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Home My WebLink About03-09-12 (2)v 1505610140 1500 EX `°'-'°' REV - OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box 2sosol 2 1 1 0 1 1 2 4 Harrisburg PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 2 0 4 3 0 6 0 0 9 1 0 2 1 2 0 1 0 1 1 2 8 1 9 3 9 Decedent's Last Name Suffix Decedent's First Name MI M i z e l l B r u c e H (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 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 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 CONFID ENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number S t e p h e n J H o g g E s g 7 1 7 2 4 5 2 6 9 8 First line of address 1 9 S H a n o v e r S t r e e t Second line of address S t e 1 0 1 City or Post Office C a r l i s l e n Road i6iLTHAAI REPRESENTATIVE Correspondent's a-mail address: 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. SIGNATURE OF PFr$~ ~ONyCESPON~IBLE OR FI RETURN DATE ADDRESS 571 N• SIGNATURE 19 S• Hanover': eet, Ste• 101 State ZIP Code r REGISTFLR~F WILLS US1r:flNLY r.,; 7.1 *- i r _ 7 ~~~ ~ .i .. ~ l ~j~ t 4 Y r ~ ttD y C r ~ _; ~, C .te _ - - ~-~ AT~ FILED . L_ ~ __._ - _._ .~ s, } , . ~.; ~ 7 P A 1 7 0 1 3 Carlisle Carlisle PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 PA 17013 ~T PA 17013 1505610140 1505610240 REV-1500 EX Decedent's Social Security Number 2 0 4 3 0 6 0 0 9 Decedent's Name: B r^ U C e H• Mize 11 RECAPITULATION 7 2 8 0 0. 0 0 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. • 1 6 3 1 2. 8 4 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).. ..... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .. ..... 6. 7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property uested Billin Re t ~ S 7 .. g q epara e (Schedule G) . ..... 8 8 9 1 1 2 . 8 4 8. Total Gross Assets (total Lines 1 through 7) ...................... ..... . 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9• 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. 11. Total Deductions (total Lines 9 and 10) ............................... 11. 12. Net Value of Estate (Line 8 minus Line 11) ................... ....... .. 12. 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. TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable 7 4 9 5 7 1 0 16 . at lineal rate X .04.5 . 17. Amount of Line 14 taxable 0 C 0 17 at sibling rate X .12 . 18. Amount of Line 14 taxable 0 0 0 18 at collateral rate X .15 . 19. TAX DUE ...................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1 3 8 6 9. 7 0 2 8 6. 0 4 1 4 1 5 5. 7 4 7 4 9 5 7. 1 0 7 4 9 5 7. 1 0 0. 0 0 3 3 7 3. 0 7 0. 0 0 0. 0 0 3 3 7 3. 0 7 Side 2 1505610240 1505610240 REV-15(JO EX ..Page 3 File Number 21 10 1124 vcbcvc~~a v vv... ~.~.... ... .~. _.. ---- DECEDENT'S NAME Bruce H. Mizell___ _ _ - -- - -- STREET ADDRESS 571 N. Middleton Road - -- -.---- CITY STATE ii 21P -_- --_ Carlisle PA 117013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 3,373.07 2. Credits/Payments A. Prior Payments B. Discount Total Credits (A + B) (2) 0.00 3. Interest (3) 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. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 3, 373.07 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 : ................................................................. ..... ^ ^ b. retain the right to designate who shall use the property transferred or its income; .......................... ..... c. retain a reversionary interest; or ........................................................................................... ..... ^ X ^ d. receive the promise for life of either payments, benefits or care? .................................................. ..... 2. If death occurred after December 12,1982, did decedent transfer property within one year of death ^ 0 without receiving adequate consideration? ................................................................................. h? " " ...... ^ 0 .... orpayable-upon-death bank account or security at his or her deat in trust for 3. Did decedent own an ..... 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 [i 2 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 aqe 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)j. Asibling is defines, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1`-02 E~+ (01-10) pennsylvania SCHEDULE A DEPARTMENT OF REVENUE REAL ESTATE ~~' iERITANCE TAX RETURN nESIDENT DECEDENT ESTATE OF: FILE NUMBER: Bruce H. Mizell 21 10 1124 _ All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. If more space is needed, use additional sheets of paper of the same size. REV-15~a EX t (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Bruce H. Mizell 21 10 1124 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~. M&T Bank Checking Account# 98181475 7,534.85 2. Claremont Nursing & Rehab 1,777.93 3. Interest Payment 11/15/10 0.05 4. Interest Payment 1114/11 0.01 5. Magnolia Mobile Home VIN: FGJEDMV8900 3,000.00 6. Amherst Mobile Home VIN: C11131 4,000.00 TOTAL (Also enter on line 5, Recapitulation) I $ 16.312.84 (If more space is needed, insert additional sheets of the same size) REV-15''1 E/+(10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Bruce H. Mizell 21 10 1124 Decedent's debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. 1. B 2. 3. 4. 5. 6. 7. 8. 9. FUNERAL EXPENSES: Ewing Brothers Funeral Home, Inc. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(si Clinton Mizell Street Address 571 N. Middleton Road city Carlisle State RA Year(s) Commission Paid: Attorney Fees: Stephen J. Hogg, Esquire Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State _ Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Retum Preparer Fees: Advertising: The Sentinel Cumberland Law Journal Accounting (Est) Tax Return and Inventory Filing Fees TOTAL (Also enter c~, Line 9, Rs~= _'tulation) I $ 4,776.02 ZIP 17013 ZIP 4,455.64 4,000.00 145.50 187.54 75.00 200.00 30.00 13,859.70 If more space is nee ed, use additional sheets of paper o. the sa~ :size. pennsylvania SCHEDULE DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Bruce H. Mizell 21 1 G 1124 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. Physicians of Rehabilitation, Industrial & Spine Medicine, P.C. 102.40 2. Flenniken Family Dentistry PC 183.64 TOTAL (Also enter on Line 10, Recapitulation) $ 2$6.04 If more space is needed, insert additional sheets of the same size. REVf-15 4 EX+ '71-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Bruce H. Mizell 21 10 1124 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).~ 1. Clinton E. Mizell Lineal ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. jI, 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 11 - ENTER TOT,4L NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ~ $ If more space is needed, use additional sheets Df paper of the same size.