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HomeMy WebLinkAbout12-29-11 (2)15056041125 RED/-1500 EX (06-05) PA Depa{tment of Revenue Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number PO BOX k80601 2 1 1 1 ~ f Hanisbur~PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFCtRMATN)N BELOW Social Security Number Date of Death Date of Birth 1 7 7 0 1 6 6 0 8 1 0 1 1 2 0 1 1 0 8 1 2 1 !3 1 5 Decedent's Last Name Suffix Decedent's First Name MI S I M M O N S H E L E N B (!f Applicable) Enter Survliving Spouse's information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Socal Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS flLt IN APPROPRIATE O'~/ALS BELOW © 1.Original Retum ~ 2. Supplemental Retum ~ 3.. Remainder Retum (date of death prior to 12-13-62) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Retum Required death after 12-12-82) QX 6. Decedent Died T to ~ 7. Decedent Maintained a t.iving Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of ill) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-81 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST 8E COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number H A R O L D S I R W I N I I I 7 '.1 7 2 4 3 6 0 9 0 Fmr Name (If Applicable) I RW I N L~AWOFF I CE First line of address 6 4 S O U T% P I T T S T R E E T Second line of address City or Post Office CAR L I S L E REGIBTER OF WILLS U8E ONLY, <"~ :. N ~ _..__ _,~ -,~ ~ ~ . : _ _ a >~ - - rn r 1 -_ ~:~ v - ,-~ _ 7 _~ State ZIP Code ~ P A 1 7 0 1 3 ,_ ._ i ~. ~~ r,~ ~_ a _ . ~ _. --* ~~'3 f -~ Correspondent's e-mail 1 atl.corn Under penakies of perjury, l dada drat 1 have examined this return, inducting accompa-iykig schedules and statements, and to the test of my knowledge and belief, it is true, correct and complete. of p-eparer other than the personal repieserita8ve ~ based on all infonnatian of which preparer has any krroxAedge. SIGNAfI~EiE OF PERSON RE PONSIBCE~OR F8.11VG RETURN /' DATE/ ADDRESS 7685 B DRI 64 SOUTH PITT ~STREE~ L 1505641125 ATIVE COOPERSBURG CARLISLE USE ORIGINAL FORM ONLY Side 1 PA 18036 TE _ (2 ~ r. f PA 17013 15056041125 I _ __ 15056042126 REV-1500 EX DeoedenYs soda{ Security Number Dsoedsrrrstdarne: HELEN B. SIMMONS 1 7 7 0 1 6 6 0 8 RECAPITULATION 1. Real estate (Sc~redub A) '' ................:....................... 1 ~ 0 0 0 2. Stod~s and Bonds (Schs~ub B) .................................. 2. 0 0 0 3. Ckrasly Held Corporation, (Partnership orSob-Proprietorship (Schedub C) ..... 3. Q Q Q 4. Nlortpagas A Notes Reoei~abb (Schedub Dj :.:..................... 4. Q 0 .0 5. Cash, Bank Deposits r~ M~oelbneous Personal Property (Schedub E) ....... 5. 4 1 8 5 4 5 0 8. Jointly Owned Property ( S~ ub ~ ^ Separate Billing Requested ....... ~ 8• 7. Inter-Vnros Transfers d~ M (Sched b G) °e llane°us N Property Bipi t R t d 0 0 0 u ~ ra rp e eques e ....... 7. 8. Total (cross Assets (total L~nes 1-7) ........................... 8. 4 1. 8 5 4 5 0 9. Funeral Expenses d< Adm ir~btratrve Costs (Sd~edub H) ................ 9. 2 6 8 7 5 0 10. Debt of Deoedsnt, Mortpa~ys LiabNitbs, ~ Liens Sdredub I 10. 8 6 3 3 6 4 11. Total o.ducaons (tomt unlps 9~ t 0) ..... ...................... 11. 1 1 3 2 1 1 4 12. Net value of Es~aba (Line 8 minus Lbe 11) ......................... 12. 3 0 5 3 3 3 6 13. Charitable and I BequesWSec 9113 Trusts for which 1 0 1 7 7 7 8 an abdion to tax has not n made (Schedule J) .................. 13. 14. Net Value Subject b Tax 12 minus Line 13j ............. 