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Home My WebLink About03-29-12 (2)--~ REV-1500 Exc°'_1o> 1505610143 ~~~r PA Department of Revenue pennsyl ania OFFICIAL USE ONLY Bureau of Individual Taxes DEPARTMENT OF REVENUE County Code Year File Number Po Box.2sosoi INHERITANCE TAX RETURN 2 1 1 1 0 13 1 1 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 193 14 3120 11 27 2011 09 23 1923 Decedent's Last Name Suffix Decedent's First Name COURY DANIEL G (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 ^ qa Future Interest Compromise 5. Federal Estate Tax Return Required (date of death after 12-12-82) ^ ® g Decedent Died Testate ~ Decedent Maintained a Living Trust (Attach Copy of Will) ^ (Attach Copy of Trust) 8. Total Number Of Safe Deposit Boxes ^ 9. Litigation Proceeds Received ^ 1 p 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 CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name GREGORY M K E R W I N Daytime Telephone Number 717 362 3215, First line of address 4245 STATE ROUTE 209 Second line of address City or Post Office State 21P Code ELIZABETHVILLE PA 17023 Correspondent'se-mail address: gmkerWin@hotmail.COm C.7 ~~~~ REGISTER ~ 116GI,L~S USE-ONLY ~:: `-• ~~- ,t . C_,i L ; ~^. .. T ~-1-I n~: ~l^ -~~:~-T~ x) ;_. DATE FILED r` 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, Corr ct and complete. Declaration of arer other than the personal representative Is based on all information of which preparer has any knowledge. SIGN UR F PE ON RESPONSIBLE F F ~ RETURN DATE Gregory M. Kerwin 3 _ ~ ~'-~ ~ 2 DRESS aza tat oute 209, Elizabethvi , PA 17023 SIGNA E P PAR THAN REPR E IVE DATE ~_„ Gregory M Kerwin ~ a ~'~ ADDRESS 4245 St e R to 209, Elizabethville, PA 17023 Side 1 L 1505610143 1505610143 J ~~ 1505610243 REV-1500 EX Decedent's Social Security Number Decedent's Name: (+ O lJ R Y, D A N I E L G 19 3 14 3 12 0 RECAPITULATION 1 . Real Estate (Schedule A) ..................................................................................... ..... 1. 2 . Stocks and Bonds (Schedule B) ........................................................................... .... 2. 3 6 9, 2 1 9. 7 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)...... .... 3. 4. Mortgages & Notes Receivable (Schedule D) ...................................................... .... 4. 5. Cash, Bank Deposits & Miscellaneous Personal Pro a p rty (Schedule E) ............. ... 5. 4 1 0, 9 6 6 3 9 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .......... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested .......... ... 7, 2 3, 2 9 2 3 7 8. Total Gross Assets (total Lines 1-7) .................................................................... ... g. 8 0 3, 4 7 8. 4 6 9. Funeral Expenses & Administrative Costs (Schedule H) ...................................... ... g. 5 6, 3 4 1 6 4 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................. ... 10. 1 , 9 3 7.12 11. Total Deductions (total Lines 9& 10) ................................................................... ... 11. 5 8, 2 7 8 7 6 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... ... 12. 7 4 5 , 1 9 9 7 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............................................... .. 13. 1 4 , 0 0 0 0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) ............................................... .. 14. 7 3 1 , 19 9 7 0 TAX COMPUTATION -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 .00 15. 16. Amount of Line 14 taxable at lineal rate X .045 16. 17. Amount of Line 14 taxable at sibling rate X ,1P 12 1, 8 6 6. 6 1 17. 14 , 6 2 3 9 9 18. Amount of Line 14 taxable at collateral rate X .15 6 0 9, 3 3 3 0 9 18, g 1, 3 g g g 6 19. Tax Due .................................................................................................................... . 19. 