HomeMy WebLinkAbout04-0891 PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of ~-~d.//J~/l'f ~' ~A.J No.C~i_ oq- ql
also known ~ To:
Register of Wills for the
Deceased. County of in the
Social Security No. ~f ~ ~ /~ Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, app~ for letters of administration
on the estate of
' (d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
Decendent was domiciled at death in ~ ~ ~ ~ County, Pennsylvania, with
h /5 last f~ily or principal residence at /~ ~ ~.
(iist street, number an~municip~li~y)
Decendent, then ~ ye~s of age, died ~//~/~ ~ O~ ,
Decendent at death owned property with estimated v~ues as folllows:
(If domiciled in Pa.) All person~ property $
(If not domiciled in Pa.) Person~ property in Pennsylvania $
(If not dOmiciled in Pa.) Person~ property in County $
Value of re~ estate in Pennsylvania $
situated as follows:
Petitioner after a proper search ha ~ ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
Name Relationship Residence
THEREFORE, petitioner(s) respectfully request(s) the grant Of letters Of adm'ini~ration in the
appropriate form to the undersigned.
~°
STATUS REPORT UNDER RULE 6.12
Name of Decedent: (,~--~/lt')l''t~ ~'
Date ofDea~ :
Will No.: ~ ~ ~ ~ Admin. No.:
Pursuant to Rule 6.12 of the Supreme Cou~ O~hans' Coug Rules, I repo~ ~e
following with respect to completion of the administration of the above-captioned estate:
1. State whir administration of the estate is complete:
Yes ~No ~
2. If the answer is No, state when the personal representative reasonably believes
that the administration will be complete:
3. If the answer to No. 1 is Yes, state the following:
a. Did t~ersonal r~tative file a final accost with the CouP?
y~ No
b. The sep~ate O~hans' Corn No. (if any) for the personal representative's
account is:
c. Did the personal representative state an account info,ally to the pa~ies
in interest? Yes ~ No ~
c. Copies of receipts, releases, joinders and approval of focal or
info,al accounts may be filed with the Clerk of ~e OCh~s' Cou~
and may be attached to ~is repo~.
Date: _ Silage
'.:': Name
' ::~ Ad.ess
Telephone No.
Capaci~: ~nal Representative
~ Counsel for personal representative
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA ~ ss
COUNTY OF C_~Ac~
The petitioner(s) above-named swear(s) or affirm(s) that the
statements in the foregoing petition are true and correct to the best
of the knowledge and belief of petitioner(s) and that as personal
representative(s) of the above decedent petitioner(s) will well and
truly administer the estate according to law.
Sworn to or aff',:r~.[~and subscrib~l
befgg.e me this q' ~'"" day of
~ ~'. ~-~ Regi~t~-J[
Estate of ~~ ~ ~ ~~ , Deceased
G~NT OF LETTERS OF ADMINIST~TION
AND NOW ~ t~ ~'~1::~ ~__., in consideration of the petition on
the reverse side hereof, satisfa, ctory proof ha,ving.h~n presented before me,
IT IS DECREED that '"'~'3J~..nx ·
is/are entitled to L~ters of Administration, ~d in accord ~th such finding, Letters of Ad~nistration
~e hereby granted t~ ~
in the estate of ~
- - R~isterofWifls ~}.~
~ES
L~ters of Ad~ffistration .....
Sho~ Ce~ificates( ) ...... ' ....$ ~. o~ A~ORNEY (Sup. Ct. I.D. No.)
Renunciation ................
TOTAL ~ $ ~ .~O ADDRESS
Filed ..................... A.D. 19
PHONE
his is to certify that the information here given is correctly copied l¥om an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
/~ ~ 1.~l"!'~''~ "~''~ ~/ Local Registrar
P
~o.