14. 2 0 3 5 5 5 8 TAX COMPUTATION -SEE TRUCI'IONS FOR APPLICABLE RATES 15. Amount of Line 14 taxabb at the spousal tax rate, a ''~, transfers under Sec. 9116 ', (aj(1.z) x.045 2 0 3 5 5 5 8 15. 9 1 6 0 0 18. Amount of Line 14 taxabb 0 0 0 0 0 0 at lirbal rate X .o- 16. . 17. Amount of Line 14 taxabb Q 0 0 0 0 0 at siblkp rale X .12 17. 18. Amount of Line 14 taxabb ', Q Q Q . Q Q Q at ooMaterai rate X .15 18. 19. Tax Dus ..... ............ .. :....................19. _ , 20. FlLL IN THE OVAL IF YOU ~"~ REQUESTING A REFUND OF AN OVERPAYMENT 9 1 6~ 0 0 Side 2 1505604212!6 15056042126 J - - - _ - __ HlI.EN iti. =lMMONis ~~ ~ ~~Yf~~ NBA/! fax Payments and Credits: . Tax Due (Page 2 l~r-e 19) CreditslPaymerets A. Spousal Poverty Credit B. Prior Payments C. Discount 40.A0 Total Credits ('A +B +C ) IMerestlPereaily ifapplicable D. interest E. Penally Total interestlPenalty (D + E ) M Line 2 is greeater than Line 1 + Line 3, the differeteoe. This is the OVERPAYMENT. FIN M oval on Page 2,120 b r+squeest a redund. ~ L'eree 1 + tine 3 is greater ttearr Line 2, enter the ddferetae. This is the TAX DUE A. Enter the interest an the tax due. B. Enter the total of line 5 + 5A. This is the ~1L.AtICE DUE. (1) 016.00 (~ 4S.tl0 (3) y 0.00 (4) 0.00 (5) a70.Z0 (~) (5s) a7oso Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE F'DLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did deoederd make a and: Yes No a retain the use or of the property traresferred : ...................................................:............. ... ^ b. rr#ahr the right to who shat use the property transferred or its lreoome; ........................... .... ^ c. rake a reversionary in • or ................................................................................................ ' d. receive the prorteiae for of either payments, benefits or care? .................................................... .... 2. of death occurred aRer 12,1982, did decedent transfer property within one year of death without r~eoeivkrg adsqu~ eonsideration~ ....................................................................................... 3. Did deoederrt own an'in for' or payable upon death bank account or security at his or her death? ...... ... 4. Dkl deoeders own an I Retirement Account, annuity, ar other ran-probate property which contains a berieffdary desi~nation? ............................................................................................... ... ^ ff THE ANSWER TOANY OF-.THE ABOV~ QUESTIONS IS YE3~ YOU MU31' COMPLETE SCHEDULE G AND FILE R AS PART OF THE RETURN. x daNs of death on or after July _1,1994 and January 1,1995, the tax rate imposed an the n~ value of transfers to or for the use of the surviving spouse three (3) percent [l2 P.S. §9116 {a) {1.1) (i)]. x dates of death on ar afar Jarwary 1,1995, the rath imposed on the riet value of transfers to or for the use of the seuvivirig spouse ie zero (O) percent 2 P.S. §9116 (a) (1.1) (si11; .The statute a transfer tD a survivng spouse from tact,. and the stNutory requirements for ~sdosure of assets and th9 a tart return are stiN applicable even ff the ving spouse is the only bere~iaary. . x dates of death on a after July 1,2000: ie tax rate imposed on the rest value of transfera a deceased deild twegty-0ne years of age or irounger at death to or for the use of a riatrrral parent, an iop8ve parent, or a stepparent of the child is aero 0) percent (72 P.S. §9116(a)(1.2)]. 