HomeMy WebLinkAbout10-28-11J 1505610140
REV-1500 EX (°~-~°)
PA Department °f Rev@nlle
Bureau of Individual Taxes OFFICIAL USE ONLY
Po Box 280601 County Code Year File Number
INHERITANCE TAX RETURN
Flarrisbu PA 17128-0601
ENTER DECEDENT INFORMATION BELO RESIDENT DECEDENT 2 1 1 1 0 2 9 7
W
Social Security Number Date of Death MMDDYYYY
Date of Birth
1 8 6 2 6 3 9 5 0
0 . MMDDYYYY
2 0 1 2 0 1 1
Decedent's Last Name 0 5 2 2 1 9 2 2
K E L C H N E R Suffix Decedent's First Name
MI
D O R O T H Y ~
(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 DUP
FILL IN APPROPRIATE OVALS BEL LICATE WITH THE
REGISTER OF WILLS
OW
0 1. Original Retum ^ 2. Supplemental Retum
^
4. Limited Estate ^ 3. Remainder Retum (date of death
[~ 4a. Future Interest Compromise (date of Pnor to 12-13,82)
Fed
l
^ 5
^X 6. Decedent Died Testate ^ era
•
Estate Tax Retum Required
death after 12-12-82)
7
D
(Attach Copy of Will)
[~ 9. Litigation Proceeds Re
i .
ecedent Maintained a Livi Trust
(Attach Copy of Trust) ~ 8. Total Number of Safe Deposft Boxes
ce
ved ^ 10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95) ^ 11 • Election to tax under Sec. 9113(A)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX
Name
NFORMAT N SHOULD BE DIRECTED T0:
D A V I D H R A D C Daytime Telephone Number
L I F F E S Q
7 1 7 2~3 6 9 ~'1 8
___ ~
REGISTER t91~ LS USE 019L'eY ~~ ' T
i
First line of address r-; `~ '~ ' ~ ' s ~~
`~ ~- r ---? r_
1 0 1 1 M U M M A
R r `r' ~~ ''
~ ~~ rti ~~ ~;
O A D
Second line of address _
~ f`= <~ ~ ~' ,
_, ~ , i..l ;,_
-- t ..,
City or Post Office ~ ` ~ i
J
~ ~
L E M D Y N E ~
State ZIP Code DATE FILED ~ ~~ ~
i '
`'
P A 1 7 0 4 3
Correspondent's e-mail address: DHRAD ~~ IX_N~-rCOM.COM
Under Penalties of perjury, I dedaro that I have exammed this nnum, mdudm acoom
it is true. coned and e. Dedaralion of 8 Panrng schedWes and st~ements, end to the best
f
~n~
r
o
k
repreaer~ive is based on all information of which ~ ~e~e a~ ~18f~
SIGNATURE FR, PERSON RE ONSIBLE~ORFLING R
~~ PreParor hae any knowledge,
~1~1R~1
ADDRESS
4920 WOODBOX LANE
SIGNAT PREP Rgt}O~_
nooRESS
L011 MUMMA RD STE
L 15D5610140
LEMOYNE
PLEASE USE ORIGINAL FORM ONLY
Side 1
CSBURG / p
PA 17043
1505610140 J
~..I 1505610240
REV-1500 EX
Decedent's Social Security Number
~SN~: DOROTHY J. KELCHNER 1 8 6 2 6 3 9 5 0
RECAPITULATION
1. Real Estate (Schedule A) .........
.............................
1.
.... .
2. Stocks and Bonds (Schedule B) ................................. ..... 2. 2 0 1 4 , 5 6
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. 2 5 8 5 7. 6 0
6. Jointy Ovuned property (Schedule F) ~] Separate Billing Requested
7. ...
Inter-Vivos Transfers & Miscellaneous N -Probate Property
(Schedule G) ~ .... 6.
Separate Billing Requested ... .... 7. 1 2 8 6 2 2. 1 1
8. Tofal Gross Assets (total Lines 1 through 7) ............... 8 1 5 6
........ ....
