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HomeMy WebLinkAbout03-08-121505610140 -' REV-1500 EX ~°'-'°' PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 1 0 8 0 4 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 6 6 D 3 0 2 6 4 0 6 0 9 2 0 1 1 0 5 1 0 1 9 1 4 Decedent's Last Name Suffix Decedent's First Name MI W A G O N E R J A C K D (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 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) ^X 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - 1 HIS StCI1ON MUST tit GVMPLtI tU. ALL GUKKtSt'UNUtnGt ANU cunl•lutn I wL I AA InrurcmAl lun snuuLU rst UlKtt, I tU 1 V: Name Daytime Telephone Number S U S A N H C O N F A I R 7 1 7 ? 6 3 1 3 8 3 First line of address 2 3 3 1 M A R K E T Second line of address City or Post Office C A M P H I L L S T R E E T State P A ZIP Code REGISTE ~ ILLS USE'ONLY .--., ` ?- I t ~ C7 ,.a rJ=~>~r1 f :~~ ~ i ~ ~-1 ~ ~..~ 7 +"~f i t+ Y- ~' , -- C il -Fb-ATE FILED .F" ~ 1 7 D 1 1 Correspondent's a-mail address: SCONFAIRaREAGERADLERPC • COM 1~ :_~ _.~.. (T <~ 'Ti 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, corcect and complete. DeGaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT OF PERSON RESPONSIBLE FOR FILING RETURN /DAT 1917 COLUMBIA AVEN P SIGNATURE OF PREPAR OTHER TtjAN REPRESENTATIVE / ,Di4~E - 2331 MARKET STREET CAMP HILL PA 17011 PLEASE USE ORIGINAL FORM ONLY Side 1 15D561D140 1505610140 ,~~, 150561^240 REV-1500 EX Decedent's Social Security Number Decedents Name: JACK D• WAGONER 1 6 6 0 3 0 2 6 4 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. 7 2 4 7 . 3 6 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested . ... ... 6. 7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property (Schedule G) ~ Separate Billing Requested . ... ... 7. 3 6 5 6 1 8. 5 0 8. Total Gross Assets (total Lines 1 through 7) ..................... ... ... 8. 3 7 2 8 6 5. 8 6 9. Funeral Expenses and Administrative Costs (Schedule H) ............ ... ... 9. 1 0 6 3 6 . 5 0 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... ... ... 10. 8 9 1 0 . 8 0 11. Total Deductions (total Lines 9 and 10) ......................... ... ... 11. 1 9 5 4 7 . 3 0 12. Net Value of Estate (Line 8 minus Line 11) ...................... ... ... 12. 3 5 3 3 1 8 . 5 6 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. 3 5 3 3 1 8 . 5 6 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.o _ O. D 0 15. D. 0 0 16. Amount of Line 14 taxable at lineal rate x .045 3 5 3 3 1 8. 5 6 1s. 1 5 8 9 9. 3 4 17. Amount of Line 14 taxable at sibling rate X .12 0 0 O 17. 0. O O 18. Amount of Line 14 taxable at collateral rate X .15 0. 0 0 18. 0. D O 19. TAX DUE ............................................... ... ...19. 1 5 8 9 9. 3 4 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^ Side 2 1505610240 1505610240 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 11 0804 DECEDENT'S NAME JACK D. WAGONER STREET ADDRESS - 100 MOUNT ALLEN DRIVE -_ CITY STATE ZIP ---- MECHANCISBURG PA 17055 Tax Payments and Credits: ~ • Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 13 , 3 0 0.0 0 B. Discount 699.98 3. Interest 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) 15,899.34 Total Credits (A + B) (2) 13 , 9 9 9.9 8 (3) (4) 0.0 0 5. If Line 1 +Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 1,899.36 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 : ...................................................................... ^ X^ b. retain the right to designate who shall use the property transferred or its income; ............................... ^ X^ c. retain a reversionary interest; or ................................................................................................ ^ d. receive the promise for life of either payments, benefits or care? ....................................................... ^ X^ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ ^ 3. Did decedent own an "intrust for" or payable-upon~leath bank account or security at his or her death? ......... ^ ^X 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? .................................................................................................. ^ 0 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, yin 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)]. 