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Home My WebLink About11-07-11 (2)1505610101 REV-1500 ex t01.1°' ~"' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania oEPaA.ME~, County Code Year File Number Bureau of Individual Taxes ~ pINHERITANCE TAX RETURN PO BOX 28o6oi Harrisburg, PA 1')128-o6oi RESIDENT DECEDENT 2 1 1 1 0 0 8 ~8 1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 7~7 2~ 4 5 8 0 5 0 8 0 9 2 0 1 1 0 8 0 b 1 9 3 0 Decedent's Last Name Suffix Decedent's First Name MI M° y e, r s J a c q u e l i n `e V. .. (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouses Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE - REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 4. Limited Estate O 4a. Future Interest Compromise (date of death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) O 3. Remainder Return (date of death prior to 12-13-82) O 5. Federal Estate Tax Return Required ~ 8. Total Number of Safe Deposit Boxes O 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number A n t h o n y L, D e L u c a E s q. 7 1 7 ~~~ 8' 6.'8 4.9~.-~ -~., ~ , . _ First line of address P O B o x 3 5 8 Second line of address 1 1 3 F r o n t City or Post Office S t r e e t B o i l i n g S p r i n g s State P A zIP Code REGISTER ~_ Itx.S US~ ONLY -,.... r'-- .. r-- r _- rr7 I _Z3 ~~ - c. _ _ ~~ _~ ..T.~ , _„ .. __... -l7 { :, ~• --'; DATE FILED 1 7 0 0 7 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. SIGN URE QF PERSON SPON~}IBLE FpR FILING RETUR~N,^, )) .j DATE Side 1 1505610101 1505610101 J J REV-1500 EX Decedent's Social Security Number 1 7 7 2 4 5 8 0 5 DecedenYsName: Jacqueline V. Myers RECAPITULATION 1. Real Estate (Schedule A) ................................. . ........... 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 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. 0 ~. 0 0 - -. ., :,. _ ~9: ~ ~ ~ ~, 1 ~8~1 ~3 ~6' 7` 6 d • ~ ;0 0:0 . ;~ .~ . • OY~-0~0' 1 0;.48'3 57 2 1 3, 4 4 k7 :_~ = ,r~ o~oos - Y, 1 3 6, 4 ~ 1 ~9 ~~~ 8~~6±, _.. . 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 9. Funeral Expenses and Administrative Costs (Schedule H) .................. . 9. 1 - a .1 8 -8 1 ~_ 6 9 o ~ .two ~ ~ ~«, ~ ~ ~<~ - 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. . 10. ° 3 ? 9 1 ~ 0 4 ~, .. - ~. :, r r .,ti~.+r ,. 11. Total Deductions (total Lines 9 and 10} ................................ . 11. 1 . 2 r 2 ` 7 2 Ais 7 3 ~ n 12. Net Value of Estate (Line 8 mmus Line 11) .......... ................ . 12.. 1 2 _4 , 1 ~4 7 ~ 1` 3d~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which , ~ ' ~' an election to tax has not been made (Schedule J) ....................... . 13. ~ 0 ±~ 0 ,0 ~. ~ .,~i 14. ............ Net Value Subject to Tax (Line 12 minus Line 13) ........... .14. 1 2 4~ 1 ~ 4 ~ 7 ~1 3 ,,,. 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.045 1 2 4, 1 4 7 ~~ 1 3 15. .: ~ ~ SrS 8 '~ 16. Amount of Line 14 taxable ~ _ . , t at lineal rate X .0 _ 16. ~ ~ 17. Amount of Line 14 taxable at sibling rate X .12 ~. ~ z 17. ' 18. ~ Amount of Line 14 taxable ~ ~ ( at collateral rate X .15 <~ 18. ~. g ~ ~ z 19 ................................................ TAX DUE .19.' ~~ ~ 5 5 8 6 6 2 . ........ .a~~._ 20. FILL IN THE OVAL IF YOU ARE REQUESTING. A REFUND OF AN OVERPAYMENT 1505610105 O Side 2 1505610105 1505610105 REV-1502 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Jacqueline V. Myers 21-11-00881 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 knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. NONE -0- TOTAL (Also enter on line 1, Recapitulation) I $ -0- (If more space is needed, insert additional sheets of the same size) REV-5503 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Jacqueline V. Myers 21-11-00881 A11 property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~• 227.52 shares of Legg Mason Value Trust $7,965.47 @ $35.01 per share 2. 302.93 shares of Legg Mason Special Invest. 7,909.50 @ $26.11 per share 3. 111.583 shares of Thrivent Large Cap Stock 2,261.79 Fund Class A @ $20.27 per share SCHEDULE B STOCKS & BONDS TOTAL (Also enter on line 2, Recapitulation) f $ 18 ,1 3 6 . 