The URL can be used to link to this page

Home My WebLink About05-14-12 REV-1500 Ext°'-'°' ~ PA Department of Revenue Pennsylvania Bureau of Individual Taxes -~~~~~~ - ~°' PO BOX 28D6ot INHERITANCE TAX RETURN Harrisburg, PA 17128-o6ot RESIDENT DECEDENT 1505610101 01=FICIAL USE ONLY Code Year File Number ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Dale of Birth MMDDYYYY '!lye t2 ,.. / l /y ~ / d3 t a`/ 9aG Decedent's Last Name Suffix Decedent's First Name MI (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Su~x Spouse's First Name MI .~r, T7 ~, ...~.r Spouse's Social Security Number i °~' ,„„~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 1 ~ii,..~,., REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW ® 1. Original Return O 2. Supplemental Return 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 Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO Name Daytime Telephone Number Correspondent's a-mail address: Under penalties of perjury, I deGare that I have examined this return, including accompanying schetlules and statements, and to the best of my knowledge and belief, it is tme, correct and complete. Declaration of preparer other than the personal representative is basetl on all information of which preparer has any knowledoe. SIGN U OF PERS N RESPONSIBLE FOR FILING RETURN DATE X014 ~/O~ /a AD SS ~~ r.ta ~~ 3- 03 / - / 1- ~~ 3E OF P%'AbRER OJ,I{E%THAN REPRESENTATIVE ~ DATE A~ S L~r/wl /lU'1`/~.r.S / 7a~p PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 REV-1500 EX Decedent's Name: Decedent's Social Security Number 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. 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) .......................... ... 6. 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........... ... 10. 11. Total Deduetlons (total Lines 9 and 10) .............................. ... 11. 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. 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 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 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 17, 16. 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 1505610105 O Side 2 1505610105 1505610105 J REV-1500 EX PagA 3 File Number rlnrurlon4'c [`mm~la4a Address: ~..~~~~.-.. __- -r-___ - ___- - - - DECEDENT'S NAME STREET ADDRESS -- CITY- STATE - - ZIP Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 2. Credils/Payments A. Prior Payments 8. Discount -- Total Credits (A + B) (2) 3. Interest (3) 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. (4) 5. If Line i + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 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 Q a. retain the use or income of the properly 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, benefts or care? ................................................................ ...... ^ Q 2. If death occurred affer Dec. 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 secudty at his or her death? ........ ...... ^ Q 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a benefciary 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 ai 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 def ned, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-i5o8 EX+ (u-ao) ~ Pennsylvania DERARTMENT OF gEVENUE INHERRANCE TAX RETURN RESIDENT DECEDENr SCHEpU1rE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE'OtF,: FILE NUMBER: W i ~ ~ l ~'>+~ t~ EE ~ Include the proceeds of litigation and the date the Droceeds were received by the es[ate. All property jointly owned with right of survivorship must ba disclosed on Schedule F. u more space a needetl, use additional sheets of paper of the same size. REV-1511 EX+ (30-09) Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERRANCE TAx