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. REV-1508 EX + (6-98) SCHEDULE E CASH BANK DEPOSITS & MISC COMMONWEALTH OF PENNSYLVANIA , , . INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER JACK D• WAGONER 21 11 0804 InGude the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATFI 1. M & T BANK - CHECKING ACCOUNT #88272001 3,359.65 499 MITCHELL ROAD MILLSBORO, DE 19966 2• SUSQUEHANNA VALLEY FEDERAL CREDIT UNION - SAVINGS #4019-DO 1,387.13 3850 HARTZDALE DRIVE CAMP HILL, PA 17011 3• SUSQUEHANNA VALLEY FEDERAL CREDI UN•-LIFE SAVINGS INS•#4019-10 2,000.58 3850 HARTZDALE DRIVE CAMP HILL, PA 17011 4• PERSONAL PROPERTY 250.00 5• DEPARTMENT OF REVENUE - REBATE 250.00 TOTAL (Also enter on line 5, Recapitulation) I S 7 , 2 4 7 , (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (pg_09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY tSTATE OF FILE NUMBER JACK D• WAGONER 21 11 0804 This schedule must be completed and filed 'rf the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER.ATTACHACDPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION {iFaPe~{ TAXABLE VALUE 1. TRANSFER OF CENTRIC ACCT- WITHIN 1 YEAR OF 310,000.00 100.00 310,OD0.00 DEATH TO JEFFREY H- WAGONER AND CHARLOTTE M- WAGONER - SON AND DAUGHTER-IN-LAW. 2• TRANSFER OF DECEDENT'S 1/2 INTEREST IN 19,118.50 10D-DO 6,OD0.00 13,118.5D REAL ESTATE AT 69 CUMBERLAND ROAD, LEMOYNE WITHIN 1 YEAR OF DEATH TO JEFFREY H• WAGONER AND CHARLOTTE M• WAGONER- SON AND DAUGHTER-IN-LAW• CONSIDERATION PAID $60,000.00; $158,237.50 FAIR MARKET VALUE ON ENTIRE REAL ESTATE, VALUE OF 1/2 INTEREST TRANSFERRED DECEDENT TO SON = X79,118.50 - $60,OD0.OD PAID BY SON- 3• GIFT OF 1/2 INTEREST IN PROCEEDS FROM REAL 45,SD0.OD 100.00 3,OD0.00 42,5D0.00 ESTATE TRANSFER OF PARCEL NUMBER #12-21-0265- 444 WITHIN 1 YEAR OF DEATH FROM DECEDENT, JACK D• WAGONER, AUDREY W- WAGONER, JACK E• WAGONER TO JEFFREY H• WAGONER AND CHARLOTTE M WAGONER FOR $91,000•DO• TOTAL (Also enter on Line 7 Recapitulation) ~ a 3 6 5, 618.5 0 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER JACK D- WAGONER 21 11 0804 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. MUSSELMAN FUNERAL HOME & CREMATION SERVICES, INC• 6,0`95.00 2• FUNERAL LUNCHEON 208.00 3• FOOD FOR MEMORIAL AT CHURCH '75.00 4• PREACHER - C• DOTSON 100.00 5- PREACHER - B• SNYDER 'i0.00 B. 1 2. 3. 4 5. 6. 7. City State ZIP ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address Year(s) Commission Paid: AttomeyFees: REAGER & ADLER, PC Family Exemption: (If decedents address is not the same as claimants, attach explanation.) Claimant Street Address City State Relationship of Claimant to Decedent ZIP Probate Fees: CUMBERLAND COUNTY REGISTER OF WILLS Acxountant Fees: Tax Retum PreparerFees: 4,000.00 108.50 TOTAL (Also enter on Line 9, Recapitulation) I $ If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE( DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8~ LIENS ESTATE OF FILE NUMBER JACK D• WAGONER 21 11 D804 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. NURSING HOME - MESSIAH VILLAGE 8,840.25 2• (PRESCRIPTIONS - ALERT PHARMACY ~ '70.55 TOTAL (Also enter on Line 10, Recapitulation) I $ 8 , 9:L 0.8 D If more space is needed, insert additional sheets of the same size. REV-1513 EX+(01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: FILE NUMBER: JACK D. WAC,ONFR y~+ u uu~ RELATIONSHIP TO DECEDENT AMOUNT OR SEiARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE: I TAXABLE DISTRIBUTIONS [InGude outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. JACK E- WAGONER Lineal 45,931.41 1917 COLUMBIA AVENUE CAMP HILL, PA 17011 2. JEFFREY AND CHARLOTTE WAGONER Lineal 307,387.15 69 CUMBERLAND ROAD LEMOYNE, PA 17043 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S I I I nvl G JFJaLC W I ICCUCU, use auuulonai sneers or paper or [ne same size. 000523-00001/01.09.01/EGM/KLT1142262.1 ~~,~~ t1I tt~~ ~e~~~~~~t OF JACK D. WAGONER ..-a ~© ~ -- i ;x, ~ ~'L7 ~ C r : C. ~ ~~~ C/~ ~ O ~ ry r`,.., ~ ~ _ l_ )C?T ^~ -rj rJ ~ _ _ ~> ~ .