HomeMy WebLinkAbout03-30-121505610105
REV-1500~`tO2-'1'«, ~
PA Department of Revenue pennsytvartia OFFICIAL USE ONLY
Bureau of Individual Taxes ~""p'"`"T "`~"°` County Code Year File Number
Po BOx z8o6o1 a INHERITANCE TAX RETURN ~~ ~ ~ ~ C1 ~~~~
Harrisburg, PA i~i28-o6oi RESIDENT DECEDENT ' -
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
Decedent's Last Name Suffix Decedent's First Name MI
(if Appllcable- Enter Surviving Spousa'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 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 Return Required
death after 12-12-82)
O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9. Litigation 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 Schedule O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name ( Daytime Telephone Number
,~olt` ~ q.s «~ ~ 10,Md ~ C7 ~
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REGISTER OF WILLS USE ONLY
First Line of Address
S
Y ~
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~ n r ~ -~-r
~ O t'`J ~ i-1
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Y O
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Second Line of Address ,~~ ~ C~ ~ g~ t
~~ -~ ~ G~
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City or Post Office fate -
~'s ~ - ..-~ - ; ' .
ZIP Code OATF ~'~ -_'
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3-T~P7 KJ
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Correspondent's a-mail address:
Under penalties of perjury, 1 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. DeGaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF SON R PONSIBL FOR IN RETURN DATE
ADDRESS
/~~
~. ~~riVU
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610105 1505610105 J
1505610205
REV-1500 EX (FI)
De/ce¢de(n~t's Social SecurityN'')um~b'e~r')
Decedent's Name: ! (Jy ~~~ -'~"' %~e~.~C~~ P~
RECAPITULATION
1. Real Estate (Schedule A) ............................................. 1
2. Stocks and Bonds(Schedufe B) ....................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgagee and Notes Receivable (Schedule D) . ....... . . . ..... . . . . . .. . . . . 4.
5. Cash, Bank Deposks and Mfscelianeous Personal Property (Schedule E)... , ... 5. ~~ 'J ly1
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7.
8. Total Gross Assets (total Lines 1 through 7) ........................ ..... 8. ~
~ ~
~ r
.
9. Funeral Expenses and Administrative Costs (Schedule H) .............. ..... 9. ~ /s~ ~ 30
10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) .......... ..... 10. ol~~~J '7~~ ~~
11. Total Deductions (total Lines 9 and 10) ............................ ..... 11. ~~~7~t l y
12. Net Value of Estate (Line 8 minus Line 11) ......................... ..... 12. /1
G ~?
13.
Charitable and Governmental Bequests/Sec 9113 Trusts for which /
~
V d
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
(a)(1.2) X .0_ 15.
16. Amount of Line 14 taxable
/
at lineal rate X .0 _ ~ ~ ~ / 1 g, / ,~,
~`
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19. TAX DUE ......................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
7~, ~~
O
Side 2
1505610205 1505610205
REV-1500 EX (FI) Page 3
Decedent's Complete Address:
Flle Number
D C N ME /~
.V..(l `G - - ~, rL'FiTG ~~/C.. ~c~s"c~~
~ d~c~
--
STREETADD~RE~SS~ M ~ ~ _---
CITY STATE ZIP
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount _~ ~ -~,~~
3. Interest
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.
(1) /7~. ~Y
Total Credits (A + B) (2) ~, 7e'-
(3)
(4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~~ ~ f ", 7(
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 ........................................................................................................................ ...... ^ I~
d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^
2. If death occurred after Dec. 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? ........ ...... ^
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a benefiaary 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 i , 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(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-iso8 EX+ (il-io)
Pennsylvania ~ SC~IED~ILE E
DEPARTMENT OE REVENUE vI'1JHr BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: /~ FILE NUMBER:
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.
u more space is neeoea, use aaaitionai sneers of paper of the same size.