1e tax rate imposed on the net value of transfers ~ or for the use d the deoedertCa Neie'al benefic4aries is four and one-halt (4.5) percent, e~coept as rated in 2 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. ~ - ietaxrate imposed an Use rest vakre of transfers ~ or for the use of the deeeder~'a eethlirigs is twelve (12) percent (72 P.S. §9116(a)(1.3)]. A aiW'ng isdeferred, under ediori 9102, as an individual who has at I~st cite ~t ke oornrreori with the deoederd, wtesllrer byblood aradoption. ;EV 1500 O( ~ 3 ~ Felo Numbsr decedent's Complefie address: __ REV 1502 4C + (e-ee) ~ SCHEDULE A co~oNwewm of PENNSIlLVANIA REAL ESTATE INHERITANCE TAX RETURN .RESIDENT DECEDENT ESTATE OF ' . FILE NUMR;ER HELEN i. ti1MMONi 11S nM properyr-owned solNp a as a Msard ~ coarmon must he nporied at tak market rakre. Fair n~loet value b dei<rred a the price et wtxdr propery would be eeodrerged helween a wiNp 6uyar a wI1Mg aeMer, neiUrer tbig aortpeNed b twin a aeN, boMr hsvhp reewrbble knowkdDs of the rebvard iscts. E _- Real which b wNh of must be dttcbeed on Schedule F. ITEM ~ VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. NONE 0.00 TOTAL (Also enter on Nne 1 ~ RecapibiaUon) ~ : !~ (If moro apace b needed. insert additlorrel sheets dlhe same sire) REV 1503 EX + (a-eel SCHEDULE B ~~TM ~ ~~~~~ STOCKS 8a BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FlLE NUII~ER HELEN t.:IMMONi , ~ ProP~! l~f~~wd wlfh riDM of swv(vaship mint b~ dNcloWd on SdmduM F. ITEM. _ . VALUE AT DATE -~ NUMBER DESCRIPTION OF DEATH 1. NON! 0.00 ~v ~so4 4c+ (e•~' SCHEDULE C CLOSELY-HELD CORPORATION, ~OAi~A0N1NEALTM ~ PENNSrw~u~ PARTNERSHIP OR ~ ~ of Eo~~ SOLE-PROPR{ETORSHIP ESTATE OF ~ F~.E IRIYBER NE~EN s. snMroNS Sdiedule G1 or C 2 (lndidirg a~ppoiYng MomrYon) must be al6adied for each cb~ely-held aorporatloNPeMeiaNfp hbred d tl-e deoederd, o0er ~n a ~ -; . Ses inMn~ona br Uie g kdormetlon to be aubrt~Mled Tor eob~ropdebrafape. ~ -- REM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ,_ 1. NONE ' 0.00 0.00 - rtEV=~so~ bc+ (~ COAiMA0M4VE~ILTH OF PENNSYIV INHERIT111~E T/1X RETURN ~ RESIDENT DECEDENT ESTATE OF NELEN d. ITEM NUMBER 1. SCHEDULE D - MORTGAGES & NOTES RECEIVABLE FfLE NUMBER ~ joMly~nd twltli 1M dpht of wrvhraship mud b~ dpdoad on SdMduN F. VALUE AT DATE '' DESCRIPTION OF DEATH 0.00 -_ REY 1500 EX + (8-99) ~ SCHEDULE E COMMONWEALTH of PENNSYLVANIA CASH, BANK DEPOSITS, ~ MISC. ~' ~ I~'~"Nr oECE~ R" I PERSONAL PROPERTY ESTATE OF ~ FILE NUINER i1ELEN S. i1MtI10Ni • llndud9 tfie d iYpeElon and Ih9 date the were n~oeired by the e:dele. wMh of oast be dNdoad on Sc~adula F. ITEM NUMBER ~ DESCRIPTION 1. EMBlRS 1ST EDERAL CREDIT UNION ChsckinE Arco nt Sss Bank Scat tat Exchibit "B" . '2. PNC BANK Checking Ac flt Sse Bank Stet sot at Exhibit "B" 3. AMBULANCES RVICE REFUND 4. CHAPEL POINT NURSING HOME Rotund S. UNITED WORLDLIFE Refunds I a TOTAL (Also enter an line 5, Rec~pilula6on) _ (~ mots apeoe b needed, Gaert addllontl eheels d tine eeme stns) ~~__ _- VALUE AT DATE OF DEATH .. 16,63630 18,484.29 T7.15 5,340.63 1,322.23 . 