~ . ~~ , I, JACK D. WAGONER, of the Borough of Lemoyne, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare thlS aS a;iu ttir iiiy bast ~ viii and i',Su.,i~C;it, l:eTel7y .eVC1r.II:g 2..':l~ m31{lna 'Old a1?.y and all Wills or Codicils at any time heretofore made by me. ARTICLE I DEBTS I direct the payment of all my legal debts, and the expenses of my last illness and funeral from my Estate as soon after my death as conveniently maybe done. ARTICLE II TANGIBLE PERSONAL PROPERTY I give and bequeath my motor vehicle(s), household and personal effects and other tangible personalty of like nature (not including cash or securities), together with any existing insurance thereon, unto my wife, AUDREY T. WAGONER. If my wife, AUDREY T. WAGONER, fails to survive me, I give and bequeath the same under my sons, JACK E. WAGONER and JEFFREY H. WAGONER, to be divided between them by my Executrix or successor with due regard for their personal preferences in as nearly equal shares as practical. In the event that either of my sons predeceases me, I give and bequeath the items described in this Article II unto the survivor of them. 000523-00001/01.09.01/EGM/KLT/142262.1 ARTICLE III REST, RESIDUE AND REMAINDER I give, devise and bequeath all the rest, residue, and remainder of my Estate, of whatsoever nature and wheresoever situate unto my wife, AUDREY T. WAGONER If my wife, AUDREY T. WAGONER, fails to survive me, I give, devise and bequeath the same unto my then-living issue, per stirpes. ARTICLE IV UNIFORM TRANSFERS TO MINORS In the event that any beneficiary of my Will shall not have reached the age of twenty-one (21) years at the time for distribution of his or her share, distribution of said share may be made in the discretion of my Personal Representative after considering the age and needs of the beneficiary, either directly to the beneficiary or to a Custodian under the Pennsylvania Uniform Transfers to Minors Act, 20 Pa. C.S.A § 5301 et seq., or the applicable Uniform Gifts to Minors Act or. Uniform Transfers to Minors Act in the state of residence of such beneficiary as the case may be. My Personal Representative may designate as such Custodian any institution or person, including my Personal Representative, qualified to act as a Custodian for such beneficiary under such Act in effect at the time such distribution is made. A receipt for any payment or distribution so made shall be a full discharge therefor to my Personal Representative, who shall not be responsible to see to, or be liable for, the application of such proceeds thereafter. 2 000523-00001!01.09.01/EGM/KLT/142262.1 ARTICLE V APPOINTMENT OF PERSONAL REPRESENTATIVE I name, constitute and appoint my wife, AUDREY T. WAGONER, :Executrix of this my Last Will and Testament. Should my wife, AUDREY T. WAGONER, fail to qualify o:r cease to so act, I name, constitute and appoint my son, JACK E. WAGONER, alternate Executor to complete the administration of my Estate, and should my son, JACK E. WAGONER, also fail to qualify or cease to so act, I name, constitute and appoint nay son, .'EFFREY Ii. ~~'AGONER, alternate Executor to complete the administration of my Estate. I direct that no fiduciary appointed herein shall be required to post bond for the faithful administration of the duties required in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will acid Testament, this ~ day of January, 2001. n r t- ~~ v~-~-- _(SEAL) J K D. WAGONER Signed, sealed, published and declared by the above-named Testator, as and for his Last Will and Testament, in the presence of us, who at his request, in his presence and in the presence of each other, have hereunto subscribed our names as witnesses. ~~~ Y ~~ 3 ii000523-00001/01.09.01/EGM/KLT/142262.1 AFFIDAVIT AND ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS We, JACK D. WAGONER, ~rn,v;~ C'1. ~~-efS _ and -- ~1;t~1c;c~ ~ Cc~a'S'~d~l ,the Testator and the witnesses, respectively, whose names .are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and that he had signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as witness and that to the best of his/her knowledge the Testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. ~d CK D. WAGON Witness r .~ Witness Subscribed, sworn to and acknowledged before me by JACK D. WAGONER, Testator, and subscribed and sworn to before me by ~ ti-~U•~, ~,, -1'~.,zv j~ and ~~~:~~~lC%~~, ~ ~ C~~LSS~~ ~ ,witnesses this ~ ~' ~ _ da of Janua 2001 , y ry, . Notarial Seal Public C~ar`~; ~. F'armar, Notary t_em:~y~ ~e Boro, Curr,be+~an~ County My Commission E Ar,:`r'> i?r.c. 29, 2001_,_..._., ~d~mF~cr: Fennsyivart~~u J;~~~sac~a. Notary Public 4