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Home My WebLink About05-09-12 1505611185 1500 EX REV (02-11)(FI) - OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes Po sox 2eosot INHERITANCE TAX RETURN 21 11 1224 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW SOCIaI $eCUflty NUmbef Date of Death MMDDYYYY Date Of Blrth MMDDYYYY 168-26-4147 11112011 03291931 Decedent's Last Name Suffix Decedent's First Name M I BLACK SAMUEL H (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name M I Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE - - REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (Date of Death Prior to 12-13-82) ^ 4. Limited Estate ^ 4a. Future Interest Compromise (date of ^ 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) ^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit (Date of Death ^ 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTIOPI MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number RICHARD C• SNELBAKER 717-697-8528 First Line of Address SNELBAKER & BRENNEMAN, P.C. Second Line of Address 44 WEST MAIN STREET City or Post Office State ZIP Code MECHANICSBURG PA 17055 Correspondent's e-mail address: REGISTER~WILLS USEOrN~Y ~.~ .,~ <_ rte- ='=: ~ 1 -' ~. '- - t~ - ~; ~'_~~'. - c:~~ , - = - ,w.. ~ ! { G~ r ~7 D~E FILED ~ "~ 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. Declaration of preparer other than the personal repn:sentative is based on all information of which preparer has any knowledge. CONSTANCE E• ROLAND, EXECUTRIX 1519 FISHER ROAD, MECHANICSBURG OFpJ~ARER OTHER THAN REPRESENTATIVE YA 1/U57 ADDRESS - RICHARD C• SNELBAKER, ESQUIRE 44 WEST MAIN STREET, MECHANICSBURG PLEASE USE ORIGINAL FORM ONLY pA 17055 1505611185 Side 1 OM4647 3.000 1505611185 1505611285 REV-1500 EX (FI) Decedent's Social Security Number 168-26-414? ~ecedenl's Name: BLACK SAM UEL H RECAPITULATION 1. Real Estate (Schedule A) 1 0 • 0 0 2. Stocks and Bonds (Schedule B) . 2. 2 , 8 6 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) , _ 3. 0 , 0 0 4. Mortgages and Notes Receivable (Schedule D) 4 0 • 0 0 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) 5, 8 3 , 4 2 5.9 0 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested g. Q . Q Q 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested 7. Q . Q Q 8. Total Gross Assets (total Lines 1 through 7) 8 83, 428 •76 9. Funeral Expenses and Administrative Costs (Schedule H). g. ], 2 , 4 4 0.18 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) 10. 9 ,12 4 •5 8 11. Total Deductions (total Lines 9 and 10) , 11 21, 5 6 4 •7 6 12. Net Value of Estate (Line 8 minus Line 11) _ 12 61, 8 6 4 •0 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 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 61, 8 6 4 •0 0 -- - TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES - 15. Amount of Line 14 taxable at the spousal tax rate, or transfers un~er Sec. 9116 16. Amount of Line 14 t xable 4~ at linealratex.o 61,864.00 1s. 2,783.88 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0• O Q 18. Amount of Line 14 taxable at collateral rate X .15 0. 0 0 18. 0. 0 0 19. TAX DUE 19. 2 , 7 8 3.8 8 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT XD Side 2 1505611285 1505611285 J OM4648 3.000 REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number a 1. 1.1. 1. ~ ~ U DECEDENTS NAME BLACK SAMUEL H STREET ADDRESS MECHANICSBURG BOROUGH CUM ERLAND COUNTY CITY STATE ZIP MECHANICSBURG PA 17055- Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 2 , $ 0 0.0 0 B. Discount 14 0 • 0 0 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refund. (4) (1> 2,783.88 2,940.00 (3> 0.00 ],56.12 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0 • 0 0 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 ^ ^X c. retain a reversionary interest ^ 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 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 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(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. Total Credits (A + B) (2) OM4671 2.000 REV-1503 EX+ (698) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS 8 BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ATE OF FILE NUMBER Samuel H. Black 21 11 1224 All property jointly-owned with right of survivorship must be disclosed on Schedule F. 3wnsss i.ooo (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (t1-10) Pennsylvania SCHEDULE E DEPARTMENiOF REVENUE CASH, BANK DEPOSITS, $c MISC. RESIDENiDECEDENTTURN PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Samuel H. Black 21 111224 Include the proceeds of litigation and the dale the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~. 