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HomeMy WebLinkAbout03-15-12 (2)J 1505610101 ~~~~J~` octoi-col OFFICU\L USE ONLY PA Departrrterat oftllavenue ~~ Cainty Code Year File Number Bureau of Indivfduat'Taxes °"""'"`~`°`""°"" PO BOx 280601: ': INHERITANCE TAX RETURN Harrisburg. PA 17128-06oi RESIDENT DECEDENT ~ ~ ( ~ I ct ~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY ,~~ 2 a~ ~ ~ 5 c, c, l c a 3 a r c Decedent's Last Name Suffix 0m (If Applicable) Eater Surviving Spouse's information Below Spouse's Last Name Suffix ~ '~ Spouse's- Social Security Number Date of Birth MMDDYYYY r1~~ ~- t fs~ Decedent's First Name MI r~~Tm o Spourse's First,Name ~~, 1r MI ~r~l i4~ , 1~ ~ ~ 11 •~~~ Q~~~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 1. Original Retum O 2. Supplemental Retum O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death after 12-12-82) ® 8. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Lfigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name ~ Daytime Telephone Number- ~ " Y ~ TTQ ~,1 t l r~~ REGISTE ~ ILLS US ~ LY ~,^~~*1 ~ C ~ ~ a` ~ C 7 ~ ~ } r. 7 t:~ First line of address ~ , F ~ ~ v p ~ ~ c:;'} ~i ^ ' a Second line of address n V ~ ~ _ - rt . A CA City or Post Office State E FILED ZIP Code -~~~ Correspondent's e-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, R is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATUR OF PERSON RESPONSIBLE F FILING RETU DATE h~ ` .i-~ ~.b\~ ADDRF~S ~ ~V ~-~ ` .~Y- r-1.@G-'~e~.a~ ~ cSb V ,~ ~ ~ ~ ~ O S s SIGNATURE rEPA~R OjHER , / , NTATIV ~ DATE t s~ ~ O ADDRE$~ ~ 0 V h ` \\ l CS ~ 1'~ ~ r" - ~ C.~~.1 a S~ v+-~ ~ 7~' ~ ~ Cl~~~ I ~ EASE USE ORIGINAL FORM ONLY Side 1 150561.0101 150561010.1 J 15D5610105 REV 15130 EX Decedent's Wame: Decedent's Social Security Number RECAf~ITUUTION TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amarnt of Line 14 taxable at the spousal ~ rate, or tn3nsfers under Sec. 9116 {a)(1.2) X A_ 16. Amount of Line 14 taxable at lineal rate X-.0 _ 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 15. 16. 17. 18. 19. TAX DUE ......................................................... 19.) ZO.. FILL IN THE OVAL sF YOU ARE REQUESTIN!'a A REFUND OF AN OYERPAYME#IT Side 2 1505610'105 15056101fl5 1. ReaiEs~te(Schedule A) :............................................ 1. roan nin monoo onino 2. Stacks and Bonds (Schedule B) ....... . ............ . .................. 2. ~ ~ 3 3. Ckrsely Held Corporation, Paxtrrership or Sole-~P {Schedule C) ..... 3. a1 ........... 4. 4. and Notes Receivable {Scheduk3 D) ................ t~ 5. Cash, Bank Deposits and Misceganeous Personal Property {Schedule E). _ ..... 5. ~ S. Jomtiy Owned Property {Schedule F) ©Sep~ate Billing Regtr~ted ....... 6. \ 7 Z 7. ink Ym>s Transfers 8 Miscellaneous i~bn-Prob2ibe Property {St~red~e G) p Separate Besting Requested........ 7. ~ t 8. Toth Gross Assets (tc~ta! Lines 1 ihrrwgh 7) .........:................... 8. ~} C 6 9. Funeral Expenses and Administrative Costs {Schedule H) ................... 9. ~ ~ 10. Deb#s of Decedent, Mortgage Liabilities, and Liens {Schedule: 1) .............. 10. 11. T+otai Daductlons {total Lines 9 and 10) ........................... , .:... 11. ( `E ~ ~ 12. Net Vah» of Estate {Line 8 mows Line 11) .............................. 