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Home My WebLink About11-21-11J 1505610105 REV-1500 EX (oz-ii) (FI) ~!1 j~ OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes °°°""`"`"'°`"°°`"°` County Code Year File Number Po Box z8o6oi INHERITANCE TAX RETURN Harrisburg, PA 1'712&o6oi RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death ,..___-------- ___. r _..__._._._.__.~~ ._ ` 173-38-6418 ~ 04/18/2010 Decedent's Last Name m -_ ~ ~~~ _ .~___..__ Lewis ~_. ~ __ _ _ ._ ..~ ....__ _ _ __! (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name ,Lewis Spouse's Social Security Number MMDDYYYY Date of Birth MMDDYYYY 08/02/1953 Suffix Decedent's First Name ~ MI Sherry ~ I A _. _ _.._ _a 1.._.._,,,.~ Suffix Spouse's First Name --~_ _........_. _ -- -._- ~.. W__..~ __ MI , ~ - ~ ~ Forrest ~ ` R --- -- - ~ ~ - THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW O 1. Original Retum OD 2. Supplemental Return O 3. Remainder Retum (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone ~N~umber '~ Mindy S. Goodman, Esquire ~ ! (7r 1-7;1540-8742: r? ~; I REGISTER OF"tf1pL~S~ U E ONLY'° First Line of Address 2215 Forest Hills Drive Second Line of Address Suite 35 City or Post Office Harrisburg State ZIP Code PA 117112 ~,_ ~ - t r" ii :.. ~_ -- t-.~ -~_,; - C--' r -. DATE FILED Correspondent's a-mail address: gOOdmanlBW@VerIZOn.net ^? .i ,j :~- ~.~ :) U -~r y 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 kno~yJpcl®e. ,~ sl~__nla~e~O~PERS~I ~E~0~1t31B~f.,~OR ING RETURN AT/E~ ADDRESS GNATURE OF PRE RER OTHER THAN REPRESENTATIVE ATE ADDRESS 2. Z i ~' ~ -~ ~}- 1-~ 11 S 7t"- . S ~ ~ 3 ~ }-~ b R ~~ A l -~- ~ i Z PLEASE USE ORIGINAL FORM ONL Side 1 1505610105 1505610105 J~ 1505610205 REV-1500 EX (FI) Decedent's Socia I Security Number ~a~»ae~es Name: Sherry A. Lewis _ 173-38-6418 t RECAPITULATION 1 R l E t t S h d l A ~ _ 259 800 00 . ea a e e ) .......................................... s e ( c u ... 1. ~ , . 2. Stocks and Bonds (Schedule Bj .................................... ... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 4 Mort d N t R i bl S h d l D ~ ~ . gages an o es ece va e ( c u ) ........................ e e ... 4. ~ 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).... ... 5. 3,000.00 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. < 29,614.50 7. Inter-Uvos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. 1 8. Total Gross Assets (total Lines 1 through 7) .......................... ... 8. 292,414.50 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. 13,127.50 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............ ... 10. 179,345.20 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. 192,472.70 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. ~ 99,941.80 i 13. Charitable and Governmental BequestslSec 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. 99,941.80 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 .0_ _ __ .....49,970.90 15. 0.00 16. Amount of Line 14 taxable .~ ~ °` ""- ~""""°'°"° at lineal rate X .0 4~ 49,970.90 16. ' 2,248.69 17. Amount of Line 14 taxable w ~ i at sibling rate X .12 17, ', 18. Amount of Line 14 taxable -~~~ ~"'~ at collateral rate X .15 ~ ____~_ ___ ~ ~ 1 g, 19. TAX DUE ...................................................... ...19.: 2,248.69 ~ I 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 2505610205 1505610205 REV-1500 EX (FI) Page 3 1'1er"ednn4~~ rmm~loto Ot~f11rL>!CC' File Number ~~~~~.~.._. -----r---- - ----- - DECEDENTS NAME Sherry A. Lewis ---- --- -------------- - -- ---..-..---- STREET ADDRESS 301 S. Stoner Avenue CITY STATE PA ZIP 17101 Shiremanstown Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments 6. Discount ___ 3. Interest 148.46 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (1) 2,248.69 148.46 (3) (4) 52.87 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 2,153.10 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: Yes No a. retain the use or income of the property transferred .......................................................................................... ^ b. retain the right to designate who shall use the property transferced ar its income ............................................ ^ c. retain a reversionary interest .............................................................................................................................. ^ 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)j. