attorney's Fees Salzmann Hughes, P.C. 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 2,368.00 2,415.78 2, 500.00 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1,337.22 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 8,621.00 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Ayers, Jeremy L. 21-09-0953 ITEM NUMBER DESCRIPTION AMOUNT 1 Funeral Ex erg nses Carol E. Tate Ayers -funeral services paid to Hollinger Funeral Home 8~ Crematory, Inc. 2,368.00 H-A 2,368.00 2 Other Administrative Costs Healthport -fee paid to receive date of death information 26.69 3 Healthport -fee paid to receive date of death information 32.51 4 Met-Ed -utilities service 424.04 5 Register of Wills -filing fees 30.00 6 Salzmann Hughes, P.C. -reimbursement for probate fees 296.00 7 Salzmann Hughes, P.C. -reimbursement for short certificate 4.00 8 Salzmann Hughes, P.C. -reimbursement for payment to Cumberland Law Journal for legal 75.00 advertising 9 Salzmann Hughes, P.C. -reimbursement for payment to The Sentinel for legal advertising 208.78 10 Salzmann Hughes, P.C. -reimbursement for FedEx mailing 15.50 11 Salzmann Hughes, P.C. -reimbursement for payment to Met-Ed for electric service 224.70 H-B7 1,337.22 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 EX+112-OB) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER A ers, Jerem L. 21-09-0953 Report debts incurred by the decedent prior to death [hat remained unpaid at the date of death, including unreimbursed medical expenses. VALUE AT DATE ITEM DESCRIPTION OF DEATH NUMBER 1 Apex Asset Management -balance due for medical service from Boiling Springs Medicine on 15.39 6/1 /2009 2 Carlisle HMA Physician Managem -balance due for medical service on 511812009 and 40.39 6/1 /2009 3 Frost -Arnett Company -balance due for medical services from UHS of Pennsylvania Inc. 250.00 4 Irwin & McKnight, P.C. -balance due for services in March and April 2008 1,072.07 5 Members 1st Federal Credit Union -balance due on 2nd mortgage 35,063.33 6 NCO Financial Systems, Inc. -balance due to Carlisle Regional Medical Center for service on 90.00 7122/2009 7 NCO Financial Systems, Inc. -balance due to Carlisle Regional Medical Center for service on 100.00 511312009 8 Sovereign Bank -balance due on 1st mortgage 46,684.68 9 U.S. Treasury Department -Federal Tax lien 6,779.23 TOTAL (Also enter on Line 10, Recapitulation) I 90,095.09 (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08) REV-1513 EX+~11-08) SCHEDULE J COM INHERITANCE TAX RETURNANIA BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER. A ers, Jerem L. ~ 21-09-09 53 _ NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT (Words) ($$$) I TAXABLE DISTRIBUTIONS [include outright spousal ~ distributions, and transfers under Sec. 9116 a 1.2 Averie Marie Ayers Daughter _ 3180 Spring Road Carlisle, PA 17013 Total Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 150 0 cover sheet, as a r o 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 SHEET Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) 11/06/2009 FRI 12:46 F:1Y 7177955178 ME1tBERS 1ST FCU INSIIRANC f~001 SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner LOAN ACCOUNT: Account NumberlSuffix Date Loan Established Principal Balance at Date of Death Loan Type Collateral Secured Interest Rate Name of Co-Borrower MEMBERS lgt FEDERAL CREDIT UNION 228826-1)Q 04/09/2003 $5.00 $.00 $5.00 None 228826-02• 01 /03!2006 $35,063.33 Home Equity/Contractual Pledge of Shares 29 Mountain Street, Mt. Holly Springs, PA 17065 8.19% None "Loan does not have credit life insurance. MBERS 1ST FEDERAL CREDIT NION Danielle A. lin` I[ e Insurance Services Specialist November 5, 2009 Estate of: JEREMY L. AYERS Date of Death: 09!09!2009 Social Security Number: 197-68-75'16 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania ]7055 (800) 283--2328 wwwmemberslst.org L0/29/2J99 Tav ':FF F.r~x 61C98FL690 sovereign a~nk I~J001/002 ~;~~ 1~" ~- -= S overel n B a~r~k :- , ,,~, . Attn: 1 p-427-GN2 450 Penn Street Reading, PA 19G01 ******Payoff Statement**** bate: October 29, 2p09 Loan Number: Primary Borrower's Name: Property Address: Quote sent to: '"`'**Payoff Galculations~*~` 035B106p54 Jeremy Ayers Estate 29 Mountain Street Mount Holly Springs, PA 17p65 Salzmann and Hughes Attorneys Fax 7172497334 Principal Balance $ . 46560.97 Interest calculated to p9/09109 $ 61.71 Accumulated Late Gharge Balance $ p LifelAH insurance Calculated to $ p Escrow/Impound Advance Balance $ 1 o0p.1 S Processing Fee and other fees as applicable$ 25.0p Recording Fees $ 37.00 Prepayment Penalty Fee $ p Grant Payoff (if applicable) $ p Less Unapplied Funds $ a TQTAL REQUIRED TO PAYOFF.LOAN 46684.68 PMI/FHA to be deducted from escrow balance $0 Payoff quote prepared by: Mel Weinman For questions related to this payoff quote please call us at 1-800-232-5200 Page 1 of 2