RETURN ADMINISTRATIVE COSTS RESIDENT OECEDEM ESTATE OF FILE NUMBER WILLIAM KEEN Decedent's debts must be reported on Schedule I. ITEM NUMBER DESC0.1PT10N AMOUNT A. FUNERAL EXPENSES: 1' OLIVERIE FUNERAL HOME 15,897.00 2 C M C MARKER 150.00 3- B, ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 274.00 Name(s) of Personal Representative(s) JOHN KEEN Street Address 100 FURNMAN RD City DILLSBURG State FA ZIP 17019 Year(s) Commission Paid: 2. Attorney Fees: 7~ Family Exemption: (If decedent's address is not the same as claimant's, attach ezplanation.) Claimant Street Address City _ State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 112.00 5. Accountant Fees: B. Tax Return Preparer fees: 125.00 7. TOTAL (Also enter on Line 9, Recapitulation) I $ 16,558.00 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-OB) ~ Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERRANCE TA%0.ETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER WILLIAM KEEN Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. tr more spate Is OeeeeO, Insert d001tl0ndl sheets of the same sRe. Cu R E T CES NEW JERSEY P R E P A I D FUNERAL TRUST FUN D Account Disbursement Statement William J Keen C/O John Keen November 28, 2011 100 Furman Road Dillsburg, PA 17019 - Glmsutner,4ecount # : 8000885413 This statement is to confirm the disbursement of funds from a prepaid funeral account for the benefit of William J Keen Genera! Information FuneralRecipient William J Keen Purchaser William J Keen TaxpayerSSN 145-12-5056 Agreement Type REVOCABLE Disbursement Information Previous Balance $15,897.97 Amount ofl7istrursement $15,897.97 New Balance $0.00 . ~F.vRb F.Ah-.n.. Al. cA..R. !I ~!~y..._.Lc:: C•~ ~lc~x{~ ~~ir~~c~l ~~nl _~~)_>. ~ ~fti/~wrirn~ ~f2i/.`~~rnr/ro;/in .`~l~/~iS %. ~ ~/ November 22, 201 I ,~Q ~,~--~~ Mrs. Diane Mullen 634 Ollie Burke Road Jackson, NJ 08527- ~ The Funeral Service for William J Keen .'1%w'. ///N. We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZEb STATEMENT OF THE SERVICES. FACILITIES. AUTOMOTIV E EQUIPMENT. AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THF. FUNERAL ARRANGEMENTS. I. PROFESSIONAL SERVICES Basic Services of Funeral Director and Staff . 1675.00 Embalming. . - . 1050.00 Dressing, Casketing & Cosmetology 525.00 II. OTHER STAFF AND RELATED FACILITIES Visitation (viewing) 700.00 Funeral Ceremony. 695.00 Graveside Service (Including aceompaniment of remains 300.00 Itl. TRANSPORTATION Transfer of Remains to Funeral Home. 775.00 Hearse 375.00 FUNERAL HOME SERVICE CHARGES SELECTED MERCHANDISE: Marquette with changing comers . Seamless strentea . Memorial Package Comers. . THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED Cash Advances Cemetery or Ceemetory . Clergy and/or Church. Organist and/or Soloist . Certified Copies of Death Certificate and Permit Fee Death Notices . Gratuities Tolls. . TOTAL CASH ADVANCES AND SPECIAL CHARGES . Total l'otal Cost . 5116-TOTAL INITIAL PAYMENT !DISCOUNT /CREDITS l'OTAL AMOUNT DUE 609500 5410.00 2185.00 350.00 100.00 14140.00 1425.00 300.00 200.00 60.00 396.0(1 50.00 15.00 2446.00 16586.00 16586.00 0.00 15~p3 -Trvs~' ._- SA3 ~°u'sd' ___.--- ~.., ~. s.~a i m: saoo rAm.. om. tb 9ox ~o red,.uua„s, rA nsss rwwmameerststora ~ s.sa,ew~ p») ~~-»ef «(sco) zee-zsxe c.s: o,~ see-acre «(eoo) zesas~z Too: mnes~-ss+z«(aao)zaa-zszaea.s3ix rr.a„~e: pin Tsseaos «teoo) zsT-TZea Statement of Accounts Nov 01, 2011 thru Nov 30, 2011 Account Number: 242851 Balances at a Glance: Checking: o.oo Savings: o.oo Certificates: o.oo Loans: o.oo Money Management: o.oo Swipe 5 YTD Reward: 0.10 Page: 1 01 2 WILLIAM J KEEN 100 FURMAN ROAD DILLSBURG PA 17019 Your aggregate balance as of November 1st is 55,762.44. An aggregate balance of 52,500 and having 3 products wwiill place you in the Silver MLR Ievel. CHECKING ACCOUNTS 0011- .CHECKING Dab Transaction DssuiDtbn Additions SuMradions Balance Nov 01 8akmce Forward 3,700.28. Nov 01 Deposit ACH TEND PENSION 181:50 3,881-. 