1 0 6, 0 2 3 9 5 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 1505610243 1505610243 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 - 11 - 01311 Coury, Daniel G STREET ADDRESS Manor Care, Market Street CITY Camp Hill Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 97,000.00 5,105.26 TE ZIP PA 17011 (1) 106,023.95 Total Credits (A + g) (2) 102,105.26 (3) 0.00 (4) (5) 3,918.69 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. 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 :.................................... ^ c. retain a reversionary interest; or .................................................................................................................. ^ ^ d. receive the promise for life of either payments, benefits or care? ................. . .. .. x ....................................... I 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 account or security at his or her death?......... ^ a 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 January 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 retfurn 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 ears 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)]. • s tiling is definedounder Sectiont9102, as an indi dual whothasuat least one parent in c~olmmon wi hph decedent wfiether by blood oAadoption. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF COUry, Daniel G FILE NUMBER 21 - 11 - 01311 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 148.5722 shares Mid Penn Bancorp Stock 8.031 1,193.18 2 ' 15 Series HH Bonds -see inventory report attached hereto 3 Brokerage Account with PSECU, CUSO Financial Services, LP, 1 Credit Union Place, Harrisburg, PA 17110 -See list of stocks and Bonds attached hereto 14,000.00 354, 026.52 TOTAL (Also enter on line 2, Recapitulation) 369,219.70 SCHEDULE E CASH, BANK DEPOSITS, 8~ MISC. COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Coury, Daniel G FILE NUMBER 21 - 11 - 01311 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Cash & Equivalents/Money Fund with PSECU/CUSO Financial, 1 Credit Union Place, 97 851 70 Harrisburg, PA 17110 , . 2 Checking Account #512088444 at Metro Bank, 3801 Paxton Street, Harrisburg, PA 17111 1,034.25 3 Savings (S1) account with PSECU, 1 Credit Union Place, PO Box 67013, Harrisburg, PA 855.08 4 Checking (S4) with PSECU 33,775.69 5 Money Market (S7) with PSECU 550.15 6 Certificate (S51) with PSECU 7,689.12 7 Certificate (S56) with PSECU 9 328 87 8 Certificate (S58) with PSECU 24,811.53 9 Certificate (S59) with PSECU 15,613.37 10 Certificate (S60) with PSECU 58,449.90 11 Certificate (S62) with PSECU 17,035.65 12 Certificate (S63) with PSECU 11,344.55 13 Certificate (S64) with PSECU 8,770.80 14 Certificate (S65) with PSECU 6,027.62 15 Certificate (S68) with PSECU 16,414.06 TOTAL (Also enter on Line 5, Recapitulation) 410,966.39 SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT continued ESTATE OF COUry, Daniel G FILE NUMBER 21 - 11 - 01311 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM DESCRIPTION VALUE AT DATE OF NUMBER DEATH 16 Certificate (S71) with PSECU 101,314.05 17 VA Death Benefit 100.00 Page 2 of Schedule E COMMONWEALTH OF PENNSYLVANIA SCHEDULE G INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS & RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY ESTATE OF Coury, Daniel G FILE NUMBER 21 - 11 - 01311 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH % OF EXCLUSION NUMBER ~~~~ InGude the name of the transferee, their relationship to decedent i VALUE OF ASSET DECD'S ~ TAXABLE VALUE and the date of transfer. Attach a copy of the deed for real estate. j INTEREST (IF APPLICABLE) I Variable Annuity account #P37A3012661 with SunAmerica, PO Box 54299, Los Angeles, CA 90054-0299; Beneficiaries: Barbara Scott and Joseph Coury 23,292.37 j 100% 23,292.37 TOTAL (Also enter on line 7, Recapitulation) j 23,292.37 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H /~FryU~N~ER~A~LpD•(~PE~N/S-/E~S & f'Y.JIYNI\1~7 1 ISI~\ 1 1 V G ~.