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Home My WebLink About03-14-12 1505610140 REV-1500 EX I°'-'°' PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes Couniy Code Year File Number Po Box 2sasol INHERITANCE TAX RETURN Harrisburg, PA 17128-0801 RESIDENT DECEDENT 2 1 1 2 0 0 8 7 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 3 2 0 1 1 D 4 1 7 1 9 4 8 Decedent's Last Name Suffix Decedent's First Name MI S M I T H R O N A L. D J (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 INAPPROPRIATE OVALS BELOW ^X 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) 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 0 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 -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTWL TAX INFORM~ION SHOULD B~°DIRECTED T0: Name Daytime Telepjm~ Number; _:, Y ~ ~; mm~ r :~ f~ S U S A N H C O N F A I R 7 1 7 =~ 3 ~''~u ~_ REGIST~~ j~LS U$E'ONLY~ -:` ""' -:~ ....~ `_' C ' C :J -Tl - First line of address- r ~, =~ ~ ~ r~ '=ra 2 3 3 1 M A R K E T S T R E E T L ~.. ~.~ Second line of address ~" City or Post Office State ZIP Code DATE FILED C A M P H I L L P A 1 7 0 1 1 Conrespondent's a-mail address: Under penalties of perjury, I deGare that I have examined this return, inGuding axompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. DeGaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RE ~ ONSIBLE FOR FILING RETURN _ DATE ~ ADDRESS ~l 512 POPLAR CHURCH ROAD CAMP HILL PA 17011 SIGNATURE OF EPA/RER OTHER THAN REPRESENTATNE DATE 2331 MARKET STREET... CAMP HILL PA 17011 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 :1505610140 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: RONALD J• SMITH 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 De osits and Miscellaneous Personal Pro e p p rty (Schedule E)....... 5. 1 6 1 9 2 . 7 9 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 1 2 3. 3 4 7. Inter-Vivos Transfers 8 Miscellaneous N -Probate Property (Schedule G) ~] S r t Billi R t d 7 epa a e ng eques e ....... . 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 1 6 3 1 6 • 1 3 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9• 9 1 3 5 . 5 0 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. 5 6 3 1 6 . 0 9 11. Total Deductions (total Lines 9 and 10) ............................... 11. 6 5 4 5 1. 5 9 12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. - 4 9 1 3 5. 4 6 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. - 4 9 1 3 5. 4 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.0 _ 0 . 0 Q 15. 16. Amount of Line 14 taxable at lineal rate X •045 0 . 0 0 16, 17. Amount of Line 14 taxable at sibling rate X .12 0 . 0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 . 0 0 18. 19. TAX DUE ...................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1505610240 Side 2 1505610240 0. 0 0 0. 0 0 0. 0 0 0. 0 0 0. 0 0 REV-1500 EX Page 3 Flle Number Decedent's Complete Address: 21 12 RONALD J• SMITH STREET ADDRESS 512 POPLAR CHURCH RO CITY STATE CAMP HILL PA Tax Payments and Credits: ~ • Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments 8. Discount 3. Interest 0087 ZIP 17011 (1) 0.OD Total Credits (A + B) (2) 0.0 0 4. If Line 2 is greater than Une 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3) Fill in oval on Page 2, Line 20 to request a refund. (4) 0.0 0 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 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; ............................... ^ 0 c. retain a reversionary interest; or ................ ................................................................................ d. receive the promise for life of either payments, benefits or care? ................... .......................... ^ ^ X^ a .......... 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ...................................................... ^ O ................................. 3. Did decedent own an "in trust for" or payable-upon-death 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? ..................................................................................... 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)). • 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~ (11-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, 8 MISC. PERSONAL PROPERTY - - RONALD J• SMITH FILE NUMBER: 21 12 0087 All properly indy ownedwaiN~i rigln of survivon<hip mod l b di l e n ITEM a e sc os d o Schedule F. NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1• HERITAGE MEDICAL GROUP - REFUND HCA 40.00 2• GGNSC CAMP HILL WEST SHORE LP - REFUND 4,596.27 3• GGNSC ADMINISTRATIVE SERVICES LLC - REFUND 4,885.04 4• GGNSC ADMINISTRATIVE SERVICES LLC - REFUND 6,671.48 TOTAL (Also enter on Line 5, Recapitulation) I S 16 ,192 79 if more space ~ needed, insert additional sheets of paper of the same size REV-1509 EX+ (01-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ~.