HomeMy WebLinkAbout11-02-11--~ REV-1500 Ex (o1-'°) 1505610143
~;
PA Department of Revenue Pennsylvania OFFICIAL USE ONLY
Bureau of Individual Taxes DEPARTMENT OF REVENUE COUnIy COdB Year
PO BOX.280601 File Number
Harrisburg, PA 17128-0601 INHERITANCE TAX RETURN 21
ENTER DECEDENT INFORMATION BELOW RESIDENT DECEDENT 1 1 0 019 3
Social Security Number Date of Death
16 9 2 4 5 2 5 6 Date of Birth
02 03 2011 05 30 1930
Decedent's Last Name
S TE VE N S Suffix Decedent's First Name
MI
DOROTHY J
(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 WITH THE
FILL INAPPROPRIATE OVALS BELOW REGISTER OF WILLS
® 1. Original Retum
^ 2. Supplemental Retum
^ 3. Remainder Return (date of death
^ 4. Limited Estate prior to 12-13-82)
^ qa, Future Interest Compromise
(date of death after 12-12-82) ^ 5. Federal Estate Tax Retum Required
® g, Decedent Died Testate O
(Attach Copy of Will) ^ 7. Decedent Maimained a Uving Trust
(Attach Copy or Tn,st) 8. Total Number of Safe Deposit Boxes
^ 9. Litigation Proceeds Received
^ 10. be~Mreen12-31-91 andtl(datge5 (death
^ 11. Election to tax under Sec. 9113(A)
Name
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX WFORMAT O)N SHOULD BE DIRECTED
DEBRA R WALLET To:
Daytime Telephone Number
717 737 1300
REGISTER OF W~~ SE ONL:Y_'
First line of address -`. , ~ a -- ~ ~~t
24 NORTH 32ND STREET
~~ I
Second line of address " , .:~ t~,~ 1 , ~;
J C ~ {. ~ _.., ~ _.,..
' ,_.,I
City or Post Office ~ `~ ` ' ~-
State DATE I?flElj ~'' = ~ ~"
ZIP Code i- °- ~ `V
CAMP HILL ,- ,~
PA 17011
Correspondent's a-mail address: W a l l e t d e b@ a O I. C O m
Under penalties of perjury, I declare that I have examined thts 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 OF PEON RE~ ON$IBLE FOR FILING RETURN
f/J,. _ /~ ,L n
ADDRESS
3709 Rosemont Avenue, Camp Hill, PA 17011
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
~'~'~ k • Wes' Debra K Wallet
ADDRESS
24 North 32nd Street, Camp Hill, PA 17011
L 1505610143
Mary Shorter
Side 1
d
DATE
/oJ3~ l i~
1505610143
1505610243
REV-1500 EX
Decedent's Name:
_ STEVENS, DOROTHY J Decedent's Social Security Number
RECAPI ITECAPI p l
- 16 9 2 4 5 2 5 6
------
1. Real Estate (Schedule A) .............................. __
............................................................ 1.
2. Stocks and Bonds (Schedule B) ..........................
..................................................... 2.
3. Closely Held Corporation, Partnership orSole-Proprietorship (Schedule C)
.......... 3,
4. Mortgages & Notes Receivable (Schedule D) ............................
............................
4
..
.
5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ 5.
1 0 4
1 4 7
$
6. Jointly Owned property (Schedule F
Request
d
7
^ ,
.
9
e
............. 6,
. Inter-Vivos Transfers & Miscellaneous Non
-Probate Property
(Schedule G)
~ Separate Billing Requested ............
7
.
.
8. Total Gross Assets (total Lines 1-7)
16,979.63
................
.......................................................
8.
9. Funeral Expenses & Admini
t
121,127.52
s
rative Costs (Schedule H) ......
................................... g,
4,930.95
10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I)
................................ 10.
11. Total Deductions (total Lines 9 & 10) ................ 3 , 2 8 7 . 4 6
......................................................
11.