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
FILE NUMBER
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
l 7a3,On
~11 /~7 L.~ r~ ~cl~..~`~1' 4L ~ ~,~U ~U~.G~ 074 ~ b b
~,v ~ ~,~~~.,9v~~u G J"3o . as
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s) _
Street Address -' a-~ ~ -
City _ __ State ___ ZIP __~~~~
Year(s) Commission Paid:
Z• Attorney Fees: ~~~
3. Family Exemption: (If decedent's address is not the sa as claimant' ,attach explanation.)
Claimant ~,f~y
StreetAddress_~ bd _ ~ _~a-j ~y~
City ______ _ __ State Z1P
Relationship of Ciaiman//t~~t~~o Decedent _ _/~ L_ _G ~/
4. P ate Fees: may- tL.lL•.f'y F ~ G~ ~~~ ~ / I ~~iN` -1~4~1-- ~ ----
5. Accountant Fees: J
6• Tax Return Preparer Fees: p /~
~~.c-. s G
~~,,~e
TOTAL (Also enter on Line 9, Recapitulakion) I ;
If more space is needed, use additional sheets of paper of the same size.
Pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
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 / DESCRInPT-IO"N OF DEATH
>.. ~®~, a, fuf~.c~ d w~ ~~ ICJ vU G c~ip,{ al ~~ ~ 7~• Frd'
3• ~w N,aa~t ~~~ d1~p.T~ .~.,- oz~, vfl
Ste, O
Z• 6i~(, jD~-,~~- ~`w.vA~c~~c ~1P~T-'~•Q 14Q7. 6
~ ~ ~~ z07 ~S
~~--ra~•
TOTAL (Also enter on Line 10, Recapitulation) I; ,2 Q 7? /~ 0.00
If more space is needed, insert additional sheets of the same size.
u~ns,nns RF\'ls%'^
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance with
the Vital Statistics Law of 1953, as amended.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
6648412
No.
a2
~1
y~
C
Marina O'Reilly Matthew
State Registrar
MAR 0 8 2012
Type/Print In COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RECORDS
Permanent ['FRTIFIC•ATF CIF CIFATN
Date
1. Decedent's Legal Name (First, Middle, lax, Suffix) 2. Sex 3. Social securky Nu mber~,e a,•pate of Death (MO/Day/Yr) (Spell Mo)
Jeanne S_ Fletcher Female 185-36-4052 February 10, 2012
sa. Age-Lax Birthday (Vrs) sb. Under 1 Vear 5c. Under 1 Da 6. Date of Birth (MO/Day/Vear) (Spell Month) 7a. Birth (~tc y and rate or Forel Country)
~
l~
~
g
f
l Ka s-
arre,
gl Months DaYS Hors Minuces December 10, 1920
PA
Tb. Birthplace (cpunty) Luz erne
8e. ~esldence (5(ate or F reign Country) 8b. RezWence (Street and Number -Include Apt No.) Sc. pid Decadent Uye in a Townshlp ~7
ennsy van a
480 Woodcrest Dr, w¢s, decedent uy¢d in riampden tyl
p
8d. Residence (County)
Cumberland Se, Residence (Zip Coda) ONO, decedent lived wthin limits of city/born.
9. Ever in US Armed ForcesT 30. Marital Status at Time of Death ~ Married ~ Widowed 11. Surviving Spouse's Name (If wke, give name prior to firs[ marriage)
~ Ves ~ NP Q Unknown Q DHorced ~ Never Married ~ Unknow
12. Father's Name (FJrst, Mldd)e La}T, Suffix)
MMarvin o8s White 13. Mother's Name Prior to LJ s[ [Np IagR(First, Middle, Last)
a e Hammonds
14a. Informant's Name 146. Relationship to Decedent 14c. Informant's Malling Address (street and Number, City, State, Zip Cede
Moll
Solomon D
h
y
aug
ter 480 Woodcrest Dr. Mechanicsbur
g , A 1 70
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.
a~e
o
on
on
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................... ....................I,fy ...................._..............................
.
.
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...