CERTIFICATE OF DEATH
CO.MONW *'T. OE REV' 1500 OPr,C,*.USE O..V
~ PENNSYLVANIA
~~.~ DEPARTMENT OF REVENUE
HARRISBURG, PA 17128-0601 RESIDENT DECEDENT
DECEDENTS NAME (~ST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURI~ NUMBER
DATE OF D~TH (MM-DD-YEAR) DATE OF BIRTH ~M-DD-YEAR) THIB RETURN MUST BE FILED IN DUPLICATE WITH THE
~ 8//~/O ~ ~ REGISTER OF WILLS
(If APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST. AND MIDDLE INITIAl) SOCIAL SECURI~ NUMBER
~Original Return ~ 2. Supplemental Return ~ 3. Remainder Return Nateofdea*priorto12-13-82)
~ 4. Limited Estate ~ 4a. Future Interest Compromise(dateofdeatha,~r1242.82) ~ 5. Federal Es~teTax Return Required
~ 6. De.dent Died Testate (A~ach ropy of Will) ~ 7, Decedent Maintained a Living Trust (Amch ropy of Trust) 8. Total Number of Safe Deposit
Boxes
~ 9. Litigation Proceeds Received ~ 10. Spousal Pove~ Credit (date of death be~een 12 31 91 and 1-1-95) ~ 11 Election to tax under Sec. 9113(A) (A~ch Sch O)
NAME D/~ ~' ~~5~A =OMPLETEMAILINGADDRESS
TELEPHONENUMBER(7/7 ) -P T
1, Real Es~te (Schedule A)
2. Stocks and Bonds (Schedule B) (2)
3. Closely He~d Corporation, Padnership or Sole-Proprietorship (3) I
4. Mo~gages & Notes Revivable (Schedule D) (4) /~
(Schedule E) / .~
6. Joistly ~ned Prope~ (Schedule F)
~ Separate Billing Requested
7. Inter-Vivos Transfem & Miscellaneous Non-Probate Properly (7)
(Schedule G or L)
9. Funeral Expenses & Administrative Costs (SchCule H) (9) ~
18. Beb~ of Becedent, Mo~gage Liabilities, & Liens (Schedule I) (1 O)
11. TO"I Deductions (total Lines 9 & 10) (11)
12. Net Value of Es~te (Line 8 minus Line 11) (12)
13. Charitable and Governmental Bequest¢Sec 9113 Trus~ for which an ele~ion to ~x has not ~en (13}
made (Schedule J)
14. Net Value Subje~ to Tax (Line 12 minus Line 13) (14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE ~TES
rate, or trans~o~ undor Soc. ~1~ (a)(~2)
19. Tax Due (19)
Decedent's Complete Address: · ,
I sTATE I
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount ~ _
~,.,,,,""Tot~redits ( A + B + C ) (2)
3. Interest/Penalty if applicable
D. Interest
E. Penalty ~'
.~' Total Interest/Penalty ( D * E ) (3)
4. Check box on Page~request a refund (4)
If Line 2 is greater than Line 1 + Line 3, enter the di~ec~ce. This is the OVERPAYMENT.
5. If Line 1 + Line 3 is gre~ 2, ~nt~r th~ di~rence. This is the TAX DUE. (5)
A. Enter t~ the tax due. (SA)
B. Enter'~to-takof Line 5 + 5A/This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
'~l" ................
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; ............................................ [] []
o. retain a reversionary interest; or .......................................................................................................................... [] []
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
without receiving adequate consideration? .............................................................................................................. []
3. Did decedent own an "in trust for" or payable upon death bank acceunt or secudty at his or her death? .............. []
4. Did decedent own an ~ndividual 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,
Under penalties of perlury, I declare that I have examined this return, including accompanying schedules and statements, and to fbe 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 PERSON RESPONSIBLE FOR FILING RETURN DATE
_
ADDR-~S~ ' ~ -
SIGNATURE OF PREPARER OTH~ THAN REPRESENTATIVE DATE
ADDRESS
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. {}9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net va~ue of transtam to or for the use of the surviving spouse is 0% [72 RS. {}9116 (a) (1.1) (ii)].
The statute does not exemDt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are stil~ 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 twenty-one 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% [72 RS. {}9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedenfis lineal beneficiaries is 4.5%, except as noted in 72 P.S. {}9116(1.2) [72 ES. {}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% [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 blood or adoption.
