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Home My WebLink About12-15-11---I REV-1500°((01-70' 1505610143 OFFICIAL USE ONLY PA Department of Revenue pennsyNania Bureau of Individual Taxes oFrMt/,EMOFREVEl1UE County Code Yeer FAe Number PO 80X.280601 INHERITANCE TAX RETURN 21 11 1119 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 202 20 4148 08 28 2010 11 24 1924 Decedent's Last Name Suffix Decedent's First Name MI BLACK MARTHA E (H Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Securiiy Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW ® 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death pnor tD 12-13-82) ^ 4. Limited Estate ^ 4a. Future I"rarest ComprorMse ^ 5. Federal Estate Tax Return Required (dare a deaa~ aner ~2-~z-~> ® 8. Deoedant Died Testate ^ 7. Decedent Melntakred a llvirg Trual (Attach Copy of VJ~ (Attach Copy of Trust) 8. Total Number of Safe Deposit Boxes ^ 9. Litigation Proceeds Received ^ 10. ~2P'~y~i amid ~i-e5a ^ 11.Election bo tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number THOMAS A CAPPER 717 232 8731 First line of address 2303 MARKET STREET Second lute of address City or Post Office CAMP HILL State 21P Code PA 17011 RE(iISTER OF WILLS U~^ONLY S gq ~= ~7 c~ ~ ~ ~., '~ 7 ~~ ~ ~ ~~ ~ ' ' ~7 - r ~ C'? s;3 -ri _- S FILED ,,,,_ ri :a ~~ r, r-,a ~' correspondenese-mailadaress: capper~bmc-law.net Under penalties of perjury, l declare that I have examined this return, iriduding accompanying schedules and statements. and 6o the best of my knowledge and belief, it is titre, oorred and complete. Dedaratbn of preparer other than fhe personal representative rs based on all information of which preparer has any krrovrA9dge. 2303 Market Street, Camp Hill, PA 17011 SIGNATURE O EPARER OTHER R SENTATIVE DATE ,~ w ~.- Thomas A Capper ~ ali3~ / 2303 Market Street, Camp Hill, PA 17011 Side 1 L 1505610143 1505610143 ~..~~~' 1505610243 REV-1500 EX oeceaenrs Name: BLACK , M A R T H A E Decedent's Social Security Number 2 0 2 2 0 414 8 RECAPITULATION 1. Real Estate (Schedule A) .......................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................... 2. 3. Closet' Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3. 4. Mortgages 8 Notes Receivable (Schedule D) .......................................................... 4. 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ 5. 8 , 5 2 9 . 4 8 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............. 6. 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ............. 7. 8. Total Gross Assets (total Lines 1-7) ....................................................................... 8. 8 , 5 2 9 . 4 8 9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 1 , 19 5 . 5 0 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ................................ 10. 7 6 , 9 4 6.11 11. Total Deductions (total Lines 9 8 10) ...................................................................... 11, 7 8 , 141.61 12. Net Value of Estate (Line 8 minus Line 11) ............................................................. 12. - 6 9 , 612.13 13. Charitable and Governmental Bequests/Sec 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. - 6 9 , 612.13 TAX COMPUTATION -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 .00 15. 16. Amount of Line 14 taxable at lineal rate X .045 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. Tax Due .......................:............................................................................................. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 1505610243 0.00 REV 1500 EX Page 3 Decedent's Complete Address: File Number 21 - 11 - 1119 Black, Martha E STREET ADDRESS 210 Big Spring Road CITY Newville STATE PA ZIP 17241 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. (1) 0.00 Total Credits (A + B) (2) 0.00 (3) 0.00 (4) (5) 0 . ~ ~ 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: Yss No a. retain the use or income of the property transferred :.................................................................................. x b. retain the right to designate who shall use the property transferred or its income :.................................... x c. retain a reversionary interest; or .................................................................................................................. x d. receive the promise for life of either payments, benefds or care? .............................................................. x 2. If death occurred after December 12, 1982, did decedent transfer properly within one year of death wkhout receiving adequate consideration? ....................................................................................................................... ^ 3. Did decedent own an °in trust for' or payable upon death bank account or security at his or her death?......... ^ Qx 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 fT AS PART OF THE RETURN. For dates of death on or after JuN 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 p2 P.S. §9196 (a) (1.1) (7]. 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 surviving spouse is 0 percent p2 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 disGosure of assets and filing a tax n3tum are still applicable even if the surviving spouse is the ony 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 ears 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 blooootltl or adoption. SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. °O~D~~TM~°E~^"~' PERSONAL PROPERTY WHERRANCE TA%RETURN RESDENT DECEDENT FILE NUMBER ESTATE OF Black, Martha E 21 -11 -1119 InGude 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. NUMBER DESCRIPTION VALUEDAETADHTE OF Orrstown Bank Checking I 8,529.48 Account No. 301035 TOTAL (Also enter on Line 5, Recapitulation) ~ 8,529.48 SCFEDl1LE H coArAONUUE/~T'N of rawsnwwu /F~y~~~~-~p/~~ //~~$~t INHERITANCE TAX RETURN ~'YA~\h71 rW 1 1 YG ~.-LJ7 1 ~7 RESIDENT DECEDENT FILE NUMBER ESTATE OF Black, Martha E 21 -11 -1419 Debts of decedent must be reported on Schedule I. ITEM NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT A. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Thomas A. Capper 0.00 street Address 2303 Market Street City Camp Hill State PA Zip 17011 Year(s) Commission paid n/a 2. Attorney's Fees Ball, Murren 81 Connell 1,000.00 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. Probate Fees Register of Wills, Cumberland County 120.50 5. Accountant's Fees 6. Tax Return Prepan:r's Fees 7, Other Administrative Costs 1 Estate Notice Publication (Cumberland Law Journal) 75.00 TOTAL (Also enter on line 9, Recapitulation) 1,195.50 SCHEDULEI DEBTS OF DECEDENT, MORTGAGE °OA'~ON~^~TMOF~~~A~A LIABILITIES, & LIENS tt~M1ERRANCE TAX RETURN RE8IDENT DECEDENT - FILE NUMBER ESTATE OF Black, Martha E 21 -11 -1119 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM DESCRIPTION AMOUNT NUMBER 1 Department of Public Welfare - Pa. Medical Assistance Estate Recovery 22,175.14 Class 3 Claim 2 I Department of Public Welfare - Pa. Medical Assistance Estate Recovery I 54,770.97 Class 5.1 Claim ~ TOTAL (Also enter on Line 10, Recapitulation) ~ 76,946.11 REV-~s~a Ex+l»ae) SCHEDULE) COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERRANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ri~~~ nn~rth~ F FILE NUMBER -~-- -' ~ 21 -11 -111 9 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$S) RECEIVING PROPERTY Do NotlfstTrusbaa(s) I~ TAXABLE DISTRIBUTIONS[include outright spousal dlstributons and transfers under Sec. X116 (a) (1.2)] 1 Richard A. Black, Sr. Son 1/4 of residue 698 Mountain Road Newville, PA 17241 2 George M. Black, Jr. Son 1/4 of residue 82 Lonnie Burke Road Portal, GA 30450 3 Delores J. Garman Daughter 1/4 of residue 4585 Mont Alto Road Waynesboro, PA 17268 Eller dollar amourrts for distributions shown above on lures 15 t hrough 18 on Rev 1500 cover she et, as appropriate. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET) 0.00 REV-1613 EX+ (8.00) SCHEDULE) COAi1A"ON1A'EP'`TMOF~""~""A"'" BENEFICIARIES continued ' INHERRANCE TAX RETURN RESIDENT DECEDENT ESTATE OF I FILE NUMBER Black_ Martha E ~ 21-11-111 9 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) (3SS) RECEIVING PROPERTY Do Not ust Trustee(s) I~ TAXABLE DISTRIBUTIONS[ncludeoutrigM sal disMbutions andnsfers under Sec. )116 (a) (1.2)i 4 Sherry D. Wiest Daughter 1/4 of residue 319 Highland Court Berkeley Springs, WV 25411 Page 2 of Schedule J