-~./~7~ ESTATE OF Coury, Daniel G FILE NUMBER __ 21 -11 -01311 Debts of decedent must be reported on Schedule I. ITEM '~ NUMBER FUNERAL EXPENSES: DESCRIPTION ~'~ AMOUNT - i A. 1 I' Parthemore Funeral Home, balance due on funeral 577.07 2 '~, Coakley's Restaurant & Pub, Funeral meal 888.02 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Gregory M. Kerwin Street Address 4245 State Route 209 city Elizabethville state PA zip 17023 Year(s) Commission paid 2 Attorney's Fees Kerwin & Kerwin, LLP 3. ', Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant 27,389.00 26,406.00 Street Address ', ' i City State Zip ', ', Relationship of Claimant to Decedent a. I Probate Fees Register of Wills ,' 515.50 i 5. ~ Accountant's Fees 6. I Tax Return Preparer's Fees 7. ~ Other Administrative Costs 1 ! Notary fee on Oaths of Subscribing Witness 10.00 I TOTAL (Also enter on line 9, Recapitulation) 56,341.64 Schedule H Funeral E~er~s & COMMONWEALTH OF PENNSYLVANIA ~,Ylln~fllfe ~~ continued INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Coury, Daniel G 2 ', Notary fee on Affidavit of Domicile 3 Cumberland Law Journal. Estate Advertisement 4 ', The Sentinel, Estate Advertisement 5 ', Vital Records, Death certificates 6 ~I~ US Postmaster, Express mail for death certificates 7 ~ Register of Wills, additional probate 8 II', Reserved for closing costs FILE NUMBER 21 - 11 - 01311 5.00 75.00 62.10 45.00 18.95 150.00 200.00 Page 2 of Schedule H SCHEDULEI - DEBTS OF DECEDENT, MORTGAGE COMMONWEALTH OF PENNSYLVANIA LIABILITIES & LIENS INHERITANCE TAX RETURN f RESIDENT DECEDENT FILE NUMBER ESTATE OF COUry, Daniel G 21 - 11 - 01311 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM DESCRIPTION AMOUNT NUMBER 1 Department of Veterans Affairs, return of overpayment 243.00 2 ~ The State Employees' Retirement System, return of overpayment ~ 121.11 3 ~ US Department of Treasury, return of December's Social Security payment ~ 1,060.00 4 ~ Manor Care Health Services, account payable ( 45.00 5 ~ PPL Electric Utilities, final payment for electric ~ 118.05 6 ~ Adult Mdeicine & Aesthetics, LLC, account payable ~ 132.80 7 ~ West Shore EMS-BLS, account payble for ambulance calls ~ 217.16 TOTAL (Also enter on Line 10, Recapitulation) ~ 1,937.12 REV-1573 EX+ (~ ~ •081 SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Coury, Daniel G 21 - 11 - 01311 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY i, Do Not List Trustee(s) I~ TAXABLE DISTRIBUTIONS [include outright spousal ~i distributions, and transfers under Sec. 9116 (a) (1.2)] 1 Robert Gray I Nephew 1/6th Residue of 11060 Meade Court ~ Estate Westminister, CO 80031-2108 2 ~ Joseph Coury Brother j 1/6th Residue of 37 Seventh Avenue Estate Bonita Springs, FL 34134 I 3 Barbara Scott Niece 1/6th Resdue of 137 East Holland Street Estate Summit Hill, PA 18250-1511 Enter dollar amounts for distributions shown above on lines 1 5 through 18 on Rev 1500 cover sheet, as appropriate. III NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1 Our Lady Help of Christians Catholic Church, 732 East Main Street, Lykens, PA 17048, 9,000.00 specific bequest 2 St. Theresa Catholic Church, 1300 Bridge Street, New Cumberland, PA 17070, specific 5,000.00 bequest B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 14,000.00 REV-1513 EX+ (9.00) .a. SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES continued INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Coury, Daniel G 21 - 11 - 01311 T RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY Do Not List Trustee(s) I TAXABLE DISTRIBUTIONS [include outright spousal ~ distributions, and transfers under Sec. 9116 (a) (1.2)] 4 Kathleen A, Demetor Sister-in-Law 1/2 Mid Penn 38 New Pond Lane Bancorp Stock & 1 /2 Levittown, PA 19054-3822 Residue of Estate i I 5 Kathleen Bley ,Niece 1/2 Mid Penn 38 New Pond Lane ~ Bancorp Stock Levittown, PA 19054-3822 6 , Sharon Madden ~ None $2,500.00 2,500.00 ' 1280 Rosstown Road Lewisberry, PA 17339 I I ~i i ~' I ~I Page 2 of Schedule J