HomeMy WebLinkAbout05-11-12,,~k. Lsas61D1Ds
REV-1500 IX (ca-v) (Fl) _~
PA Department of Revenue pennsylvarda OFFICIAL USE ONLY
Bureau of Individual Taxes `~"'" County Code Year File Number
PO Box ztio6o>. INHERITANCE TAX RETURN i~
Harrisburg, PA t.7tz8-G6o>. RESIDENT DECEDENT /~- I
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
~ 0~~8'Sao~ ~~IaRlaoio ~~~ ~'.~~
Decedent's Last Name Suffix Decedent's rst Narn MI
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p11~I~E (~~~ -- +
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(N Applicable) Enter Surviving Spouse's Information Below
Spo
us
e' Last Name Sufix Spouse's First Names MI
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Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
_ REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Odginal Return O 2. Supplemental Return O :3. Remainder Return (Date of Death
Pdor to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O :i. Federal Estate Tax Return Required
death aker 72-12-62)
O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 6. 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 1'I. Election to Taz under Sec. 9113(A)
Between t2-31-91 and 1-1-95) (Attach Schetlule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTUIL TAX INFORMATN)N SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
i~a~i.l Ho~~ti~ -~ ~ -~~~-ra~-~
REGISTER OF WILLS USE ONLY
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First Line of Address t~`-T~l ~'
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f 1~ nl. ~Po~t ~ I~-~ri.t--. P~ r"~ ,
Second Line of Address ~ <~ '' '~ ---
City or Post Office
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Correspondent's a-mail address: ~~G ~ l~
Under penalties of perjury I dedare that I have examined this return, it
it is true, correct and complete. DecWrekon of preparer other than the
SIGNATa1 E OF PERSON RESPONSIBLE FOR FILING RETURN
State ZIP Code
~PA i~oSD
accompanying schedules and statements, and to the
rl representative is based on all information of which
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DATA-FILED
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test of my knowledge
zeperer has any knov
DATE
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 150561D105
~~
J
1505610205
REV-1500 EX (FI)
Decedent's Name: il)Q~ _ J~ ~~V~
RECAPITULATION
1. Real Estate (Schedule A) ............................................. 1. /~ r
2. Stocks and Bonds (Schedule B) ....................................... 2.
3. Closely Hetd 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. f ~°)
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. pl a~ Q i 55
9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. /l~v ~ ~/V'1
C..II.JJ
10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............ ... 10.
11. Total Deductions (total Lines 9 and 10) .............................. ... 11. ~Q~a
12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. I ~,~
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ..................... ... 13.
14. Nat Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. l ~,~
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Lina 14 taxable
at Me 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.
~3 ~'
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
Side 2
1505610205 1505610205
~3~1
O
J
REV-1500 EX (FI) Pa9e 3
Decedent's Complete Address:
Fil• Numberc
DECEDENPSnnN..A~yME~ 11
STRE~~EjT~~'A~~ODRESS
~~
CITY ', l ST ~P
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credi4s/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.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
Total Credits (A+ H) (2)
(3)
(4)
c,) ~3' ~~
(5)
Make check payable to: REGISTER OF WILLS, AGENT.
i
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 ........................................................................................................................ ...... ^
d. receive the promise for life of either payments, benefts 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 properly
which
,
contains a beneficiary designation? .................................................................................................................. ...... ^ KA
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 far 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 al Beath 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.
RE0.1500 E%~ (t9])
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHRESIDENT Df~ DENTRN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
AEI a ~~ N~sotil .~. ~ oaa~a~
InrAUde the proceeds of Ihigation and the dale the proceeds were received by the estate. All property jointlyowned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
TOTAL (Also enter on line 5, Recapitulation) $ ~~~i
(If more space is needed, insert additional sheets o(the same size)
REV-1511 EX+(10-06)
SCHEDULE N
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
Debts of decedent must.be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES: ( ~~ ~~~
c~~
Cow ~'~ ~ ~~~
-~crr -q~~ .cx~
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City __ State Zip
Year(s) Commission Paid:
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City Slate Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
/~'] -d~
TOTAL (Also enter on line 9, Recapitulation) ~ $
(If more space is needed, insert additional sheets of the same size)
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FUNERAL HOME 6t' CREMATOF,Y, INC.