76 TYPE PENStONID:1226063702CO:TENJPENSION Nov 01 Chedc.000653Tracer0001238997 1,853.19• 1,928:57 Nov05 Deposes by Cheox 1.865.44 794.01-. Nov 14 Check 000654 Tracer 0003082552 204.50- 5 Nw25 Depoak.Divkkard 0.22 ,568. Annual Peroe-daga Y/e/d Earoed 0.100X from 11/O1rtO1 f through 11/30/2011 ' Based on Ayarape flatly BaMnee of 2,711.50 Nov25 WOhdrawal Transfer To Share 0000 3,589.73• 0.00. CHECKING Closed. "'Thht kt the llnalstatemenrp-asenOGlgirtfoimationwr this produeY" '"' Please rehln drls. ftna/ sbtenwrrt fwfaz rspa'dng Pa~ea "' CHECK SUMMARY Cheek # AnwuM Date -. Check # Araourrt. Dab 000653 1,953.19 Nov 01 -000854 204.50 Nov 14 2 Checks Cbusd fw 2,157.69 SAVINGS ACCOUNTS 0000- REGULAR SAVINGS Nov 01 Deposit ACH CNTRL PEN 2'[1.00 TYPE: MON PF CKS ID: 1238262789 DATA: MONTHLY PFCHECKS CO: CNTRL PEN Nov 25 Deposit Transfer From Share 0011 3~g, ~ Nov 25 Deposit Dividend 0.31 Annual Feroentage Y/efd Earned 0.250% from 1110 1/2 0 1 1 through 11/~/20f] Nov 25 WlOrdrawal --- Cordinuad on following page --- 8,470.41 5,470.72 5,470.72- 0.00 -- - SARAH TODD HDME rcw~ ~~'~~ 02123/2012 11:20 7172459733 Sarah A Todd Memories Noma 1090 West South Street Carlisle, PA 17013-2748 Telephone: (717) 245-2187 STATEMENT Statement Dale: 12/13(2011 Due Date: 17J26/2911 Amount Enclosed S _ Amamt Due: ; .00 AccbuM ~: 102132 RE: William ]Keen ]ohn Keen 100 Furman Road D6lslwrg, PA 17019 _ y.. ,i g. -*%e .• _ ~..W' .. +•F pfd-•~~ ` TJiy •.y r- nr ~~:kV„~i::. '..lrP.v ~~j'ti y 9,"-07u. rA~K t.r ::Ss ...y .. nR`7r. it 11(26!11 ,]0l1N 1,953.19 .00 12/01/11 ]Ot{N 24.75 -24.75 11/18)11 Ule Tekvldon - I 24.75 24. CwrwR 1-30 eeye 91-80 Orye ei-!0 wys Cher 98 Days MbuM Due .~ l .00 THE iSIH OF TtE MONTH •"'• Pleff! nsret ere IASf AMOUIT -- of yae GheCk. Psymenp ~s 11 dp nOtnekctgl sta0[mYet. NOTE: "~ <ATrt DArMENIS ARE 5Ai7ECT ib A 1.25% UlE t]iARGE DER A SI0.00 FEE WTLL aE CHARGED bor RERIRNlD ptL'IXS ~ W HBam) Keen - Aarourd #: 102132 'Sarelr A Todd 1 Ibme 1000 West Street Te~honep(717 ,452167 Statement Gate: 12/13/2011 Due Date: 128612011 RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 KEEN WILLIAM J Estate File No.: 2011-01259 Paid By Remarks: JOFWIN KEEN ------------------------ Receipt Distribution Receipt Date: 11/232011 Receipt Time: 15: 0:19 Receipt No.: 1067851 Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 30.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 24.00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check $97.50 Total eceived......... $97.50 ~ I~} ~~- ~~ ~~ ~ J ~~~ !~ N C'1 N ~ W ~ 4 t" (~ 6 , i W Z 6. T ~~~ ~ pO r O~ oO ~" Q N~ r r r ~ 0 tt1 `S1 M r r- m .~ ~ > L d N N gg ~ 6- $ +' ~'r ~ ~ N x ~% ~ ~ 7. r 7 N W ~ ~oc N ~ ~ ~ O . p A J +' Y al N'„ ~ O r ~ .=p ~ p 3 e p p S A nn Y _ L yO V{) Y W C~ d N i-' = d ~ N ~ d l ~ ~._ 4 - - _ Y- t- U O p_ r _.. _. ._..._.. _... - . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO ROX BAGS HARRISBURG PA 1T105~BIBS February 10, 2012 STATEMENT OF CLAIM SUMMARY NAME EsNate of KEEN, WILLIAM ID ' 280254710 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 3.50 3.50 LONG TERM CARE 20,402.23 55,960-56 76,362.79 DRUG 7.58 18.06 25.64 REIMBURSEMENT TO DPW 20,409.81 55,982.12 F ~ ' 76,391.93 ...~ ~,. COMMONWEALTH OF PENNSYLVANW DEPARTMENT OF PUBLIC WELFARE EIN- 23hi003173 Page 1 of 1 Front: John F Keen, Executor 100 Furman Rd DlYeburg, PA 17019 suana~u 3.5'~ ~ I r: 23 138 2 24 i1: 2 1844 i0690s' ~06 ~~ ~ ~~~~M ,~~~• Back https://mlonline.memberslst.org/OnlineBanking/AccountSummary/AccountDetail.px 5/10/2012 ~. a N °~ g 3 ,~ - 'J ~ ( - ~~ b ~ ~ ~ t~ ~. c'~ o °e --v `~ J -~ ~ ~ ~ ~ ~ ~