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal benefiaaries is 4.5 percent, except as noted in [72 P.S. §9116(a)(1)j. 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)]. 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. Total Credits (A + B) (2) coMMONwEA~TH of rENNSVwANu INHERRANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Lewis, Sherry A 21 - 10 - 00487 All r@81 pf0~76fLr VYIIfICY >bVIC~ v~ as a av~~ana n~ vw nn w.. ......-.. .... ... ~. .~~ ... .~.. ..._..-_- __.___ . _.. ...~_____ _____ -_ at which property would be exc anged between a willing buyer and a wil ing 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 DESCRIPTION VALUE AT DATE OF NUMBER DEATH 1 301 S. Stoner Avenue, Shiremanstown, PA -- recent countywide assessment valued property at $171,800 171,800.00 2 400 East Chestnut Street -- owned as tenants in common with Decedent's son 88,000.00 FMV - $176,000 TOTAL (Also enter on Line 1, Recapitulation) ~ 259,800.00 ,- ~~~ -._ SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY INHERITANCE TAX RETURN flESIDENT DECEDENT ESTATE OF I FILE NUMBER Lewis, Sherry A 21 - 10 - 00487 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 DESCRIPTION VALUE AT DATE OF NUMBER DEATH 1 2005 Nissan Maxima -very poor condition 3000 00 TOTAL (Also enter on Line 5, Recapitulation) I 3~ppp,pp x . < ~. SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Lewis, Sherry A 21 - 10 - 00487 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 A Forrest R. Lewis 301 S. Stoner Avenue Husband Shiremanstown, PA 17011 C JOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE I MADE JOINT nclude name of financ al 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 DECEDENTS INTEREST 1 A PNC Checking Account 42,202.73 50% 21,101.37 2 A PNC Money Market 1,076.25 50% 538.13 3 A 2007 Nissan Murano 15,950.00 50% 7,975.00 4 B TOTAL (Also enter on line 6, Recapitulation) I 29,614.5U F SCHEDULE G INTER-VIVOS TRANSFERS ~ ~MINHERTANCETAXERETURNANIA MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Lewis, Sherry A 21 - 10 - 00487 h h4 2i es This schedule must be compietea ana rnea ff the answer to any of questions 1 t roug on page s y ITEM DESCRIPTION OF PROPERTY Include the name of the transferee, their relationship to decedent and the date of transfer. DATE OF DEATH ~° OF DECD'S EXCLUSION TAXABLE VALU E NUMBER Attach a copy of Me deed for real estate. VALUE OF ASSET INTEREST IlF App~cnsl.E> 1 Retirement with SERS -beneficiary is Husband and not subject to tax. COMMONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN RESIDENT DECEDENT S(~EDULE H wF~UyW_E'R~ALpD~~ /~-/ 5~8~ MLJI.w\171 Iv11 IYG W~71 ~7 ESTATE OF FILE NUMBER Lewis, Sherry A 21 - 10 - 00487 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A, FUNERAL EXPENSES: 1 Myers-Harner Funeral Home, Inc. 5,681.00 2 Flowers 250.00 3 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Forrest R. Lewis Social Security Number(s) / EIN Number of Personal Representative(s): Street Address 301 S. Stoner Avenue City Shiremanstown State PA Zip 17011 Year(s) Commission paid 2. Attorney's Fees Mindy S. Goodman 3, Family Exemption: (If decedent's address is not the same as claimants, attach explanation) Claimant Forrest R. Lewis Street Address 301 S. Stoner Avenue C;ty Shiremanstown State PA Zip 17011 Relationship of Claimant to Decedent Spouse 4. Probate Fees Register of Wills Advertising Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1 3,250.00 3,500.00 323.50 123.00 TOTAL (Also enter on line 9, Recapitulation) 13,127.50 SCHEDULEI DEBTS OF DECEDENT, MORTGAGE COMMONWEALTH OF PENNSYLVANIA LIABILITIES, & LIENS INHERRANCETAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Lewis, Sherry A 21 - 10 - 00487 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1 Nissan Maxima 2,456.00 2 Nissan Murano -total debt $18,080 -jointly owned vehicle 9,040,00 3 Chase INK Credit Cazd 1,145.90 4 Chase Disney 2,613.40 5 Capitol One 3673.64 is total for jointly held card 1,836.82 6 CitiBank 8,917.15 7 Discover 3,417.29 8 Mortgage 136,636.07 9 General Finance Installment Loan 6,650.00 10 General Finance Installment Loan 1,577.91 11 School Property Taxes 1,356.26 12 County Tax 704.91 13 2008 Federal Income Tax (joint obligation -total $813.88) 406.94 14 Chase Amazon 449.98 15 HSBC Bank 1,633.57 16 2010 State Final Income Tax Return cn~ nn