If Death Occurred in a~FiosPital: yy~ln Patient ;If Death Ottumed Somewlie~e Other Than a~HOSPiiil: ~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ """""""""""""""""'"'"'""'"
"
"'
t~ Flospice Facility Deced
t'
H
en
s
om¢
0 Emergency Room/Outpatient peed on Arrival Nursin Home/long-Term Care Facility Other (specify)
•
15 b. Facility Name (If not inxitution, glue xreat and number)
15c. CKy or Town, state, antl ZIP Coda lSd. County of pearl,
Harrisburg Hospital Harrisburg, PA 1710'1 Dauphin
16a. Method of Disposition Q Burial Crematbn 16b. pate of Dispositon 16c. Place of Dispos Klon (Name of cemetery, crematory, or other place)
O Removal from state p Donation Feb. 13, 201 Hoover Funeral Homes Cremator
o[n.r (sPedfy) y
v 16d. Location of Disposition (City or Town, stale, and Zip) 17a. Signatu cal service Llcenaee or P on in Ch
arge of Interment S7b. License Number
H
i
b
-
~ arr
s
urg, PA 17112
~ ~~_;_~- FD 011921 L
0 17 Name and Cplr, plete Addres~OfOFmu ~81 Fac111UC
hoover 1'-uneral IS Oo C:remator
Inc
6011 Li
l
y
_
ng
estown Rd. Harrisbur
g , PA 1 7 112
.~ 18. Deceden['s Education -Check the box Shat bex describes the 19. Decedent of Hispanic Origin -Check the 20. DecedenS's Race -Check ONE OR MORE races to Indicate what
.- highest degree or level of school completed at the time of death. box that bex describes whether the decedent the decedent considered himself or herself to be
.
Q 8th grade or less is spanish/Hlspanic/La[ino. Check the •NO" ke
Q Korean
N
~
o diploma, 9th - 12th grade box If decedent is not 5
panish/Hispanic/Latino. 0 lack or African American Q Vietnamese
11~lilgh school
raduate
GEO
l
g
or
comp
eted No, not Spanish/Hispanic/Latino 0 American Indian or Alaska Native ~ Other ASlan
r~ same
ll
di
b
co
age cre
t,
ut no degree ~ Yes, Mexican, Mexican Amercan, Chicano 0 Asian Indian 0 Native Hawaiian
0 Ass
i
te d
oc
a
agr¢e (e.g. AA, AS) ~ Yes, Puerto Rican
~ Guamanian or Ch
'
W
amorro
O Bachelor
s degree (e.g. 8A, AB. Bs) O Yes, Cuban- 17 ~I
ino
p O Samoa
'
n
Q Master
s degree (e.g. MA, M5. MEng, MEd, MSW, MBA) O Ves, other 5
panish/HispaniULatino Qlapanese I~Other P
ifi
I
ac
c
slander
0 Doctorate (e.g. PhD, EdD) or Professional degree (S
if
pec
y) Q Other (Specify)
. MD DDS DVM LLB JD
21. Decedent's single Race self-Designation -Check ONLY ONE fo Indicate what the decedent considered himself or hers¢K to be. 22a. Decedent's Usual Occu
atbn -Indi
t
t
~
p
ca
e
ype of work
hlte r~ )open ese ~ Samoan done durin
most
f
k
g
o
wor
ing IHe. DO NOT UsE RETIRED.
~ Black or African American ~ Korean Q Other Pacific Islander
RE:Ce tionist
Q American Indian or Alaska Natlye Q Vietnamese Q DOnY Know/Not Sure P
O Asian Indian Q Other Asian Q Refused
226. Kind of Business/Induxry
Chinese Q Naive Hawai(an ~ Other (Specify)
Fi1lPino Q Guamanian or Chamorro =118 i1r8nCe
ITEMS 23a - 23d MUST BE COMPLETED 23a. Data Pronounc d Dead (MO pay/Vr) 23b. Slgnaf ure of Person Pronouncing Death (Only when applica blef 23c. Ucense Number
BV PERSON WHO PRONOUNCES DR Februa 1 O, 201 2
CERTIFIES DEATH ry
23d. Date Signed (MO./Day/Yrl 24. Time of Death
04:45 AM zs. was Meelol Examiner or coroner conraccedz ® Yes O Nn
CAUSE OF DEATH
Avproximate
26. Part 1. Enter the chain of events-diseases, Injuries, or complications--chat dlrettly caused the death. DO NOT emer terminal events such as wrdlac arrex
I
i
l
.
