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1505610140
"~ REV-1500 Ex `°'-'°'
PA Department Of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number
PO BOX 280601 2 1 1 1 0 0 2 3 3
HarrtsburSt, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYW
1 9 1 4 6 4 8 1 3 0 1 1 9 2 0 1 1 1 1 1 0 1 9 5 6
Decedent's Last Name Suffix Decedent's First Name MI
M c L A U G H L I N W A Y N E R
(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
^X 1. Original Return
4. Limited Estate
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
2. Supplemental Return
4a. Future Interest Compromise (date of
death after 12-12-82)
7. Decedent Maintained a Living Trust 0
(Attach Copy of Trust)
10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
R I C H A R D M M O H L E R A T T Y 7 1 7 2 4 8 5 4 6 2
First line of address
1 4 S M A I N
Second line of address
City or Post Office
L E W I S T O W N
Correspondents e-mail address:
S T R E E T
State ZIP Code
P A 1 7 0 4 4
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
REGISTE
F WILLS US NLY
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Under penalties of perjury, I declare tlrat I have examined this return, induding accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Dedaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF P SON RES IBLE F R FI I' URN DATE
29 ROLLING RIDGE DRIVE MILTON PA 17847
SIGNATURE OF PREPARER OTHER THAN REPRESENTATNE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
1505610140
Side 1
1505610140
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1505610240
REV-1500 EX Decedent's Social Security Number
Decedent's Name: WAYNE R• MCLAUGHLIN 1 9 1 4 6 4 8 1 3
RECAPITULATION
1.
.......................................
Real Estate (Schedule A) t •
.... '
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.
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)... .... 5. 1 1 5 5 1. 4 1
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ... .... 6.
7. Inter-Vivos Transfers & Miscellaneous Nip-Probate Property
arate Billin
Re
uested
(Schedule G) Se
7
5
9
4 3
8
2
g
q
...
p ....
. .
8. Total Gross Assets (total Lines 1 through 7) ....................... .... 8. 1 7 4 9 5. 2 3
9. Funeral Expenses and Administrative Costs (Schedule H) .... ..... ....... .. 9. 5 4 4 4 . 0 8
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .... ....... :. 10. 2 4 3 7 6 . 5 6
11. Total Daductlons (total Lines 9 and 10) ................. ..... ....... .. 11. 2 9 8 2 0. 6 4
12. Net Value of Estate (Line 8 minus Line 11) .............. ..... ....... .. 12. - 1 2 3 2 5 . 4 1
13. Charitable and Governmental Bequests/Sec 9113 Trusts for whi ch
an election to tax has not been made (Schedule J) ........ ..... ....... .. 13. 0 . 0 0
14. Net Value Subject to Tax (Line 12 minus Line 13) ........ ..... ....... .. 14. - 1 2 3 2 5 . 4 1
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
t 5. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(t.2)x.o _ 0. 0 0 t5. 0. 0 0
16. Amount of Line 14 taxable
at lineal rate X .045 0 0 ~ 16. 0• 0 0
17. Amount of Line 14 taxable
at sibling rate x .1z 5 9 4 3. 8 2 t7. 7 1 3. 2 6
18. Amount of Line 14 taxable
at collateral rate x. t 5 0. 0 0 t 8. 0. 0 0
19. TAX DUE ........................................ .... ........ ..19. 7 1 3. 2 6
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
1505610240 1505610240
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 11 00233
DECEDENTS NAME
WAYNE R. McLAUGHLIN
STREET ADDRESS
2504 Rolo Court
CITY
Mechanicsburg STATE
PA ZIP
17055
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.
(3)
0.00
(4) 0.0 0
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 713.2 6
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 : ...................................................................... ^ ^Q
b. retain the right to designate who shall use the property transferred or its income : ^ ^Q
:::::::::::::::::::::::::::::::
c. retain a reversionary interest; or ............................................................ ^ ^X
d. receive the promise fw I'rfe of either payments, benefits or care? ....................................................... ^ ^X
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 'intrust for' or payable-upon~eath bank account or security at his or her death? ......... ^ 0
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? .................................................................................................. ^X ^
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 i.
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 1, 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(1.2) p2 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 defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
(1)
713.26
Total Credits (A + B) (2)
REV-1508 EX+'(11-10)
pennsylvania
DEPARTMENT OF REVENUE
INHEWTANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, S MISC.
PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
WAYNE R. McLAUGHLIN 21 11 00233
Include the proceeds of litigation and the date the pproceeds were received by the estate.
AA property jointly owned with right of survhonhip must be dkcbsed on Schsdub F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Members 1st Federal Credit Union Checking Account No. 194793-11 645.34
2. Members 1st Federal Credit Union Savings Account No. 194793-00 4,735.70
($4,735.11)
Accrued interest to date of death ($0.59)
3. Minnesota Life Insurance Company, life insurance under Plan No. 0.00
0402601 999 with Members 1st Federal Credit Union, insuring
Wayne R. McLaughlin in amount of Loan Account balance ($3,842.48)
(Not taxable)
4. 2002 Pontiac Grand Am SE 2,500.00
5. State Farm Insurance Co., refund of unused premium upon cancellation 67.90
of car insurance
6. 1974 Community Mobil Home 500.00
7. Gross proceeds from private sale of sofa, recliner and bedroom set 930.00
($500.00), vacuum ($30.00), TV, personal computer, mower and
line trimmer ($260.00), ladder ($40.00) and speaker system ($100.00)
6. Gross proceeds from yard sale of contents 656.60
9. Amerigas, refund for unused propane ($191.95) and minimum usage fee 373.57
late charge credits ($161.62)
10. U. S. Treasury, 2010 Federal Individual Income Tax refund 663.00
11. Gross proceeds from private sale of Remington Pump Action rifle 215.00
12. Rolo Court Trailer Park, return of security deposit 298.30
13. Kinetic Imaging, refund of overpayment on account 16.00
TOTAL (Also enter on Line 5, Recapitulation) ~ S
If more space is needed, Insert additbnal sheets of paper of fhe same size
REV-1510 EX'+ (OB-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMIBER
WAYNE R. McLAUGHLIN 21 11 00233
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME OFTFffTRPNSFEREE,THEIRREIATIDNSHIPTODECEDENTAND
THE DATE OF TRANSFER.ATfACHACOPYOFTHEDEEDFORREALESTATE.