7 6 (It more space (s needed, insert additional sheets of the same size) REV• t X04 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Jacqueline V. Myers 21-11-00881 Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1~ NONE -0- TOTAL (Also enter on line 3, Recapitulation) I $ -0- (If more space is needed, insert additional sheets of the same size) REV-1507 EX+ (1-97) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER Jacqueline V. Myers 21-11-00881 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. NONE _ ~ _ TOTAL (Also enter on line 4, Recapitulation) I $ -0- (If more space is needed, insert additional sheets of the same size) Rev-~eos ex. ~~a7> SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHRESIDENTDECEDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER Jaccrueline V. Myers 21-11-00881 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~• Money Market account at Morgan Stanley Smith $14,413.12 Barney, account #73H-01281-11 5LP 2. Accrued interest on bonds/CDS at Morgan Stanley 866.02 Smith Barney, account #73H-01281-11 5LP 3. Certificate of Deposit at Morgan Stanley Smith 89,556.58 Barney, account # 73H-01281-11 5LP TOTAL (Also enter on line 5, Recapitulation) I$ 1 0 4, 8 3 5. 7 2 (If more space is needed, insert additional sheets of the same size) REV-~sos Ex+h-s~1 SCHEDULEF COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Jacqueline V. Myers 21-11-00881 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT N•Micnele xae Clippingerl 209 Forge Road Boiling Springs, PA 17007 B. C, JOINTLY-0WNED PROPERTY: Daughter ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar identifying number. Attach deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. 7/13/ 08 Checking account, #3309797, $73.47 50~ $236.50 at F&M Trust 2. A. 7/13/ 08 Checking account, #3308413, 26,421.76 50$ 13,210.88 TOTAL (Also enter on line 6, Recapitulation) ~ $ 1 3 , 4 4 7. 3 8 (If more space is needed, insert additional sheets of the same size) REV-1570 EX * (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Jacqueline V. Myers SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER 21 -1 1 =00881 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIRRELATIQNSNIPTOOEGEDENTANDTHE DATE OFTRANSEER. ATTACHACOPY OF THE DEE~FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IFAPPLICABLE TAXABLE VALUE ~~ NONE -O- TOTAL (Also enter on line 7, Recapitulation $ - ~ - (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Jacqueline V. Myers 21-11-00881 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: i. Hollinger Funeral Home & Crematory,Inc. $5,738.:41 501 North Baltimore Avenue Mt. Holly Springs, PA 17065 B. 1 2. 3. 4. 5. s. ~. 8. 9. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address __ City Year(s) Commission Paid: State Zip Attorney Fees Anthony L. DeLuca, Esquire 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 Probate Fees Accountant's Fees Tax Return Preparer's Fees Legal Advertising - Cumberland Law Journal Legal ADvertising - The Sentinel Filing Fee Inheritance Tax Return and Inventory 5,000.00 327.50 500.00 75.00 210.78 30..00 TOTAL (A{so enter on line 9, Recapitulation) I $ 1 1 , 881 .69 (lf more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) scNE®u~E ~ COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Jacqueline V. Myers 21-11-00881 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~ Church of God Home, Inc. $387.54 Nursing Home 2. Continuing Care RX -Medication 3.50 '~°~TAL (Also enter on line 10, Recapitulation) $ I 3 91 . 0 4 Qf more space is needed, insert additional sheets of the same sizel _ ~^` REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Jacqueline V. Myers 21-11-00881 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' Michele Rae Clippinger Daughter 100 209 Forge Road Boiling Springs, PA 17007 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. NONE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ -0- (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMiJIVT OF JACQUELINE V. MYERS t J _ _ ~-: ~.. `C ^ -- _- _i - -rn - ~ ~-~ _ -~-, -~~ _ ~ _ •,I .. - _.~, c: T, JACQUELII~IE V. NIYERS, a resident of i3oiling Springs, Cumberland County, Pennsylvania being of sound mind, memory and understanding, do hereby make, publish and declare this to be my Last Will and Testarnent, hereby revoKing all Wills and Codicils heretofore made by me, ITEM 1: I direct that all my just debts, the expenses of my last illness and funeral expenses be paid as soon after my decease as the same can conveniently be done. ITEM 2: I direct that there shall be paid out of my residuary estate all estate, inheritance and like taxes together with any interest or penalty thereon imposed 'by the government of the United States, or any state or territory thereof, or by any foreign government or political subdivision thereof, in respect to all property required to be included in my gross estate for estate, inheritance or like tax purposes