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Home My WebLink About12-07-11 (2)..- 1505610105 REV-1500 EX (02-11) (FI) 1 ~1 PA Department of Revenue Pennsylvania Bureau of Individual Taxes °`°""'"`"' `w` " PO BOX z8o6oi ~ INHERITANCE TAX RETURN Harrisbur , PA ~7~z8-o6oi RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth 152-18-2049 07/04/2011 11/16/1926 OFFICIAL USE ONLY County Code Year File Number 21 ~~ I~C'L/ MMDDYYYY Decedents Last Name Suffix Decedent's First Name Rogers III MI Claude (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 0)D 1 Ori final R t g e urn O 2. Supplemental Return O 3. Remainder Return (Date of D O 4. Limited Estate O 4a. Future Interest Compromise (date of eath Prior to 12-13-82) O 6. Decedent Died Testate death after 12-12-82) O 5. Federal Estate Tax Return Required O (Attach Copy of Will) 7. Decedent Maintained a Living Trust (Attach Copy of Trust ) $• Totat Number of Safe Deposit Boxes O 9. Litigation Proceeds Received O . 10. Spousal Poverty Credit (Date of Death O Between 12-31-91 and 1-1-95) 11. Election to Tax under Sec. 9113(A) CORRESPONDENT - THIS SECTION MUST BE COMPLET N ED. ALL CORRESPONDENCE AND CON u ame FIDENTIAL TAX INFORMATION SHOULD BE D RECTED TO: David A Rogers Daytime Telephone Number (203) 722-5891 ~ First Line of Address 26 Half Moon Way Second Line of Address City or Post Office Stamford State ZIP Code CT 06902 REGISTER OF WILLS U~,SE ONLY , -~ ~:~j ~~ .. DATE FILED Correspondent's a-mail address: drogerS daymon.com 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. SIG TURE OF P SON RESPONSIBLE FOR FILING RETURN ~' n D TE ADDRESS Or ~~ 26 Half Moon Way Stamford, CT 06902 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY 1505610105 Side 1 1505610105 ~1 ~~~ . y_,I J REV-1500 EX (FI) Decedent's Name: ciaUde RO9@rS ~~~ RECAPITULATION 1505610205 Decedent's Social Security Number 152-18-2049 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 , 6. Jointly Owned Property (Schedule F) O Separate Billing Request d 7 I 3,170.86 e . ....... g. nter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7, 8. Total Gross Assets (total Lines 1 through 7) ...... . ..................... s. 9. Funeral Expenses and Administrative Costs (Schedule H) ... 3,170.86 .. . ~' ~ "' 9. 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) 1,529.01 ....... 10 11. Total Deductions (total Lines 9 and 10) ......... ..... . ... . .. 11 12. Net Value of Estate (Line 8 minus Line 11) ... , . 1,529.01 .. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 12 an election to tax has not been made (Schedule J) ... 1,641.85 ............... . .... . 13. 14 . Net Value Subject to Tax (Line 12 minus Line 13) ....... . TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICAB 14 1,641.85 15. LE RATES Amount of Line 14 taxable at the spousal tax rate or , transfers under Sec. 9116 (a)(1.2) X .0_ 16. Amount of Line 14 taxable 15. at lineal rate X .0 45 73 88 17. ' Amount of Line 14 taxable 16. 73 88 at sibling rate X .12 . 18. Amount of Line 14 taxable 17. at collateral rate X .15 18. 19. TAX DUE ................. ........................... .......... .. 1s. 73.88 20. FILL IN THE OVAL tF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O ],505610205 Side 2 1505610205 J REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number Claude Rogers III STREETADDRESS _ - - - - _ _ Forest Park Health Center _ 700 Walnut Bottom Road ___ CITY - - _ __ - __ _ _ - __ -- -- aisle - _ _ STATE ZIP PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments (1) 73.88 A. Prior Payments B. Discount _ _ 3. Interest Total Credits (A + g) (2) 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (4) (5) 73.88 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 a. retain the use or income of the property transferred ............... No b. retain the right to designate who shall use the property transferred or 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? .. ....... . . Did decedent own an "in trust for" orpayable-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 survivin s o 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 survivin s o g p use [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 filing a tax return are still applicable even if the surviving spouse is the only beneficiary. g p use is 0 percent and 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 arent 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 2 F p • 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 sibSng9sldefin(ed] under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. ' REV-1508 EX+ (is-io) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY FILE NUMBER: Include the proceeds of litigation and the date the Drocaarlc ~.,o.o ...,...:.._~ All nrnnn.+.. :..:_.~_. _-- _ i2E~-1511. Ei:: 1u-09j pennsylvania r1EPARTMENT Of REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT CCTwTr n SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS Claude Rogers III Decedent's debts must be reported on Schedule I. ITEM NUMBER A. FUNERAL EXPENSES: DESCRIPTION 1' Thomas Funeral Home -Balance due 2• Willow Tree -Refreshments Arlington Monumental Works -Grave Site marking FILE NUMBER B• ADMINISTRATIVE COSTS: I• Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP _ Year(s) Commission Paid: 2. 3. 4. 5. 6. 7. Attorney fees: 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 Fees: Tax Return Preparer Fees: PNC Bank Safe Deposit box entry fee Short Cerificate Fees 500.06 576.45 285.00 100.00 67.50 TOTAL (Also enter on Line 9, Recapitulation) $ 1,529.01 If more space is needed, use additional sheets of paper of the same size. REV-1513 EX+ (01-10) Pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT FCTeTe ne. Claude Rogers III NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1• Cynthia Kane - 1863 Park Forest Ave, State College, PA 16803 2~ Laura Blomquist -9410th Avenue, Holtsville, NY 11752 3. David Rogers - 26 Half Moon Way, Stamford, CT 06902 4. Richard Rogers - 2055 Evanstown Road, Irwin, PA 15642 RELATIONSHIP TO- pE~EpENT Do Not List Trusteelsl Daughter Daughter Son Son ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, I APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1 FILE NUMBER: AMOUNT OR SHARE OF ESTATE 25% 25% 25% 25% TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. If more space is needed, use additional sheets of paper of the same size. # r :~ U D ~~ J ~ 0 --~,- ~? ~~ al 0 s C° ~~ ~o M M l M v O r 01 J .~ ~h 0 .~ ,~, v- Z