Karen Hoffman
113 North Sporting Hill Road
Mechanicsburg, PA 17050
219 PIMh Firnover Street
CarGSle, Perruylvania 17013
777.243.4571
toll free 1.%6.451.4571
fax 717.243.3723
~w.w;~rarott~.ox:
~rom~
~rii 22, 2011
Statement of Funeral Expenses for: Norman A. Anderson, Jr. ~~+-~~ ~) ~~o~~
Date of Death: December 29, 2010 Acx:ount Id: 16126-006
PACKAGE:
immediate Cremation
OPTION 5 -Cremation $ 1,890.00
Sub Total: E 1,890.00
TOTAL FUNERAL HOME CHARGES: S 1,890.00
CASH ADVANCES:
10 Certified Death Certficates at $ 6.00 each S 60.00
Coroner's Fee $ 25.00.
Sub Total: S 85.00
Total Funeral Expense: $ 1,975.00
Total Payments Made: $ 200.00
Payments Made:
Karen Holtman Check 3313 Jan 14, 2011 200.00
Please return this portion wkh your Remktance.
Amount Enclosed
Norman A. Anderson, Jr.
Service ID#: 18128A08
Accrued Late Fees: $ 38A5
Balance: S 1_E13AG
$ E R V 1 N G OUR COMMUNITY S I N C E 1 9 0 7
METRO
BAN K
03769 6913345 001 092140
NORMAN A ANDERSON JR
50 BONNYBROOK RD LOT 21
CARLISLE PA 17013
Metro Bards
380, Paxton Street
Herrisburg.PA 17111-1418
1.888-937-0004
mymatro6ankcan
1
WeYe here 7 days s weak, 21 hours a day at 1-BB&997-0OOl
50 PLUS CHECIaNG 05372737
Interest Summary
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Sprkgtlme 4 Homo EquRy Time! Annual Pwprdaga Rate as low as 3.89%. Apply today for the oaelr you need at you rravast Metro
Bank aloe, oNYla d ng9rretrohsrrkaorrr or d Losn-0Y~Plans at 800.290.1019. Ask a nprprdetlve for dslaBs on rates snd tamrs.
Equal DPPOrhurkY Urrdw- _ ~ -
The Wtro Bank Visae DWk Card will soon partldpste M VarlMd by VMsia~hw arM easy wrvlea Mat piovkMs an extra IwN of
proteetlorr for oNkre puretrasas- VerBiad by Vba wM wx8y your WenOly_wRh s pswarord prior to Nlaslcad. You'0 M asked to
esthete Nda wrvke for your dealt prd Mts sprbig rrhlN shopping on8ee fta par8dpatlng nwrNrrd. Juat kpk fa the VaMkd bll
VW symbol. -
FEES b CHARGES: Csrtelnfaaa wW be rsvbed as follows affsUivs Juno 1, 2011: ACH RwoeatloNStop Paymarrt - f30.00; Bond
Coupon Emalope -;10.00; Casldar'a CMek -f10.00; Dormam 9aWngs Aeedrm - f1200; Dormant Cheekkrg AttouM -f1200; 8a6
Deposk last lcay - f29Jq;_ Stop Paymard ONer-f30J10;-brcoming Domeue ywn - N9.o9: outgoing DomesOo wke -tz9.oo;
Inwming In6errre0orrsl VAra -f18a0; OulgaLg kderrwtlanM 1Nhe - ti4D.00. ,
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NOTE :SEE REVERSE SIDE FOR IMPORTANT INFORMATION ~ Merirher'~UIC
Oats Debit Credk Balwwe
Fees Summary
For your mnreraerxx, a summary of owNaR and rasaned kem toes appears an your rrpnOry shYnwnL PI®ae nde Thal the orerdra8 fee
summay krdudas nan~euflkJeM TuMS Teea, u1Natled 1uMS hee and ureveBadn (ands teva. TM aunwrwy doaa nol rsMU refunded a waNed
aerrrs CredMed Oo Your emwrit.
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