4.50 REV ~ soo 4_ c + (e-oe~' SCHEDULE F COI~AONWEALTH of PENNSYLYANIA JOINTLY-AWNED PROPERTY INHERITANCE TAX RETURN _ RESIDENT DECEDENT ESTATE OF Fi1.E NUMBER , NELEN i3. sfMMIONs M an past Wade joNrt rdtlrkr one yar of tln deaderll's deb of desNr, R naat be nporWl on Sdwdeis ti. _ d SURVMNG JOMIT TENANT(S) NAME, ADDRESS RELATIONSHIP TO DECEDENT Ar NONE IdNTI_Y.a7MINED PRAPERTY: TEM JMBER tFrTER FOR JONT TENANT DATE MADE JOINT DESCRIPTION OF PRDPERTY INCLUDE OF FMIANCIAI INSTITIRION AND BANK ACCOUNT NUN6ER OR SIMILAR NUMBER ATTACH DEED FORJONTLY-HEIR REN. ESTATE. DATE OF DEATH YAI lIE OF ASSET X OF DECDS NTERESf DATE OF DEATH VAUIE aF DECEDENPS INTEREST . A. NONE . TOTAL (Abo enter on ins 6, Rerapihllaf~lT) I : - - (It more apsoe is needed. insert raddiSorrel aNeeb of the sane sixs~ r REV-1510 EX + (8+~ SCHEDULE G INTER-VNOS TRANSFERS S C~ HERRANCE~/1X RETURN~w ~ MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT = ESTATE O!F ' FILE NUMBER HELEN S. siMMONS This schedule must be and filed Y the answer b any o(quesgor~a 1 thnwph 4 on the nrierae aide of tl~e REV 150D COVER SHEET b yes. DE OF PROPERTY ITEM rauoenE-wEaFnE nai~nawrroaecmtwrno DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE ~ -.: tUA~ER nEahaFnwNrfn. ~ ~aonoFnEO®rortat~sr~. VALUE OFASSET INTEREST ~A .VALUE ~-- 1. NONE 0.00 0.00 i ~I ~. I i n I I i TOTAL (Also enter on line 7 Rec (If mole »Oeos to needed, MroeR addNblal aheeb of the same alas) ~0 REV-1511 fiX + (1~2-aB) SCHEDULE H COAiMAONWEJILT" of PENNSYLVANU-' FUNERAL EXPENSES ~ a~"ERrrANCE TAx RETUa" ADMINISTRATNE COSTS RESroENr ~ECEOENr ESTATE OF FILE NUMBER HELEN S. SIMMONS ~' gable of dacedant naut ba reporbd on Srdredrda L Y_ ITEM NUMBER ~! DESCRIPTION AMOUNT A. FUNERAL. EXPENSES: 1. 3. ADMINISTRATIVE COS S: - 1. Personal 's Commissions Named Repreaenh~e (a) Social Searrity ~Vumber(syEtiY Number d Personal Represer~re(s) SUeetAddress I~~ ~ ' She ~ Yeer(a) Cortxrri~sfon Paid: y, Atbmey Fees IRWI~1 LAW OFFICE 2,800.pp 3. Fancy Exemption: (N deopdenCa address is rat the same es dafrrrenPa, atiadr eocplaretion) Clairrrard Strad Address . Gy ShNs Zlp Relationship d too Deoedern 4. p~ Fees CUMBERLAND COUNTY REGISTER OF WILLS 157.50 5. AooourMarKs Fees ', 6. Tax Rehm Preparer's Fes _ . _ 7. gIMdERLAND C~UNTY REGISTER OF IAflLLS - flN Imnntory and AppralWmMt 50.00 I REV-1512 EX + (12-03) - SCHEDULE i = - G~,un, of r~EENNSnvANU-', DEBTS OF DECEDENT, '""E ~~ ~ MORTGAGE LIABILRIES ~ LIENS ~` R , . ESTATE OF ~ ~ FILE NUMBER HELEN s. sIMMONi Report debit inarrnd t1y tM prbr to deMh which rorneined unpdd ae ~ the date of death, indudNrp tmrehrdsureed medical - ITEM ' VALUE AT DATE NUMBER ' DESCRIPTION OF DEATH 1. ClNTURY LINKI, 74.72 - Phones Bills - 2. TIL LlACOCK ', 1,000.00 3. CHAPlL POIN~ 7,426.50 Nursitt8 Homo ill 4. - MILLlNNIUM PI~ARMACY sYSTEMS - 73.52- ' Medical Bill - 5. SPRINT ~ 37.82 6. MILLlNNIUM PI~ARMACY sYSTEMS Zq.Og TOTAL Also erg Iine f0 °" , Recapitulation) i' a lls3.at ((If more specs b needed, inert addidonel aheeb of the aerrre aiae) . REY-1518 D(~ (Y-0OP ~ SCHEDULE J caeloNwE,tiTH or PENNSYWANIA BENEFICIARIES . INMERRANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER , HELEN S. sIMYONs NUMBER NAME AND ADDRE OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustas(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS dbtributlons, and transfers ceder . 9116 (a (1 ]j 1, JlFFREY N. SIMM NS uns~l 8700 west Sstll Av ue 1/3 Residue Nlheat RIdOs, CO SS , 2. LINDA S. MILANK W Lp,N( 7151 Oak Pointe C role 1/3 Residue Noblesville, IN i • ENTER DOLLAR AMOUNTS F DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGFI 18, AS APPROPRIATE, ON ; REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUT A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. ~rNe w1.~lANC~ Noe 1o,1n.78 77o south Hanover street Carlisle, PA 17015 { B. CHARITABLE AND GOVERf~IMENTAL DISTRIBUTIONS . 