12. Net Value of Estate (Line 8 mi
8,218.41
nus Line 11) .............................................................
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 12.
an election to tax has not be
1 12 , 9 0 9.11
en made (Schedule J) ..............
...................................
13.
14. Net Value Subject to Tax (Line 12 minus Line 13) ..............
...... . .
14
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABL
1 12 , 9 0 9.11
E RATES
15. Amount of Line 14 taxable -- ------
atthe spousal tax rate
or
,
transfers under Sec. 9116
(a)(1.2) X .00
16. Amount of Line 14 taxable 15.
at lineal rate X .045 112 , 9 0 9.11 16.
17. Amount of Line 14 taxable
5 , 0 $ 0.91
at sibling rate X .12
18. Amount of Line 14 taxable 17.
at collateral rate X .15
18.
19. Tax Due ....................
.........
........................................................................................ 19.
5,080.91
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAY
MENT.
Side 2
1505610243
1505610243 J
REV-1500 EX Page 3
Decedent's Complete Address:
Stevens, Dorothy .1
3709 Rosemont Avenue
Camp HIII
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.
File Number 21 - 11 _ 00193
PA ~ 17011
3,500.00
1 284 21
(1) 5,080.91
Total Credits (A + B) (2)
3,684.21
(3) 0.00
(4) ------------
(5) 1,396.70
Make Check Payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROP
1. Did decedent make a transfer and: RIATE BLOCKS
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 :.................................. No
- - rx
c. retain a reversionary interest; or .................................................................................................................. L_)
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 r_ I i` x 1
receiving adequate consideration? ................ ..........,.....~.. ~..~.~~~~~~~•~~~~~~~~~~~~~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?...., r-
__, _
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate pro a H, . L-J I x J
-~ I x
contains a beneficiary designation? ................. P rty hich
..................................................................................................... rx'I ~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PA
For dates of death on or after JuI~ 1, 1994 and before Jan. 1, 1995, the tax r RT OF THE RETURN.
spouse is 3 Percent [72 P.S. §91 i6 (a) (1.1) (i)j, ate imposed on the net value of transfers to or for the use of the surviving _~
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 survivin s o
I72 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
assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
9 P use is 0 percent
For dates of death on or after July 1, 2000: disclosure of
• The tax rate imposed on the net value of transfers from a deceased child 21 ears of age or younger at death to or for the use of a na
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 tural parent, an
72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)].
percent, except as noted in
• 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 q
sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, wfiether by blood or ad
option.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
COMMDNwEALTN OF pENNSy~yANIA PERSONAL PROPERTY
INNERRANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Stevens, Dorothy J -~ ___- -__
__.-. FILE NUMBER
-___
Include the pproceeds of litigation and the date the proceeds were received by the estate. All ro rt 21 _ 11= 00193
survivorship must be disclosed on schedule F.
P pe y jointly owned with the right of
ITEM
NUMBER -
- DESCRIPTION
~-
1 M&T Bank Checking Account #97676802 --
2 M8T Bank Checking Account #98234706
3 Coins (based on proceeds from actual sale)
4 Cash in possession of Decedent
5 2010 federal income tax refund
6 1979 Mobile Home and contents (old furniture) (based on proceeds from actual sale)
7 1997 Buick (based on proceeds from actual sale)
TOTAL (Also enter on Line 5, Recapitulation)
VALUE AT DATE OF
DEATH
87, 326.58
4,008.31
1,162.00
1, 500.00
951.00
7,900.00
1, 300.00
104,147.89
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Stevens, Dorothy J
FILE NUMBER
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2os 1 es.