~,Ev-~,,~ ~×~- (6-9~ SCHEDULE A
DOM'~ON~'E^LT, OE'~NNS~^N'A REAL ESTATE
INHERITANOE TAX ~ETU~N
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
All real pm~r~ owned solely or as a tenant in common must ~ reported at fair market value. Fair market value is defined as the price at which prope~ would be
exchanged between a willing buyer and a willing seller, neither being compelled to buy or sefl, both having reasonable knowledge of the relevant facts.
Real pmper~ which Is Jointly-owned with right of survlvo~hip must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
/~~ ~ ~ ~/~-o ~~ 7OdD
TOTAL (Aisc enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
.~-~.,.,~.~,.,7,. ~ SCHEDULE B
COUMONWULTNOrPE"NS~'V^N'^ STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
All properly jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
· SCHEDULE C
COMMONWEALTH OF PENNSYLVANIA CLOSELY-HELD CORPORATION,
INHERITANCE TAX RETURN PARTNERSHIP or SOLE-PROPRIETORSHIP
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Schedule C-I or C-2 (Including all suppo~ng informalJon) must ~e attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship.
See instructions for the supporlJng information to be submitted for sole-proprietorships.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
TOTAL (Also enter on line 3, Recapitulation) $
(if more space is needed, insert additional sheets of the same size)
SCHEDULE C-1
oF PENNSY'V^N,^CLOSELY-HELD CORPORATE
INNERITANC~ TAX RETURN
REa,OE.TDEC NT STOCK INFORMATION REPORT
ESTATEOF ~,// ~ ~ ~, ~~~ 'FILE NUMBER
1. Name ~ Co.ration State ~ In~orafiea
Address Date ~ In~r~ion
Ci~ S~te ~p C~e To~l Number ~ Shamholdem
2. F~eml Employer LD. Numar Business Re~ffing Year
3. Ty~ of Busings
4, STOCK TYPE NUMBER OF SHARES VALUE OF THE
SNARES O OWNED BY THE DECEDENT DECEDENT'S STOCK
m ~mmon $
m Prefe m =
ghts and m~th~ions ~aining to e~h class ~ st~k.
5. on? ~ Yes ~ No
mf yes, Position Annual Sama~ $ Time Devot~ to Busines~
6. Was ~e Co.ration indebt~ to the de~ent? ~ Y~ ~ No
mf yes, provide amount of indebtedness $
7. Wasthemmifeinsuran~payabletothe~orationu~nthedeath~thed~ent? ~ Y~ ~ No
mf yes, Cash Su~nder Value $ N~ p~ds ~yabme $
~ner of the ~micy
8. Did the d~ent serum or franker st~ of this ~m~ny within one year p~or to de~h or within ~o yearn if the date ~ death was prior to 12Jl ~27
~ Yes ~ No mfy , ~ Transfer ~ Sale Num~rofSha~
Tmnsfer~ or Purchaser Cons)der~ion $ D=e
A~ a ~m~ sh~t for add~ona) ~n~m an~or ~,
9. Was there a w~Uen shamhomdeKs ~mement in eff~ at the time of the d~en~s death? ~ Y~ ~ No
If yes, provide a ~py ~ the agr~ment.
10. Was the d~ent's st~k sold? ~ Yes ~ No
mf yes, provide a ~py of the ~r~ment of same, etc.
11, Wasthe~rationdissorv~ormiquidatedafferthede~ect'sdeath? ~ Y~ ~ No
mf yes, provide a breakd~n of disthbutions ~iv~ by the estate, including dates and amounts r~iv~.
12. Didthe~rafionhaveanintemstinotherco~rationsorpa~nemhips? ~ Yes ~ No
mf yes, re~ the n~sa~ information on a separ~e sh~t, including a S~ume C-1 oF ~-2 for each inter~t.