1. f ~i TOTAL OF PART II - ENTEf~ TOTAL NON-TAXABLE OISTitIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET ~ I S ,t 0.1 n.>ra (If mae space is needed, wrsert _- l same size) EXHIBIT °A" ~_- -- r ~ ~ I, HELEN B. SIMMQNS, of 9 Alliance Drive, Apartment 101, Carlisle, Cumberland County, Pennsylvan#a 17013, do hereby make, publish and declare this to be my last will and testament, hereby revoking all wills heretofore made by me. 1. I direct my pe onal representative to pay all of my debts, funeral and administrative expe ses as soon as convenient after my decease. I direct that all inheritance taxes im sed or payable by reason of my death and interest and penalties thereon with respect to all property, whether or not such property passes under this Will, shall be paid by my ~ersonal representative out of my estate. 2. I authorize an empower my personal representative to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or privates le or sales and to give good and sufficient deeds and/or bills of sale therefore, in fee simple, as I could do if living. My representative is authorized and empowered to engag in any business in which I may be engaged at my death, for such period of time after y death as seems expedient to said representative. 3. I give, devise and bequeath all of my estate of whatever nature and wherever situate as follows: ~' ,. T F r A. 1/3 to T~e Alliance Home, Carlisle Pennsylvania, for general purposes; _. _. _. B. 1/3 to my son, Jeffrey H. Simmons, or if he is deceased, then to Shaunna Simmons; and C. 1/3 to y daughter, Linda S. Milankow, or if she is deceased, theca to her children, share and share alike. ~ _ - ~ _ _ ~, - ~__ __ . . 4. I nominate ar~d appoint Judie Gretz, or if she cannot or does not serve, Dick Gretz, to be the personal representative of my estate, to serve without~bond. 5. I suggest tha~ my personal representative retain the services of Harold S. Irwin, Ilt, Carlisle, Pennsyl~rania in the settlement of my estate. ~I IN WITNESS WHEREOF, I have hereunto set my hand and seal this 27~' day of February, 2007. ', j ~ (SEAL) HELEN B. SIM ONS ~- Signed, sealed, publi~hed and declared by the above-named person as and for a last will and testament, in our presence, who at said person's request, in said person's presence and in the ~resence of each other have hereunto set our names as subscribing witnessed. F 1 ~ M ~ ~ WE, HELEN B. SIM ONS, HAROLD S. IRWIN, III and SARAH A. HARDESTY, the testatrix and witnes es respectively, whose names are signed to the foregoing instrument, being fi t duly swom, do hereby declare to the undersigned authority that the testatrix signed 'nd executed the instrument as her last will and that she had signed willingly, and that sh executed it as her free and voluntary act for the purpose herein expressed, and that ach of the witnesses, in the presence and hearing of the testatrix, signed the will as a fitness and that to the, best of their knowledge the testatrix was, at that time, eighteen y ars of age or older, of sound mind and under no constraint or undue influence. ~ j HAROLD S. IRWIN, 111 COMMONWEALTH ~F PENNSYLVANIA :ss: COUNTY OF COMB I RLAND Subscribed, swom to and acknowledged before me by HELEW B. SIMMONS, the testatrix herein, and ubscribed and swom to before me,by HAROLD S. IRWIN,111,`and SARAH A. HARDES ,witnesses, this 27T" day of February, 2007. ~ ~~~~ sed Cade Bau, V ~- ;_ .. -- i ~~ ~:. s't 1 EXFIIBIT "B" s