ITEM DESCRIPTION OF PROPERTY y
NUMBER ! Indude the name of the transferee, their relationship to decedent
and the date of transfer. Attach a copy of the tleed for real estate. I DATE OF DEATH i % OF
VALUE OF ASSET ~ DECD'S ~ excLUSION TAXABLE VALUE
1 M&T IRA #35004201806188 ~ INTEREST (IF APPLICABLE)
12,780.96 ! 100% '
12, 780.96
2 ~ M&T IRA #35004201806360
I 4,198.67 I' 100%
I 4,198.67
i
INTER-VIVOS~ RANSFERS ~
MISC. NON-PROBATE PROPERTY
~- -•-- -•••~~ ~~~ nne i, rtecapitulation)
16,979.63
'- r~U.E H
COMMCNWEALTN of PENNSYLVANIA FM`«/'11~
INNERITANCE TA% gETURN ~- "''~~++~~A77
RESIDENT DECEDENT ~C7~A~ /C
ESTATE OF Stevens, Dorothy J
----
- - Debts of decedent must be reported on Schedule I.
ITEM -- --
NUMBER ;FUNERAL EXPENSES: DESCRIPTION
A• 1 ~ Musselman Funeral Home (death certificates, obituary, flowers, minister's rat
g uity)
2 '' Musselman Funeral Home (cemetery inscription)
B.
21= 11 - 00193
FILE NUMBER
AMOUNT
651.45
140.00
j ADMINISTRATIVE COSTS:
1. i Personal Representative's Commissions
Name of Personal Representative(s)
,' Mary Shorter
Street Address 3709 Rosemont Avenue
City Camp Hill state
PA ZiP 17011
Year(s) Commission paid 2011 ----
2• ' Attorney's Fees Debra K. Wallet, Esquire
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
s• ~ Tax Retum Preparer's Fees H&R Block (2010 lifetime return prep)
7. Other Administrative Costs
1 ~ Postage, photocopies, mileage, etc.
TOTAL (Also enter on line 9, Recapitulation)
100.00
3,500.00
359.50
150.00
30.00
d 04A oe
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
CCMM'CNWE~ EOF~ ETURN ANIA
RESIDENTDECEDENT LIABILITIES, & LIENS
ESTATE OF Stevens, Dorothy J ~ - _ _____
FILE NUMBER
21-11-00193
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbur
sed medical expenses.
ITEM
NUMBER DESCRIPTION
----_-__
1 Manor Care Camp Hill AMOUNT
2 Mobelex USA 872.00
3 James R. Harty, MD 13.54
4 Heartland Pharmacy 148.46
5 Advanced Podiatry Services, LLC 2,229.05
24.41
TOTAL (Also enter on Line 10, Recapitulation) ----
3,287.46
REV-1513 EX+ (11.08)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
___ RESIDENT DECEDENT
ESTATE OF
Stevens, Dorothy J
SCHEDULE J
BENEFICIARIES
FILE NUMBER
NUMBER NAME AND ADDRESS OF PERSON(S)
RECEIVING PROPERTY
I. TAXABLE DISTRIBUTIONS [include outright spousal
distributions and transfers
under Sec. X116 (a) (1.2)]
1 Wendy Grumbling
P.O. Box 573
Tonto Basin, AZ 85553
2 ;Sherry Lynn Sayler
5525 Lupin Drive
Reno, NV 89433
II.
I 21-11-00193
RELATIONSHIP TO SHARE O EF STgTE --
DECEDENT (Words) I AMOUNT OF ESTATE
Do Not List Trustee(s) I ($$$)
i Daughter
i Granddaughter
3/4 of residuary
I Estate
1/4 of residuary
Estate
i
(Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 coverlsheet as a
NON-TAXABLE DISTRIBUTIONS: ~ "r~'riate.
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
I
i
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
__ , 0.00
__
LAST I~YILL AND T~ST~1bII;NT
0 ~'
DOI;OT~IY J. ST~Y~NS
I, DOROTHY J. STEVENS, of Mechanicsburg, Cumberland County, Pennsylvania,
being of sound and disposing mind, memory, and understanding, do hereby make, publish, and
declare this to be my Last Will and Testament and hereby revoke, all other Wills and Codicils,
that I have made, including the Will dated December 4, 1990.