. 4 9 4 , 2 7
9. Funeral Expenses and Administrative Costs (Schedule H)
.............. .... 9. 1 6 4 4 0
4
. 9
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ......... .... 10. 5 9 0 6 0 4
11. Total Deductions (total Lines 9 and 10)
........................... ....
11.
2 2 3 4
6. 5
3
12. N~ Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 12 1 3 4 1 4 7. 7 4
an election to tax has not been made (Schedule J) ................... ... 13.
14. Net Value SubJect to Tax (Line 12 minus Line 13)
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 14 1 3 4 1 4 7. 7 4
15. Amount of Line 14 taxable
at the spousal tax rate
or
,
transfers under Sec. 9116
16. Amount of Line 14 taxable 0 . 0 D
at lineal rate x .045 1 3 4 1
4 7.? 4
17. Amount of Line 14 taxable N is.
6 0 3 6.
6
5
at sibling rate X .12 0 . 0 0 17
18. Amount of Line 14 taxable .
0 .
0
0
at collateral rate X .15 0 . 0 0
18.
0.
0
0
19. TAX DUE ...................................................... 19.
6 0 3 6. 6 5
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
0
Side 2
L 150561D240 1505610240
REV-1500 EX Page 3
Decedents Complete Address
Ffle Number
71 11 nnn~
~• Tax Due (Page 2, Line 19)
2. Credits/Payments (1) 6 036.65
A. Prior Payments 5 500.00
e. Discount 289.47
3. Interest Total Credits (A + B) (2)
5 789.47
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3)
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) 247.18
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:
a. retain the use or income of the Yes No
property transferred; .....
b. retain the right to designate who shall use the ro ~ ~ ~ ~ ~ .................:::::::::::::: 0
p party transfenred or its income;
c. retain a reversionary interest or ............................................................................................... ^
d. receive the promise for life of either payments, benefits or care? ........................................ ~ a
2. If death occurred after December 12, 1982, did decedent transfer ro
without receiving adequate consideration? .......,.... P ~~ unthin one year of death
3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her deaths ^ ^
4. Did decedent own an individual retirement account, annuity or other non-probate ro ^ ^
contains a beneficiary designation? ........................................... P ~~~ which
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 im sad on the net value of transfers to or for the use of the survivin
3 percent p2 P.S. §9116 (a) (1.1) (i)]. p° g spouse is
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 evenrf 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 p2 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.
~ aw rayrnenLS Ind (;r@ditS:
REV-1503 EX + (e-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
~] 4 A A
ITEM
NUMBER
1.
1 1
Ail property jointly.owned with right of survivorship must be discbsed on Schsduk F.
DESCRIPTION
Shares Prudential Financial ~~~~ aF~~~r,
TOTAL (Also enter on line 2 Recapitulation) I s
(If more space ~ needed, insert additional sheets of the same size)
VALUE AT DATE
OF DEATH
2,014.56
REV-1508 EX + (6_gg~
COMMONWEALTH OF PENNSYLVANW
INHERITANCE TAX RETURN
RESIDENT DECEDENT
:STATE OF
DOROTHY J. KELCHtut=Q
SCHEDULE E
CASH, BANK DEPOSITS, 8 MISC.
PERSONAL PROPERTY
Include fhe proceeds of Ifigation and the date fhe 21 11
All propsAy jol„gy.ownsd with right of survhorsh ~ disc~e~d ~ ~~ k F.