2010 Dodge Grand Caravan 15,200.00 sale value 2 Boats and trailers 250.00 a. 1986 Smoker Craft Bass boat $50.00 b. 1972 C-Spirit John boat $25.00 c. 2002 Carry on trailer $150.00 d. 1987 Load EAZ Trailer $25.00 3 Cumberland Valley Motors 33.86 wages due the decedent 4 Erie Insurance 348.00 premium refund due decedent on auto insurance 5 Internal Revenue Service 74.00 refund due the decedent on 2011 Final Individual Taxes 6 Lincoln Financial Group 63,634.13 annuity #924426780 7 Members 1st Federal Credit Union 363.70 savings account #199599-05 8 Members 1st Federal Credit Union 3,017.21 checking account #199599-11 9 Members 1st Federal Credit Union 5.00 savings account #199599-00 10 Proceeds from sale of chair lift 500.00 11 PSERS 0.00 net amount of pension payment due the decedent in the amount of $222.12 This asset is non-taxable and listed for informational purposes only TOTAL (Also enter on line 5 Recapitulation) $ 83 , 425.90 ow4sAD 2.000 If more space is needed, use additional sheets of paper of the same size. REV-7511 EX+„ao9' SCHEDULE H pennsylvania DEPARTMENiOFREVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Samuel H. Black 21 11 1224 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t, Hollinger Etianeral Home funeral services 4,139.44 Total from continuation schedules . 211.72 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2. Attorney Fees: Snelbaker & Brenneman, P. C. 2 , 913.75 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) 3 , 500.00 Claimant Margaret A. Woll Street Address 12 East Portland Street City Mechanicsburg State PA ZIP 17055 Relationship of Claimant to Decedent DAUGHTER 4. Probate Fees: 198.50 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. 1 Cumberland Law Journal advertise Executrix Notice 75.00 Total from continuation schedules 1,401.77 TOTAL (Also enter on Line 9, Recapitulation) $ 12, 440.18 swaeAC 2 ooo If more space is needed, use additional sheets of paper of the same size. Estate of: Samuel H. Black Schedule H Part 1 (Page 2) Item No. Description 2 Margaret A. Woll reimburse for food for funeral luncheon Total (Carry forward to main schedule) 21 11 1224 Amount 211.72 211.72 Estate of: Samuel H. Black 21 11 1224 Schedule H Part 7 (Page 2) 2 Members 1st Federal Credit Union check printing fee 6.87 3 PA Fish & Boat Commission boat transfer fees 56.50 4 Penn Dot duplicate title and transfer fees 90.00 5 Register of Wills filing fee for Inheritance Tax Return 15.00 6 Register of Wills short certificates 12.00 7 The Sentinel advertising Executrix Notice 221.40 8 Reserve for filing fees, accountant fees and other miscellaneous costs associated with the administration of the Decedent's estate 1,000.00 Total (Carry forward to main schedule) 1,401.77 REV-~512EX+„~_o8' SCHEDULE Pennsylvania DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES $c LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Samuel H. Black 21 11 1224 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 DESCRIPTION OF DEATH 1• Heritage Medical Group medical expenses 29.78 2 Hospital telephone and TV services 40.00 3 Joseph P. Cardinale medical expenses 10.00 4 Members 1st Federal Credit Union payoff auto loan #199599-01 8,759.85 5 Members 1st Federal Credit Union auto loan payment deducted from decedent's checking account on 11/12/2011 240.00 6 PA Department of Revenue tax due on 2011 Final Individual Tax Return 10.00 7 Ritter's Hardware payoff revolving credit account 34.95 TOTAL (Also enter on Line 10 Recapitulation) ~ $ 9 , 124 ewasAH z o0o If more space is needed, insert additional sheets of the same size. REV-1513 EX+(01-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTA SCHEDULE J BENEFICIARIES FILE NUMBER: Samuel H . Black 21 11 1224 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [InGude outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. Susan C. Eagen 109 Winslow Lane Fairfield Glade, TN 38558 20~ of Residue: 12,372.80 Daughter 12,372.80 2 Margaret A. Woll P.O. Box 598 12 East Portland Street Mechanicsburg, PA 17055 20~ of Residue: 12,372.80 Daughter 12,372.80 3 Constance E. Roland 1519 Fisher Road Mechanicsburg, PA 17055 20~ of Residue: 12,372.80 Daughter 12,372.80 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 1 8 OF REV-1500 COVER SHEET, AS APP ROPRIATE. [[ NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: L TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 0.00 9W46AI 2.000 n civic aNai.c is nccucu, use auunwnai sneers or paper of the same size. Estate of: Samuel H. Black Schedule J Part 1 (Page 2) Item No. Description 4 Jessica A. Black 5722 N. Berkeley San Bernardino, CA 92407 20~ of Residue: 12,372.80 5 Aaron J. Black c/o Kierna S. Black and Constance E. Roland, Trustees 1776 Springwillow Drive Mechanicsburg, PA 17055 10~ of Residue: 6,186.40 6 Jordan D. Black c/o Kierna S. Black and Constance E. Roland, Trustees 1776 Springwillow Drive Mechanicsburg, PA 17055 10~ of Residue: 6,186.40 21 11 1224 Relation Amount Daughter 12,372.80 Grandson 6,186.40 Grandson 6,186.40 LAST WILL AND TESTAMENT I, SAMUEL H. BLACK, of the Borough of Mechanicsburg, County of Cumberland, and Conuvonwealth of Pemisylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void all former wills and codicils by me at anytime heretofore made. FIRST. I order and direct Ihat all my just debts and funeral expenses be paid by my Executrix, hereinafter Warned, as soon as conveniently may be done after my decease. SECOND. I give, devise and bequeath all the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situated, unto my wife, namely, JOANNE M. BLACK, absolutely and in tee simple, if she survives me by as many as sixty (60) days. THIRD. In the event that my wife, JOANNE M. BLACK, does not survive me by as many as sixty (60) days, then and in that event, I order and direct that my Estate be distributed and disposed of as follows: A. I order and direct that all the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situated, shall be divided into ten (10) equal parts, which parts I give, devise and bequeath iu the amounts and to the persons as follows: LAW OFFII:ES SNELBAK ER fjt BRENNEMAN, P.C. (1) "fwo (2) parts unto my daughter, namely, SUSAN C. EAGEN, absolutely and in fee simple. (2) Two (2) parts unto my daughter, namely, MARGARET A. WOLL, absolutely and in fee simple. (3) Two (2) parts unto my daughter, namely, CONSTANCE E. ROLAND, absolutely and in fee simple. (~) "fwo (2) parts unto my daughter, namely, JESSICA A. BLACK, absolutely and in fee simple. (5) One (1) part unto my grandson, namely, AARON .i. L31,ACK, absolute)}~ and in fee simple, subject, however, to the protective trust provisions contained in Yaragraph C of this Item Third. (6) One (1) part unto my grandson, namely, JORDAN D. BLACK, absolutely and in fee simple, subject, however, to the protective trust provisions contained in Yaragraph C of this Item Third. if any of my said daughters should predecease me, I order and direct that the liiregoing share of my residuary Estate attributai~le to such deceased daughter shall be distributed unto her issue per slirpes by representation and not per capita. B. In the event that either of my grandsons, namely AARON J. BLACK or JORDAN D. BLACK, have not attained the age of twenty-five (25) years at the time of my death, I order and direct that the subject matter of the foregoing diapositive provisions shall be paid over and distributed unto CONS"fANCE E. ROLAND (my daughter) and ICIERNA S. BLACK (mother of my grandsons, Aaron and Jordan Black), or either of them in die event chat one so nominated shall fail