~ ~ r+~ ~ vr: FILE NUMBER: RONALD J• SMITH 21 12 0087 ff an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. VIRGINIA L• SMITH 512 POPLAR CHURCH ROAD SISTER CAMP HILL, PA 17011 B. C. JOINTLYAWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY 96 OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALIIE OF ASSET INTEREST DECEDENT'S INTEREST ~~ IA. I6/2009IPNC BANK CHECKING *1026240699 I 246.68 50• 123.34 TOTAL (Also enter on Line 6, Recapitulation) I S 123• 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 ~~ ~ ~ ~ ~ yr FILE NUMBER RONALD J. SMITH 21 12 0087 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A• FUNERAL EXPENSES: 1• HOOPER MEMORIAL HOME, INC. 5,218.00 B. ADMINISTRATIVE COSTS: 1 • Personal Representative Commissions: Name(s) of Personal Representative(s) VIRGINIA L . SMITH 8 D 0.0 0 Street Address 512 POPLAR CHURCH ROAD City CAMP HILL State PA ZIP 17011 Year(s) Commission Paid: 2012 2. AttomeyFees: REAGER 8 ADLER, PC 3. Family Exemption: (If decedents address is not the same as claimants, attach explanation.) 3,OD0.00 Claimant Street Address Cdy State ZIP _ Relationship of Claimant to Decedent 4• Probate Fees: CUMBERLAND COUNTY REGISTER OF WILLS 117.5D 5. Accountant Fees: 6• Tax Retum Preparer Fees: 7. TOTAL (Also enter on Line 9„ Recapitulation) _ If more space is needed, use additional sheets of paper of the same size. 9,135.50 REV-1512 EX+ (12-08) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8 LIENS ESTATE OF FILE NUMBER RONALD J• SMITH 21 12 0087 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, Including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VAOF DAETADHTE 1• PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE CLAIM CIS ~-: 440251809 24,025.24 2• IRS TAX LIEN 27,619.53 3• GOLDEN LIVING - WEST SHORE - aQ0092 7.84 4• HEALTHDRIVE PODIATRY GROUP #231 4.16 5• HEALTHDRIVE EYE CARE GROUP GROUP s231 27.46 b• CITIBANK - CREDIT CARD #1150056200316 4,530.11 7• HOLY SPIRIT HOSPITAL - #38885513 A 101.75 TOTAL (Also enter on Line 1 C~, Recapitulation) I S If more space is needed, insert additional sheets of the same size. 5 6 , 316 REV-1513 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: RONALD J. SMITH NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS pndude outtsn'qht spousal distributions and transfers under Sec. 91I6 (a) (1.2).j 1. JERON SMITH 8343 LAKE VIEW DRIVE DESOTO, KS 66018 RELATIONSHIP TO DECED Do Not List Trustee(s) Lineal I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV 1500 COVER SHEET, AS APPROPRIATE II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAk;EN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. IUNT OR SH OF ESTATE 0.OD TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I s If more space Is needed, use addrtlonal sheets of paper of the same size. Theodore A. Adler* John P. Neblett*' David W. Reager Susan H. Confair Linus E. Fenicle Wayne S. Martin, P.E *** ATTORNEYS AND COUNSELORS A T LAW Thorrias O. Williams Jay C. Whittle**** *Certified Civil Trial Specialist *"Certified in Consumer Bankruptcy "**Licensed to Practice in N.J. ****Special Counsel March 7, 2012 Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013 RE: Estate of Ronald J. Smith Estate File: 21-12-0087 Our File: 12-114 Writer's Email Address: JGros~ ReaaerAdlerPC.com ,..__, ~,.. ~~ ~ y ^~ -ti.Z~ ~? C1? ~ -~,.~; r?~{~~ - ~ '~'> O -n ~ : --' i ~ s = = - ~ , ,, ~ _ t r, ~ ~' .~- ~~ ~ Dear Sir or Madam: Enclosed please find the Inheritance Tax return and Inventoe cor f lof he filing n the enclosed r $30.00 on the above referenced matter. Please return a time stamp pY envelope. Should you have any questions, please feel free to contact me. yours, nni er Gross Para gal Enclosures P R O V E N R E S O U Fi C E S 2331 Market Street, Camp Hill, Pennsylvania 17011-4642 T: 717 763-1383 F: 717 730-7366 www.reageradlerpc.com R ~. • ~ N ~ Y ~ ~0°° N ~~ N ~ w ~0<c°~ 1 aO~a N ~, o e\ m ~ ~LL _ ~a ~ °- ~ ~ Y6~~~31.IN(~ o o ~ l3//'lr. 1"i~~7i;_~ t ~!~/~~ ~ 1 r!,,,~ c(1i2 ~~,~ i 4 ~ h! 12: t ORPF~I~~~,,, + ^^ . %0., P,4 Ua w ~ rya W o o ~ 0 A ~ ~ ~Ha ~°~a ~ U °~o ax ~ ~ a as ~ W ' ,U yyW, ,.., ~ r~i ~' U a O O M .~.. O O"' p a p'H o ~ o a °? ° ' °~' ~ . .r ~ ~ ~ ~ a~~ U 0 F