ITEM
NUMBER
~• $50 EE U.S. Savings Bond issued 9/1986 CRIPTION
2• Retum unearned premium -American Progressive Life
3• Dividend -Prudential Financial
4• Jersey Shore State Bank Acct #385034
5• PNC Bank Acct #51-1202-9812
6• Muncy Bank 8 Trust Company -Certificate Deposit
7• Muncy Bank -interest
8• ING - uncashed income check
TOTAL (Also enter on line 5 Recapitulation) ~ s
(If more space ~ needed, insert addrhonal sheets of the same sae)
VALUE AT DATE
OF DEATH
90.94
598.89
82.49
8,348.35
10,947.05
5,575.42
43.50
170.96
REV-1510 EX+ (08-09)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
21 11 0297
This schedule must be completed and filedrf the answer to any of questions ~ through 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY
NUMBER INCLUDE THE NAAE CF THE TRANSFEREE, THEIR RELATIONSHp TC DECEDENTAND DATE OF DEATH °6 OF DECD'S EXCLUSION
THE DATE OF TRANSFER, ATTACH A COPY OF THE DEED FOR REAL ESTATE.
1• ING Annuity #90083390 VALUE OF ASSET INTEREST prnPauca3~
33,211.41 100.00
2. ING Annuity #608001
24,423.89 100.00
3. ING Annuity #90123085
70,986.81 100.00
TOTAL (Also enter on Line 7
H mare space Is needed, use additional sheets of paper of the same size.
TAXABLE
VALUE
33,211.41
24,423.89
70, 986.81
1
REV-1511 EX+ (10-09)
Pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN FUNERAL EXPENSES AND
RESIDENT DECEDENT ADMINISTRATIVE COSTS
.STATE AF
UURUTHY J. KELCHNER tore nu
21 11
~ecedern's debts must be reported on Schedule I.
ITEM
NUMBER
DESCRIPTION
A• FUNERAL EXPENSES:
~~ McCarty-Thomas Funeral Home
AMOUNT
B• ADMINISTRATIVE COSTS:
~ • Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City
State ZIP
Year(s) Commission Paid:
2. Attorney Fees: Radcliff Law Office, P.C.
3• Fanuty Exemption: (If decedents address is not the same as daimanYs, attach explanation.)
Claimant
Street Address
City
State ZIP
Relationship of Gaimant ~ Decadent
4• Probate Fees:
5, Accountant Fees:
6• Tax Return Preparer Fees:
~• Filing fees -Inheritance return & Inventory '
8. Check Print Fee -estate bank account
9• Additional Probate Fee
H more space is needed, use additional sheets of paper of the same size.
5,400.00
119.50
30.00
17.99
30.00
TOTAL (Also enter on Line 9, Recapitulation) I s
10,843.00
1
REV-1512 EX+ (12_pg~
Pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES, $ LIENS
RESIDENT DECEDENT
:STATE OF
DOROTHY J. KELCHNER FILE NUMBER
21 11 0297
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
1• Kinkora Pythian Home OF DEATH
5,581.80
2~ Harrisburg Pharmacy
110.96
3• Humana Insurance
44.00
4. Outstanding check -Harrisburg Pharmacy
169.28
TOTAL (Also enter on Line 10 Recapitulation) I s
ff more space ~s needed, insert addl6onal sheets of the same s¢e.
REV-1513 EX+ (p1.10)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
vr:
fHY J.
SCHEDULE J
BENEFICIARIES
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
j, TAXABLE DISTRIBUTIONS [Include outrtry' ~ht I distributions and transfers under
Sep.91f6(a (1.2).]
1. Darla M Magargle
4920 Woodbox Lane
Mechanicsburg, PA 17055
21 11
4TIONSHIP TO DECED
Do Not List Trustee(:)
Lineal
OF ESTATE
134,147.74
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S
If more space is needed, use additional sheets of paper of the same size.
Fax: Feb 11 2011 02:1dpm P002/027
. FAST ~x!L ARD T88TAffigNT
Off'
DOYO'1'8Y ~7. EEI,C~g
I, DOROTHY J. ~R„ of Mont
goxaery, County of Lycoming.,
Commonwealth of penn$ylvania, declare this to be mY bast Wilt and
~ Testament, hereby revoking any and all Wills ar Tegtamenta
+Writings heretofore made, ~ ~
' ' - ~ ~ ARTICLE Omg
I direct that all my just debts and funeral expenses be. aid
a~ soon as - P
practYOable after my decease.