by any of such govern- ments, whether the property passes under this Chill or otherwise, excluding, however, any property over which I have a taxable power of appointment, provided, however, that no residuary beneficiary shall by reason of this provision be denied the benefit of any deduction, credit, favorable rate of tax or other benefit which by law enures to such beneficiary. JZ1,~QUy LINE V. MYERS , -1- LAST WILL AiVD TESTAMENT OF JAC(~CJELINi=; V, lvfYERS ITEM :~: I give, devise and bequeath all of the rest, residue and remainder of my estate, real, personal and mixed, of whatsoever kind and nature, and wheresoever situate at the time of my death, unto my husband, RAY E. MYERS, provided, however, that he survives me and is living sixty (60) days after the date of my death. ITEM 4: If and in the event that my husband, RAY E. MYERS, does not survive me and i.s not living sixty (60) days after the date of my death, then and in such event, l give, devise and bequeath all of the rest, residue and remainder of my estate, real, personal and rnixed, of whatsoever kind and nature, and wheresoever situate at the time of my death, unto my daughter, MICHELE RAE CLIPPINGEH, provided however, that she survives me and is living sixty (60) days after the date of my death. ITEM 5: If and in the event that my daughter, MICHELE RAE CLIPPINGER, shall not survive me and is not living sixty (60) days after the date of my death, then and in such event, I give, devise and bequeath the interest in my estate, which such deceased child would have received, if living, to the issue of said deceased Child, per stirpes. i ,r ,, JA,~QU ~, LI1VE~ V . NIYERS ~;~ -2- . LAST WILL ANL~ TESTAMENT OF JACQUELINE V. MYERS ITEM 6: I hereby nominate, constitute and appoint my husband RAY E. MYERS Executor of this my Last Will and 'Testament, with full power to do any and all things necessary for the complete administration of my estate, and direct that no bond or other surety is required of him in this or any other jurisdiction for his performance of this office. If and in the event that my husband, RAY E. MYERS, does not survive me and is not living sixty (60) days after the date of my death, or does not complete his duties as lxecutor, then and in such event, I hereby nominate, constitute and appoint my daughter, MICHELE RAE CLIPPIldUER, Executrix of this my Last Will and Testament, with full power to do any and all things necessary for the complete administration of my estate, and direct that no bond or other surety is required of her in this or any other jurisdiction for her performance of this office . ITEM 7: If any provision of this Wi11 or of any Codicil hereto is held to be inoperative, invalid or illegal, it i.s my intention that all the remaining provisions thereof shall continue to be fully operative and effective, so far as is possible and reasonable. "', ~,, r J~i,INE V MYERS l~ -3- LAST WILL AND TESTAMENT OF JACQUELINE V. MYERS IN WITNESS WHEREOF', 1, JACQUELINE V. 1~fYERS, the Testatrix, have to this my Last Will and Testament, typewritten on four (4) consecutively numbered pages, subscribed my name and affixed my seal this ~=~ '~~~~ day of February, 1991. Signed, sealed, Testatrix, as and of us , who have witnesses hereto, each other. .,, ~ .~'.~.. .~,.r t'L* ~,.,~..~_..~~~~ ( SEAL ) J , .~QU ,LINE V . MYERS published and declared by the above named for her Last Will and Testament, in the presence Zereunto subscribed our names at her request, as in the presence of the said Testatrix, and of esiding at esiding at -~- REV-1500 EX Page 3 Fife Number Decedent's Complete Address: 21 -1 1 -00881 DECEDENTS NAME Jac ueline V. M ers STREET ADDRESS Church of God Home 801 N. Hanover Street CITY STATE ZIP Carlisle, PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments - 0 - B. Discount 2 7 9.3 3 Interest If Line 2 is greater than tine 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in ova! on Page 2, Line 2Q to request a refund. If Line 1 + Line 3 is greater than line 2, enter the difference. This is the TAX DUE. Total Credits (A + B) (2) (3) (4) (5) (1) $5..586.62 279.33 $5,307.29 Make check payable to: REGISTER OF WILLS, AGENT. . . ~ W ~~~ic ~ a~~`=~,-~~~: ti°'~ a 3.T Si. ~;'.CY,.y:~'~ :: ~...1~ ~~~44Xry.. ,.~.e ray ~_, ...sA 7-,A:~.~+F X~:cf''w'4 .. je ~. _'<~`n~.". _..... 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 Dec. 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 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}}. 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.