nterva
resp
:
ratory arrest, or ventricular fibrillation without showing the eSlology. p0 NOT ABBREVIATE. Enter only one cause on a Ilne. Add add Klonal Ilnes if necessary Ons¢t to Death
IMMEDIATE CAUSE - > a. Heart Failure
(Final disease or condition Due to (o as a consequence af):
resulting In death?
b. Complications From A Left Arm Fracture
_ __
Sequentla lly list conditions, Due to (or as a consequence of):
if any, leading to the Ouse
listed on line a. E r the
UNDERLYING CAUSE Due to (or as a consequence Pf):
(disease or InJury that
Initiated the events resu king d.
In death) LAST. Due to (or as a consequence of):
r`S 26. Part 11. Enter other sia
nlflrsnt
dit
. _
Con
nns t d h but not resulting In the underlying cause given in Part I
I 27. Was an autopsy performed?
~ Dementia, CAD, HTN, Osteoporosis O ves ® No
28. Were auto PSY Tlndings ayallable
g, to complete the cause of death?
29. If Female: O Yes No
30. Did Tobacco Use Contribute to Death? 31. Msnner of Death
of
r
egna nt within past year
~ n
a
0 Preg tat time of death .t7 Yes ~ Probably 0 Natural r~ Homicide
No ~ U
k
o n
nown ® Suic tl¢nt 0 ~
~ Not pregnant, but pregnant within a2 days of death Lq
d
nn
r'
l
ui
d
ot
ba d¢g ar
mined
~ Not pregnant, but pregnant 43 days to 1 year before death 32. Date of In Mo Da ~ ~
Jury ( / y/yr) (Spell Month)
Q Unknown if pregnant within Cho past yea. Febr:J af)/ 1 , 2012 33. Tlma of InJury
A
px 1 2:00 A
34. Place of Injury (e.g. home; conxruction zke; farm; school) 35. Lora[bn of InJury (SRBat and Number, CKy, State, Zip Cod¢)
Hospital. 111 South Front Street Harrisburg, PA 17104
36. InJury at Work 37. If Transportation InJury, spec)
fi': 38. Describe How InJury Occurred:
O Ys p DrNer/oPeratpr p Pedexrmn Fal out of hospital bed.
® No ~ Passenger 0 Other (specify)
39a. Certifier (Check only one):
Q Certifying physician - To the best of my knowledge, death occurred due to the se (s) and mann
t
t
d
er s
a
e
~ Pronouncing 8 Certifying physician - To the bast of my knowledge, death occurred at the time
data
and place
and due to th
,
,
,
e cause(s) and manner stated
® Madiol Examiner/COro n the minatlon~ and/or Investigation, in my opinion, death occurrod at the time
date
and
bca
d d
h
,
,
p
, an
ue to t
e cause(s) and manner stated
Signature of certifier- Title of certifier: Chief Dep UtV
License Number:
39b. Name, Adtlress and Zip Code of Person Com pbting Cause of Death (Item 26)
39c. Date Signed (MO/Day/Yr)
Lisa A. Potteiger, "1271 South 28th Street
Harrisbur
PA t71 ~ ~
,
g,
February 1 O, 2012
40. Registrar's DlstriuY Number 41
Re
istra
'
Si
as - ~~~ .
g
r
s
gn MUre
~Q
~C
4 42. Regixrar Fge Data (MO/Day Vr)
43. Amendments -
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0725503 HSOS-143
Disposition Permit No. REV 07/2011