ARTxCL$ 'l'WO
I devise and bequeath all the rest, residue and remainder of
my et~tate of every nature and wherever situate to m
- y humband,
RICHAI2A M. 1a;LCR~R, provided he shall survive me by Thirty `(30) -
days.
~TIOLB T~E$
Should qty husband', Riaha,rd M. iiel
ohner, predecease me or die
on or befoxa.ths thirtieth X30) day fQllowinq my death, Y dev~.se
and bequeath ali the rest, residue and remainder of my estate of
every nature and wherever situate to my daughter, DI~RLA MAI,
~~~~~, per stirpes. .
i t .
± Fax: ,Feb 11 2011 02:idpm P003/027
i
I
I
i
ARTICLE FOIIR
~ Should my husband, Richard M. KELCI~IER, predecease me or die
on or be#ore the thirtieth (30) day following my depth, I be-
queath my real property at R. D.~i, eox 549, Montgomery,
~nnsylvatiia, to my daughter, DARLA MAE MAGARGLE.
ARTICL$ $=pg
II I appoint my daughter, DARLA MAE MAGARGLg~ Farecutor of this
my Last Will and Testament.
1RT=CL7; BIX
I direst that my Executor shall not be required to file bond
in this or any ~urisdiotion #'or the faithful performance of her
duties.
YN WITNESS WFIEREpF~ I haY~ hereunto set my hand and seal
f
this ~ ay of Marsh, i99o.
Dorothy Relchr~er .
` ~ ~ Fax:
~~ .
~;
i
~~
Feb 11 2011 02:14pm P004/027
'I The preceding instrument, consisting of this and two (z)
other typewritten pages wac~ on the date
thereof, signed, pub,
lished and declared by Dorothy J. ~
DER, the Testatrix therein
named,.as and for her Last mill in the presence of each other,
'have subsoribed our names as witnesses hereto.
(r-~i ~ t
' - I Fax: Feb 11 2011 02:15am POD5/027
i
COl~1PSONW>rALTH OF PENNSYLVANIA
COUNTY OF LYCOMING 98
_ I , 6~.t,r"r~: ~
name is signed tooth ~ foregoLng ~strumentsthavin whose
duly qualified according to law;, do hereby~acknowledgen
that I signed and executed the instrument as my Last will
that I signed it willingly; ar~d that I ;signed i.t as my free
and voluntary act for the purposes therein expressed.
l'
sworn to and ubseribed
before me by ~d~t c Tes a•fsu~
the Testat„IL,]c thi ~~h'4-jt~OA
•day of ~, 194Q .
,. I,
`-NUTA"A! ~EAL ~ .
N y 1 Aili~! E AL ; Y~Qr;e~ u4;ay Publlq
• ;~ bYi1::,3;~+ ~iJ+., 1~••:•a:'a; C:,v^ly, Pe,
6JtNi't1iWi0n ~irrs Jvly ~~, ~'~
COMMQNWEALTH OF PENNSYLVANIA
COUNTY OF LYCOMING SS
we, .
I d • and
a ~.aigned•to t the witnesses whose names
oing instrument, being duly quali-
fied according to law, do depose and say that we were present
and saw Testat sign arid~execute the instrument as h
Laet Will; that, he signed willingly and that hs executed
it as h tree and voluntary act for the purposes therein
expressed; that each of us in the hearing and sight of the
Testat signed 1t as witnesses; and that to the best pf
our knowledge the Testat was at that time 18 or more
• Years of age, of.saund mind and under no constraint or undue
influence.
~. ~
•. ~ ~ tress
Sworn to and u ~ ibed
before a by ~ ,~
an Wit ess
~ witnesses,•this
(( 19 ~ _ ay O~ __~ea/-li ~
fI. ~
. ~ N~rAR~gl, s!A!
Nota y 1 ~~'•E ~ •~Ls~t .S, Notary Pubflo
W:i,id:.~ aa:. ~;;uminl6CUntyr, pa.
~ Cvmmissivn Explra Jul 19, 1991