12. 3 Z C 13. Charitable and Govemmentai Bequests/Sec 9113 Trusts for which an election to tax has not been made {Schedule J) ........................ 13. 14. Net Value &~bject to Tax (Line 12 minus Line 13) ........................ 14. 3 ~ O REV 1500 EX Page 3 Fite Number Decedent's Complete Address: ~ Q ~ 2`~~ lNrs Nar>E w p~ b ~ s»+~r nt~ss Z LAv~~ ~i ~ t~TY 1~ `~I~E ~/ ~ C.~~ V i~ ` STATE ~ ~ ~ ' '70 S~~ Tax Payments -and Credits: 1. Teri Otte {Page 2, Lrcte 19) 3. ttsd A Prior Payrrter>ss t3. t)iscoixtt {1) CJ Total Credits (A + l3~ (2) {3) 4 {~! (~~ 3. Iniierest 4. ff Line 2 is greater them Lktii 1 + Line 3, enter the . This ~ the OVERPAYMENT. t-7" tat 01r8t Olt Pil9e 2, Line Zit ti0 r@QU@!it 8 fefUnd. 5. ff Line 1 + Line 3 is greater than Line 2, ert#er the ditl+~errce. This is the TAX DUE, Make Bieck payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE fOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. t3id deoederit make a transfer and: Yes Pb a. retairr the use or income of the property transferred :.......................................................................................... ^ b. reiaur the right to designate who shag use the property tratuferred or its irxxrr-ie : ............................................ ^ c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. # death occurred after t)ec.12,1982, did decedent transfer property within one year of death withatt receiving adequate corrsi~ratiort? .............................................................................................................. ^ 3. LAd decedent own an "iri trust for" or payable-upon-death bank accoun# ar seairity at his or her death? .............. 4. lid decedent own an individual retirement account, annuity or other rton~robate property, which contains a benefiaary designation? ........................................................................................................................ ~ ^ IF THE ~R T©ANY # THE AB©VE (~JEST~i+IS IS YES, YtNJ MUST COMPLETE SCHEDULE G AND FlLE R AS PART OF TIC RETURN. For dates of on or after July 1,1994, and before Jan. 1, 1995, the tax rate imposed on ilia net value of transfers to or for ilia use of the survivir~ spouse is 3 percent j72 l?S. §9116 {a) {1.i) {i)]. For dares of de~1t on or after .fare: 1, 1995, the tax rate unposed on tare riet value of transfers to or for the use ~ file surviving spouse is 0 percent [72 t?S. §9116 {a) {1.i) ~)]: 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 ~+srt are sib ern i# the sarviving spouse is the only benefirtiary. For dam of d~t- oi7 or aft July i, 2(]00: • The tax rake on the rtet value of transfers from a deceased t~tiki 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a ~t ~ the tdtild is 0 pero~t# I72 P.S. §9116{aK12)j. • The tax rate on the net value of transfers to or for the use of the decedent's lineal benefiaaries is 4.5 percent, except as rioted in T2 P.S. §9116(1.2) I72 QS. §9116{a){1)j. • The. tare rate unposed on the net value of transfers to or for the use of the decedent's sibNrigs ~s 12 percent [72 P.S, §9116{a){1.3)J. A sibling is defined, under Ser#iori 9102, as an individual who has at least one parent in comrtion with the decedent, whether by blood or adoption. NE1F~gCj EX+ r/-u) SCMEp11LE B ~~ STOCKS & BONDS ESTATE OF FILE NUMBER Ar property iolntly a~eoad 1eNh riyUt of aeivlYOraUip uwet ba aedoead ou Schedule F. 1. ~g~3~~ 438 REV-15oa IX+1~~1 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY FILE NUMBER Q ~ Z 1 ~' indude the prooeds of litigation and the date the proceeds were n;ceived by the estate. All properly joiritly-0wned witll the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~ c~e'~S 3G W w~~ ~ t7 v s~~ L` ~ ~,~s t o TOTAL (Also enter on line 5, Recapitulation) I ; (If more space is needed, insert additional sheets of the same size) t~EV-~5o4 Dt+ (m-~a? Pennsylvania DEPARTMENT OF REVENUE ao~xma~cE ~c n~smenr ae~err SCMEp1/LE F 70INTlY-0WNED PROPERTY ESTATE OF: FILE NUMBER: ~3~ w ~t2'D 1-1 C,~-A-~~C O 1ZS S 1'f en aeeet 6acnne ioU~ owned w11Nn ane yaer of Die deoeeerit's i6e of deeih, k ew.~st be ~aporbed on sdiedula 6. svRVtvtr~ burr r~rr{s) ru~(s~ nDn~.ss r~u-noNSwi~ ro ~cc-~Fxr _ _ __ 1/' ~ec~th~c.sL.srJc., ~`~ t7oS-~ S`('~v s~ _ s. _ c. - - _ -: ~oINnY ownEO pROpERrr: ~ o~rcatr aF roore~rr x of o~ aF or~r ~ r+ae ~ wn~ aF ~ e~arc ~o~mr wu~ as o~ of u~e-- oer~e~rs wuE of ~a-r x~r merrrnes + ~ Fvn x~r rie,u nE~: ~. vaUE aF ~r gems r ~- a 2002 Njc,,,iLwl , ~s~.~:c ~ ~l-cco.,-.`~ Nei. Nb7 (. ', 3 S S 8~I s~ ` 1 '7~'~ 9 Z REV-1510 EX+ (OS-09) pennsytvama DEPoIATMEM Of A£YENUE Luc i~oerr o~rr SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ~ more space is ~ use additional sheets of paper of the same size. REV-1511 IX+ (iQ-09) pennsytvama SCHEDULE H +~~TM~T of ~++~ FUNERAL EXPENSES AND ~T~" ADMINLSTRATIYE COSTS Derr ESTATE OP PILE INNIBER ~ ~ w ~~~ N C L ~~t~ ®~a 9 >; oeoeasrt^s ae~ swat is ~Ee+ oa sa~ad~k z. r~ NUMIBER OBCR1FfloN AlMOUNT A. Ft1fiERAL EXPENSES: 1. _ _ ~. e..,..~'~.-- -7 1 0~ ~ ~' S ~ ~o ~ ~ G,.-..,, ~ r~-~y1,u.,. 3 i8d ~ s. Anf~tNisT~nrnrE cows: 1. Pew Rive Canmis~ons: S~ ~ - ~~5~ ~ state ziP vear(s} C.an Paid: t. AtOomey fees: 3 G `~' 3. Famdp Exemption: {rf deoedent~ address ~ not ttie sari as claimant s, atiadi exganation.j rtr state zrr ~~~ f 3 ~ 4. Probate Fees: 5. Accour~nt fees: 6. Tax Return Preparer Fees: 7. If more space is needed, use additional meets of paper of tfie same sig. Malpe.~zi Funeral Home ,. --- -- a ,~ ~~ 8 Mazket Plaza Way __-_ ~__ _ _ _ __ , ....~- ...... ~ Mechanicsburg, PA 17055 ~' Jeremy J. Shartzer, FD Michael J. Malpezzi, Owner, FD November 8, 2011 Marydel W. Clark 2 Laurel Drive Mechanicsburg, PA 17055 The Funeral Service for Edward H. Clark (717} 697-4696 Knipe, We sincerely appreciate the confidence you. have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES: Services of Funeral Director/Staff $4,625.00 FUNERAL HOME SERVICE CHARGES $4,625.00 SELECTED MERCHANDISE: Poplar Casket $2,220.00 Sentinel Vault $1,425.00 Green Register Package $75.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED $8,345.00 AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. CASH ADVANCES: Cemetery Equipment $170.00 Certified Death Certificates $120.00 Newspaper Notices -Patriot $475.50 Clergy/Mass Offering $125.00 Organist $100.00 Deacon Gorman $50.00 Flowers $318.00 Altar Servers $20.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES SUB-TOTAL IMTIAL PAYMENT /DISCOUNT /CREDITS $1,378.50 $9,723.50 $0.00 TOTAL AMOUNT DUE $9,723.50