HomeMy WebLinkAbout04-04-12 (2)_ ,,
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J 150561014D
REV-1500 ~` (°'-'°'
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number
Po sox zso6ol 2 1 1 1 0 5 2 5
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth Iuq~tDDYYYY
2 0 2 2 0 1 0 4 8 0 3 0 2 2 0 1 1 1 2 2 0 1 9 1 8
Decedent's Last Name Suffix Decedent's First Name MI
S a m p s o n M a r y D
(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
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 Retum
4a. Future Interest Compromise (date of
death after f2-12-82)
7. Decedent Maintained a Living Trust
(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
Name
First line of address
Second line of address
City or Post Office
Correspondent's a-mail address:
AND CONFIDENTUIL TAX INFORMATION SHOULD BE DIRECTED T0:
Daytime Telephone Number
State ZIP Code
3. Remainder Retum (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)
REGISTER OF WILLS USE ONLY
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Under penaltlea of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the beat of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal repreaentatlve is based on all information of which preparer has any knaarledpe.
SlGhjlITURE OF PERSON RESPQ/JSIBLE FOR FILING RETURN DATE
SIGNATURE OF
Road,
M
19 S. Hanover Stre ,;' to="101 Carlisle PA 17013
'' PLEASE USE ORIGINAL FORM ONLY
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L 1505610140 1505610140 J
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1505610240
REV-1500 EX
t)ecedenrs Name: M a r y D• Sampson Decedent's Social Security
2 0 2 2 0 1 Number
0 4
8
RECAPITULATION
1.
...........................................
Real Estate (Schedule A) 1
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. 3 5 0 0 . 0 D
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 9 8 5 , 0 9
7. Inter-Vivos Transfers & Miscellaneous N -Probate Property
arate Billin
h
d
l
G
~ Se
Re
uested
S
7
g
.......
u
e
)
p
q
(
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e .
8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 4 4 8 $ . 0 9
9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 1 3 4 5. 0 4
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .....:....... 10. 8 4 1 . 8 4
11. Total Deductions (total Lines 9 and 10) ............................... 11. 2 1 8 6 . 8 8
12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. 2 2 9 8 . 2 1
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ...................... 13.
14. Net Value Subject to Taz (line 12 minus Line 13) ...................... 14. 2 2 9 8 . 2 1
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.o _ 0. 0 0 15. 0. 0 0
16. Amount of Line 14 taxable
at lineal rate X .045 2 2 9 8. 2 1 1s. 1 0 3. 4 2
17. Amount of Line 14 taxable
at sibling rate x .12 0. 0 0 17. 0. 0 0
18. Amount of Line 14 taxable
at collateral rate X .15 0 0 0 18. 0. 0 0
19. TAX DUE ..................... ........................ .. ....... 19. 1 0 3. 4 2
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
1505610240
REV-1500 E,X ~Rege 3
becedent's Complete Address:
File Number
21 11 0525
DECEDENT'S NAME
Mary D_Sampson ___ _
STREET ADDRESS
CITY STATE ZIP
Tax Payments and Credits:
1 • Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments 46.55
B. Discount 5.17
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
FIII in oval on Page 2, Line 20 to request a refund.
(1) 103.42
Total Credits (A + B) (2) 51.72
(3)
(4) 0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 51.70
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; 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 "intrust 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 benefaary 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 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) [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.
Pennsylvania SCHEDULE E
DEPARTMENT OP REVENUE
CASH, BANK DEPOSITS, 8r MISC.
RESIDENTDECEDENTTURN PERSONAL PROPERTY
E OF:
Marv D. Sampson 21 11 0525
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointty owned with right of survivorship must be diacbsed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
t. trailer 3,500.00
TOTAL (Also enter on Line 5, Recapitulation) ~ S
If more space is needed, insert additional sheets of paper of the same s¢e
REV-1509 Ek+ (Ot-10)
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pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
Marv D. Sampson 21 11 0525
ff an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G.
SURVNING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A. Mary S. Mills 90 Salem Church Road, Lot 529 daughter
Mechanicsburg, PA 17050
s.
c.
JOINTLY-OWNED PROPERTY:
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY-HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET % OF
DECEDENTS
INTEREST DATE OF DEATH
VALUE OF
DECEDENTS INTERES7
1. A. 031108 M&T Bank Checking Account Number 9843866808 1,970.17 50. 985.09
TOTAL (Also enter on Line 6, Recapitulation) I S 985 09
If more space is needed, use additional sheets of paper of the same size.
RE1~Y1511 EJG+(10-09)
i
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Mary D. Sampson 21 11 0525
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
t. Richardson Funeral Home 114.75
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s) M8ry Mills 224.25
SVeetAddress 90 Salem Church Road, Lot 529
City Mechanicsburg State PA ZIP 17050
Year(s) Commission Paid:
y, AttomeyFees: Stephen J. Hogg, Esquire 500.00
3. Family Exemption Qf decedenYs address is not the same as daimanrs, attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4• Probate Fees: 81.50
5 AocountaM Fees:
6. Tax Retum Preparer Fees:
7. Advertising: Law Journal 75.00
The Sentinel 189.54
8. Tax Return and Inventory Filing Fee 30.00
9. Accounting (Estimated) 130.00
TOTAL (Also enter on Line 9, Recapitulation) I ; 1 ~a5 na
It more space is needed, use additional sheets of paper of the same size.
~tEVti:151 ~.EX`j (12-PB)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
Mary D. Sampson 21 11 0525
Repoli debts Incurred by the decedent prior to death that remained unpaid at the date of death, including unreimburaed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Verizon 25.36
2. PP&L 51.51
3. Fuel 386.97
4. Leffler-Furnace 284.00
5. PP&L 27.64
6. PPBL 23.33
7. PP&L last bill 2,90
S. Uncle Bob's Self Storage Boxes 35.83
9. Tax 4.30
TOTAL (Also enter on Line 10, Recapitulation) I S
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+Itjt-10)
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pennsylvania
DEPARTMENT OF REVENVE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE)
BENEFICIARIES
ESTATE OF: FILE NUMBER:
Marv n Samnann 21 11 0525
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outr~ht spousal distributans and bansters under
Sec. 91'f6 (a) (1.2).]
1. Mary Mills Lineal
90 Salem Church Road, Lot 529
Mechanicsburg, PA 17050
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 TAX IS NOT TAKEN:
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 mwe space is needed, use additional sheets of paper of the same size.