A. Detailed calculations used in the valuation of the decedent's stock,
B. Complete copies of financial statements or Federal Corporate Income Tax ratums (Form 1120) for the year of death and 4 preceding years,
C. If the corporation owned real estate, submit a list showing the complete eddress/es and estimated fair market value/s, If real estate appraisals have been
secured, attach copies,
D. Ust of principal stockholders at the date of death, number of shares held and their relationship to the decedent.
E. Ust of officers, their saledes, bonuses and any other benefits received from the corporation.
F. Statement of dividends paid each year. Ust those declared and unpaid.
G. Any other information relating to the valuation of the decedest's stock,
REV-15(~6 EX+ (9-00~
· ' SCHEDULE C-2
COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP
RE RN INFORMATION REPORT
RESIDENT DECEDENT
1. Name of Part s 'p ~ Date Business Commenced
Address /~"~"J ""~'~ Business Reporting Year
City ~ / ~_?./ State Zip Code
2. Federal Employer I.D. Number / L //
3. Type of Business ~,.......~ ~ Product/Service
4. Decedent was a [] General [] Limited partn f decedent was a limited partner, provide initial investment $
A.
B.
¢.
D.
6. Value of the deeedent's interest $
7. Was the Partnership indebted to the decedent? ................................. [] Yes [] No
If yes, provide amount of indebtedness $
8. Was there life insurance payable to the partnership upon the death of the decedent? ..... [] Yes [] No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was
prior to 12-31-827
[] Yes [] No If yes, [] Transfer [] Sale Percentage transferred/sold
Transferee or Purchaser Consideration $ Date
Attach a separate sheet for additional transfers and/or sales.
10. Was there a written partnership agreement in effect at the time of the deeedent's death? ...... [] Yes [] No
If yes, provide a copy of the agreement.
11. Was the decedent's partnership interest sold? ....................................... [] Yes [] No
If yes, provide a copy of the agreement of sale, etc.
12. Was the partnership dissolved or liquidated after the decedent's death? ................... [] Yes [] No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
13. Was the decedent related to any of the partners? .................................... [] Yes [] No
If yes, explain
14. Did the partnership have an interest in other corporations or partnerships? .............. [] Yes [] No
If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest.
A. Detailed calculations used in the valuation of the decedent's partnership interest.
B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years.
C. If the partnership owned real estate, submit a list showing the complete address/es and estimated tair market value/s, if real estate appraisals have
been secured, attach copies.
D. Any other information relating to the valuation of the decedent's partnership interest.
REV*1507 EX+ (1-97)
· ~ SCHEDULE D
OOMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES
INHERITANCE TAX RETURN RECEIVABLE
RESIDENT DECEDENT
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
TOTAL (Also enter on line 4, Recapitulation) $
{If more space is needed, insert additional sheets of the same size)
COMMONWEALTH OF PENNSYLVANIACASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
Include the proceeds of litigation and the date the proceeds were received by the eslate. All properly Jointly, owned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
TOTAl. (Also enter on line 5, Recapitulation) $ ,.~,~f-.-.~.~,
0f roore space is needed, insert additional sheets of the saroe size)
SCHEDULE F
COMMONW~LTN OFPENNSYLV^N'^ JOINTLY'OWNED PROPERTY
INHERITANCE T~ RETUR"
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
If an asset ~s ma~e joi~ ~hin ene year of ~e d~den~s da~ of de.h, E mu~ ~ repo~ on Sch~ule G.
B.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH
ITEM FOR JOINT MADE Include name of financial institution and bank accoun~ number or similar identifying number, Atlach DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT beed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENTS INTERE.
TOTAL (Also enter on line 6, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
· SCHEDULE G
INTER-VIVOS TEANSFERS &
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
This schedule must be completed and filed if the answer ~ any of ques'~ons 1 through 4 oa the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY % OF
ITEM INCLUDE THE NAME OF THE TRANSFEREE THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER DATE OF DEATH DECD~S EXCLUSION TAXABLE VALLIE
NUMBER VALUE OF ASSET INTEREST i~r ,m~_~C,~LE)
TOTAL (Also enter on line 7, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1511, EX+ (12-99)
~ SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Debts of decedent must be reported on Schedule ].