to qualify or cease so to serve, as my testamentary Trustees, IN SEPARA`fE TRUSTS, NEVERTHELESS, to hold, manage, rctuin, sell, lease, mortgage, invest. and reinvest, for the respective benefits of said AARON .T. BLACK and JORDAN D. BLACK, until the respective beneficiary has attained the age of twenty-five (25) years, at which latter time the trust for such beneficiary shall be terminated and the then remaining assets in such trust shall be distributed unto the said beneficiary, absolutely and in fee simple. During the existence of the foregoing Trusts, I authorize and direct as follo~.vs: (1) I authorize and empower my said Trustees to invest any cash type assets added to or generated by said Trust in ar~y reasonable manner and not be limited or restricted to so-called "legal" or statutory investments for fiduciaries. haw OrFir_[s SNELBAK ER Lk DR ENNEMA N. P.C. (2) I designate said Trust to be aspend-thrift trust. 'The beneficiaries of said Trust shall have no rigltt to invade, pledge, assign, hypothecate or otherwise dispose of the assets of said Trust (including -~- future income) nor shall any creditor of a beneficiary have any right to seize, levy or execute upon, or attach said assets by reason of auy judgment, pledge, assignment or other transfer, whether voluntarily or involuntarily made by said beneficiary. I order and direct the Trustees to reject and refuse to recognize any transfer made by said beneficiaries or any of them. LASTLY. I nominate, constitute and appoint my wife, namely, JOANNE M. BLACK, to be the Executrix of this, my Last Will and Testament, but if for any reasou she should fail to qualify as such Executrix or cease so to serve, then and in that event, I nominate, constitute and appoint my daughter, namely, CONSTANCE E. ROLAND, to be the Executrix hereof. If both of the foregoing persons should fail to qualify as my personal representative hereunder or cease so to serve, then and in that ultimate event, I nominate, constitute and appoint my daughter, namely, MARGARET A. WOLL, to be the Executrix of this my last Will and "Testament. I order and direct that none of the above named persons shall be required to post bond or other security as a condition of qualification hereunder. IN WITNESS ~~%HEREOF, I, SAMUEL H. BLACK, have hereunto set my hand and seal to this my Last Will and Testament, which consists of three (_i) typewritten pages to each of which I have affixed my signature this 31 stday of May , A.D., Two Thousand Seven (?007). - ~~~~~-___(SEAL) SAMUEL II. BLACK The preceding instrument, consisting of this and two (2) other typewritten pages, each identified by the signature of the Testator, was on the date thereof signed, sealed, published and declared by SAMUEL H. BLACK, the Testator therein named, as and for his Last Will and Testament, in the presence of us, who, at his request, in his presence and in the presence of each other, have subscribed our names as witnesses hereto. LAU! OFFICES SNEL BAKER & BR ENNEMAN, P.C. i i - ~~ ~ _.. ~ x 1- COMIv10NWEALTIf OF PENNSYLVANIA) SS. COUNTY OF CUMBERLAND ) We, SAMUEL I-I. BLACK, KICIiARD C. SNELBAKER and JANE J. GOONEY, the Testator and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that [he ~'estator signed and executed the instrument as his Last Will and Testament and that he had signed willingly, and that he executed it as lus free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as a witness and that to the best of his or her knowledge, the Testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. Testator \ ~`Y ~'~ Hess :~ , ~ L.~ _ .W,I lncsS L,% Subscribed, sworn to and acknowledged before me by SAMUEL H. BLACK, the ' 7 cstator, and subscribed and sworn to before me by RICIIARD C. SNELBAKER and JANE J. GOONEY, the witnesses, this ;,~~.,}- day of ~1co~- , 2007. Notary Public COMMONWEALTH OF PENNSYLVANIA Notarial Seal Sande IC Shrnwrs, Notary Public Mechanicsburg l3orv, Cumberland County LAW OFFII:ES My Commissbn E.~ires Nov. 22, 21x17 SNELaAKER & Member. Pennsylvania Association Of Notarlea BRENNEMAN. P.G. j ~ q i~~ I ,, ~,3 r ra