DATE OF DEATH
VALUE OF ASSET
%OFDECD'S
INTEREST
EXCLUSION
pFn~irwau7
TAXABLE
VALUE
1. Nationwide Insurance Co. 457 (b) Deferred Compensa- 5,943.82 100.00 5,943.82
tion Account No. 9764492, payable to Leo C.
McLaughlin, brother, as designated beneficiary,
invested as follows:
4,795.9769 Units of Nationwide Investors Desti-
nation Aggressive Svc at $1.4495 per share
($6,951.77)
Less: Payment by beneficiary of portion of
funeral bill ($1,007.95)
TOTAL (Also enter on Line 7, Recapitulation)I ; 5, 943.82
If more space Ls needed, use additional sheets of paper of the same size.
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
WAYNE R. McLAUGHLIN 21 11 00233
Decedent's da6ts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Hoffman-Roth Funeral Home and Crematory, Inc., funeral expenses 1,500.00
($2,507.95), less payment from person funds of Leo C. McLaughlin
($1,007.95)
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)ofPersonalRepresentative(s) Leo C. McLaughlin
Street Address 29 Rolling Ridge Drive
City Milton g~s~ PA Zlp 17847
Year(s) Commission Paid:
770.00
p. AttomeyFees: Richard M. Mohler 2,000.00
3, Fatuity Exemption: (If decedents address is not the same as daimanfs, attach explanation.)
Claimant n/a
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees:
5 Accountant Fees:
6. Tax Retum Preparor Fees:
7. Starview Mobile Homes, trailer lot rental for December 2010. Check
issued prior to death but paid after death. 340.00
8. State Farm Insurance Co., payment of premium for fire insurance
coverage on personal property 87.63
9. Dennis Zerbe, Tax Collector, payment of 2010 delinquent Real Estate
Taxes 6.45
10. Leo C. McLaughlin, reimbursement for filing fee for Petition for
Probate and Short Certificates ($105.00), for winterizing mobile
home ($100.00) 205.00
11. Glenda Farner Strasbaugh, Register, filing fees for Inventory ($15)
and PA Inheritance Tax Return ($15) 30.00
12. Glenda Farner Strasbaugh, Register, filing fee for Release 5.00
TOTAL (Also enter on Line 9, Recapitulation) S 5 , 4 9 4.08
If more space is needed, use additional sheets of paper of the same size
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
WAYNE R. McLAUGHLIN 21 11 00233
Decedent's Name Page 1 File Number
Schedule H -Funeral Expenses ~ Administrative Costs - B7.
ITEM
13. I Reserve for Estate Notice advertising and filing fees for formal
Final Account
AMOUNT
500.00
SUBTOTAL SCHEDULE H-B7 I soo.oo
REV-1512 EX+ (12-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, 8 LIENS
WAYNE R. McLAUGHLIN 21 11 00233
Report debts Incurred by the decedent prior to death that remained unpaid at the date of death, including unreimburead medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Members 1st Federal Credit Union Loan Account No. 194793-03 3,752.94
2. Members 1st Federal Credit Union Visa Credit Card Account No. 4672 1,676.92
0900 0019 8036
3. Americas, balance for purchase of propane ($181.62) and for service 208.12
labor in removal of propane tank ($26.50)
4. West Shore EMS-BLS, ambulance service to hospital on 11/15/2010 2,050.83
($1,031.78) and for ambulance service to hospital on 11/16/2010
($1,019.05)
5. Holy Spirit Hospital, balance due for professional service on 11/15/2010 3,714.80
($593.40) and for professional service on 11/16/2010 ($3,121.40)
6. Camp Hill Emergency Physicians, balance for professional services 1,287.00
rendered on 11/15/2010 ($568.00) and for professional services
rendered on 11/16/2010 ($719.00)
7. Starview Mobile Homes, balance of trailer rent for January ($38.00), 773.00
late charge ($35.00), February ($350.00) and March ($350.00) 2011
8. Comcast, balance for television cable service 82.35
9. Target Visa Credit Card, balance due for credit card purchases 538.64
10. Discover Credit Card, balance due for credit card purchases 9,645.07
11. Verizon, balance for telephone service 75.13
12. PPL Electric Utilities Corp., balance for electrical service 571.76
TOTAL (Also enter on Line 10, RecapNulation) I S 24.376.56
If more space is needed, insert additional sheets of the same size.
REV-15`13 EX+t01-10)
Pennsylvania I SCHEDULE J
DEPARTMENT OF REVENUE I BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
mnvnir n nn~T.nnr_uT.Tta 21 11 00233
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trusteels) OF ESTATE
I TAXABLE DISTRIBUTIONS [Indude ouinght spousal disfibutbns and transfers under
Sec. 91 i6 (a) (1.2).)
1. Leo C. McLaughlin Sibling 5,943.82
29 Rolling ridge Drive
Milton, PA 17897
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN:
1. N/A 0.00
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1. N/A 0.00
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. E 0.00
If more space is needed, use additional sheets of paper of the same size.