FIRST: I give and bequeath my diamond wedding ring set to my daughter,
ENDY GRUMBLING, of Cedaredge, Colorado, so long as she shall survive me by thirty
f1 ~53.6~$ays.
SECOND: All the rest, .residue, and remainder of my Estate, of whatever nature and
wherever situate, I give, devise, and bequeath as follows:
A• Three fourths (3/4) to my daughter, WENDY GRUMBLING, so long as
/~ ,; she shall survive me by thirty (30) days;
B• One fourth (1/4) to my granddaughter, SHERRY LYNN SAYLER, of
Sun Valley, Nevada, so long as she shall survive me by thirty (30) days.
Should any of these individuals fail to survive me by thirty (30) days, but be represented by
children then living, these children shall take, per stirpes, the share to which my beneficiary
would have been entitled if then living.
THIRD: If any portion of my Estate shall be payable to a beneficiary who is less
than eighteen (18) years of age, my Executrix may pay such share to the beneficiary's parent
or guardian, as custodian for said minor, who shall deposit such share in the minor's name in a
Uniform Gift to Minors' Act account in a savings institution of the Executrix's choosing,
payable to the minor at majority.
F_ H: All interests of any beneficiary in the income or principal of this Es
tate,
while undistributed and in the possession of my Executrix, even though vested and
distributable, shall not be subject to attachment, execution or sequestration for any debt,
contract, obligation or liability of any beneficiary and, furthermore, shall not be subject to
pledge, assignment, conveyance, or anticipation.
FIFTH: All inheritance, estate, and succession taxes (including interest and any
penalties thereon) payable by reason of my death shall be paid out of and be charged generally
gainst the principal of my residuary estate without reimbursement from any person.
SIXTH: In addition to all rights and powers conferred by law, I authorize and
empower my Executrix and her successors, in her absolute discretion and without necessi of
,~ ~
obtaining court approval:
A • To buy investments at a premium or discount.
B• To hold property unregistered or in the name of a nominee.
C. To give proxies, both ministerial and discretionary.
D• To compromise claims.
E• To join any merger, consolidation, reorganization, voting trust
plan, or any other concerted action of security holders and to delegate discretio dutie
~y s with
respect thereto.
F• To lend to, and buy from, my estate.
G. To borrow and to pledge real and personal property as security therefor.
H. To sell at public or private sale for cash or credit or partly for each, to
exchange, or to lease for any period of time, any real or personal property, and to give options
for sales, exchanges, or leases.
I• To exercise any option permitted by law which she believes to be
advantageous from the viewpoint of overall tax reductions, including, without limitation of the
foregoing, power and. authority to claim administration or other expenses either as income tax
deductions or inheritance or estate tax deductions, without regard to whether they were paid
from principal or income and without requiring adjustments between principal and income for
any resulting effect on income or estate taxes, and a deduction of such expenses for income tax
~~ purposes shall be given effect in computing the respective shares of all persons interested in
my estate set forth herein, even though the effect is to increase the share of one beneficiary or
class of beneficiaries hereunder at the expense of another; and to make such adjustments, if
' any, between beneficiaries with respect thereto as she shall deem appropriate in view of the
nature of the transaction and the amounts invol
- ved.
~ J. To distribute in cash or in kind or partly in each.
V The powers granted hereunder shall be exercisable with respect to all real and ersonal
P
property, including, but not limited to, income and principal held for minors or disabled
beneficiaries at any time, until the actual distribution of all property. All powers, authorities
and discretion granted here shall be in addition to those granted by law and shall be exercisable
without leave of court. However, nothing herein shall be interpreted or construed to
encourage, authorize, empower, or permit the Executrix to act or cause anyone to act in a
manner contrary to or inconsistent with accepted standards of portfolio diversification and risk
management.