ITEM
NUMBER DESCRIPTION AMOUNT
A~ FUNERAL EXPENSES:
i. ~___,/_~,--~ ,~ ~.~/- / ~/~'
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of PersonaJ Representative(s)
Social Security Number{s)/EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same es claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4, Probate Fees
5. Accountant's Fees
6. Tax Return Preperer's Fees
TOTAL (Also enter on Fine 9, Recapitulation) $
(If more space is needed, insed additional sheets of the same size)
.~,2E~<~..~,. ~ SCHEDULE I
COMMONWEALTH OF PE.NSYLV^NrA DEBTS OF DECEDENT,
,N'~ER,TAHCE TAX
RESIDENT DECEDENT MORTGAGE LIABILITIES, & LIENS
Include unr~imbu~ed medical expen~e~.
ITEM
NUMBER DESCRIPTION AMOUNT
TOTAL (Also enter on mine 1 O, Recapitulation $
(If more space is needed, insed additional sheets of the same size)
!EV-1513 ~X+ (9'00~ SCHEDULF,
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(e) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1.
/
ENTER DOLLAR AMOUNTS FO~ )ISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
I1 NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II- ENTER TOTAL NON-TAXABLE DiSTRIBUTiONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
CERTIFICATION OF NOTICE ~LE
To the Register:
I ce~y ~at notice of ~nefi~M M~t) ~ r~uired by Rule 5.6(a) of the O~h~s' Co~ Rules w~
se~ed on or mailed to ~e following benefici~es of ~e above-captioned estate on
Ad.ess
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Signature
Address
Telephone
Capacity: -~Personal Representative
~Counsel for personal representative
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INOIVIOUA~-~XE$-
INHERITANCE TAX DIVISION'
PO BOX Z80601
HARRISBURG PA 171Z8-0601
NOTICE OF INHERITANCE TAX
APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS ANO ASSESSHENT OF TAX
)~}
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
02-14-2005
ROBERTSON
08-15-2004
21 04-0891
CUMBERLAND
101
DIANE K ROBERTSON
100 RUSTIC DR
SHIPPENSBURG PA 17257
*'
REV-15~7 EX iFP 112-04)
WILLIAM
E
Allount Re..itted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV :r!'2t"'f-ix.-AFp..CBl---6J'.-Noi'-ici-"b1!-lliHErtl-TAN-ci-TAx.l"'PRA.isiinrNT~..A[LowlN"'c~.oR......_....... .-.
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF ROBERTSON WILLIAM E FILE NO. 21 04-0891 ACN 101 DATE 02-14-2005
TAX RETURN WAS: I ) ACCEPTED AS FILED
I X) CHANGED
SEE ATTACHED NOTICE
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate {Schedule AJ
2. Stocks and Bonds {Schedule BJ
3. Closely Held stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable {Schedule DJ
S. Cash/Bank Deposits/Misc. Personal Property {Schedule EJ
6. Jointly Owned Property {Schedule fJ
7. Transfers (Schedule GJ
8. Totel Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
3 , 428 . 16
.00
.00
IB)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Ad... Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequestsj Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
(10)
1,915.00
.00
(11)
(12)
(13)
(14)
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
3,428 . 16
),911; nn
1,513.16
.00
1,513.16
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
NOTE: I~ an assessment was issued previously, lines
re~lect ~igures that include the total o~ ALL
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (IS)
16. Amount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
1,513.16 X 00 =
.00 X 045 =
.00X12=
.00 X 15 =
(19)=
.00
.00
.00
.00
.00
TAX CREDITS:
IT l+J AHOUNT PAID
DATE NUHBER INTEREST/PEN PAID 1-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
~
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)
REV.1470EX(6-88)
'*
INHERITANCE TAX
EXPLANATION
OF CHANGES
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
PO Box 280601
HARRISBURG PA 17128-0601
DECEDENT'S NAME
Robertson, William E.
FILE NUMBER
Daniel Heck
ACN
2104-0891
101
REVIEWED BY
ITEM
SCHEDULE NO.
F 1
EXPLANATION OF CHANGES
The real estate has been removed from the return as real estate jointly held between the
decedent and spouse is entireties property and not reportable fro inheritance tax
purposes.
ROW
Page 1