SEVENTH: I nominate, constitute, and appoint my sisters, EVELYN L. WITMAN
and MARY SHORTER, both of Camp Hill, Pennsylvania, as Co-Executrices of this, my Last
Will and Testament. In the event of the renunciation, death, resignation, or inability of either
of my sisters to act for whatever reason in this capacity, then I nominate, constitute, and
appoint the other sister as sole Executrix.
I direct that no representative named above shall be required to post security for the
faithful performance of her duties in any jurisdiction insofar as I am able by law to relieve her
of such obligation. Any of my representatives shall be entitled to reasonable compensation for
the performance of the duties set forth here.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~y'"' day of
~R`I , 2001, on this, the fourth of four typewritten pages. I have also signed the
left-hand margin of the first three of these pages for purposes of identification only.
SIGNED, PUBLISHED, and DECLARED by the Testatrix, DOROTHY J. STEVENS,
as her Last Will and Testament, in the presence of us, who at her request, in her presence, and
in the presence of each other, have hereunto subscribed our names as witnesses.
WC~-'1c. ~~...~r
~fl ~ A' c~ ~.,y /. seJ ~.
~c.{,.-.~~cSb~~1 ~ ~A 1~oS~
ACKNOWLEDGMENT
Commonwealth of Pennsylvania
County of Cumberland
I, DOROTHY J. STEVENS, Testatrix, whose name is signed to the attached
instrument, having been duly qualified according to law, do hereby acknowledge that I signed
and executed the instrument as my Last Will and Testament; that I signed it willingly; and that
I signed it as my free and voluntary act for the purposes therein expressed.
J.
Sworn or affirmed to and subscribed before me by DOROTHY J. STEVENS, the
Testatrix, this ~~F? day of _ YY1(~u , 2001.
Notary Pu c
lVotariai seal
M. Loper, Natary Public
Came 8oro, Cumberland County
Nly Commieslon Expires Oct. 27, 2003
Member, PennsyNaniaAssodationotNotaries
AFFIDAVIT
Commonwealth of Pennsylvania
County of Cumberland
We, Debra K. Wallet and `~~. n ~nc1C~, ~ ,the witnesses whose names
are signed to the attached instrument, being duly qualified according to law, depose and say
that we were present and saw the Testatrix sign and execute the instrument as her Last Will
and Testament; that she executed it as her free and voluntary act for the purposes therein
expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses;
and that, to the best of our knowledge, the Testatrix was at that time 18 years of age or older,
of sound mind, and under no constraint or undue influence.
Sworn or affirmed to and subscribed to before me by `17. ~~i~~ ~. ~ ,~ ~ j ~ o
and ~~~~r~~~~ "~ ~,rl ~, witnesses, this _~ day of ~Y1(a:•,.t , 2001.
t
Notary Publi
Mary M. Lr Public
Camp HRI Boro, C~nberland Cairr~~ttyy
My CoRmdsslon Expires Oct. 27, 20V)3
Member, PennsyNanisASSOC9ationot
APRiB 2011
O 1VISTBariK
499 Mitchell Road, Millsboro, DE 19966 Adjustment Services
Law Offices of Debra K Wallet
24 N 32na Street
Camp Hill, PA 17011
Re: Estate of Dorothy J Stevens
Social Security: 169-24-5256
Date of Death: February 03 2011
Phone 888-502-4349
F ax (302) 934-2955
April 15, 2011
Dear Sir or Madam:
Per your inquiry on April 14, 2011, please be advised that at the time of death, the above-named decedent had
on deposit with this bank the following:
1. Type ofAccount
Account Number
Ownership (Names ofJ
Opening Date
Balance on Date of Death
Accrued Interest
Total
2. Type of Account
Account Number
Ownership (Names o, f)
Opening Date
Balance on Date of Death
Accrued Interest
Total
Checking Account
97676802
Dorothy J Stevens
Mary E Shorter (POA)
0128/09
$87,326.58
$ .00
^-$87,326.58 ----~--~----
Checking Account
98234706
Dorothy J Stevens
Mary E Shorter (POA)
03/13/98
$4,008.28
$ .03
$4,008.31