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Home My WebLink About06-13-12 (2)1505611188 REV-1500 EX(02-1¶(FQ Pennsylvania OFFICIAL USE ONLY PA Department of Revenue JO{'""''"°`""'- County Code Year File Number Rar.aa of maivitlaal taxes INHERITANCE TAX RETURN po eoxze6eot 2]y 12 0352 Harrisburg, PA 1]128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYVY Date of Birth MMDDYVYY Decedern's Last Name Suffix Decedem's Rrst Name MI Sellens E• Blanchle (If Applicable) Enter Surviving Spouse's Informadon BNow Spouse's Last Name Suffix Spouse's Brat Name MI Sellens Morley E Spouse's Social Secudty Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Retum D 2. Supplemental Retum p 3. Remainder Retum (Date of Death Prior to f 2-13-t32) D 4. Limited Es[ate O 4a. Future Irnerest Compromise (date of D 5. Federal Es[ate Tax Return Required death after 12-12-a2) ~ 6. Decedem Died Testate D 7. Decedem Mairnained a Living Tmst ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Utigation Proceeds Received O iD. Spousal Poverty Credit (Date of heath O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - This sectlon must l>e wmpleted. All Correspondence and Confitlendal Tax Informatlon Should lx Directed to: Name Daytime Telephone Number Robert R• Church, Esq• 717 255 8059 Rrst Line of Address Keefer Wood Allen & Rahal, LLP State ZIP Code Second Line of Address P•0• Box 11963 City or Post Office Harrisburg REGISTER OF WILLS USE ONLV N c: t rv ~~~' x ~ ~r-1 r., ~ ~'-' w o~118q ~ :l ~: -~ r..,~ r7 ';; r~ PA 17108-1963 ':' [~ ' ~r72 w Correspondents e-mau address: rchurch@keeferwood.com Under penalties of perjury, I tlaclara that I have examined this return, including accompanying schedules antl statements, and to the bast of m y knowledge and belief, it is true, correct and complete. Declaration of the pnparer other thangraonal representative is based on all information c,f which preparar hae any knowledge. Side 1 15056171188 L505611188 J Harrisburg, PA 17108-1963 PLEASE USE ORIGINAL FORM ONLY 1505611288 Rev-1500 EX (Fl) Decedent's Name: E Blanche Sel lens Decedern's Social Security Number RECAPITULATION ~ • ~ ~ 1. Real Estate (Schedule A) ...................................... ... 1. 2. Stocks and Bonds (Schedule B) ................................. ... 2. 4 5 , 4 9 0 • 8 7 3. gosely Held Corporarion, 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. 2 0 , 4 9 3 •3 0 6. Jointly Owned Property (Schedule ~ O Separate Billing Requested ... ... 6. ~ ' 0 ~ 7. Inter-Vivos Trarrsfers & Miscellaneous Non-Probate Property O • 0 a (Schedule G) l~ Separate Billing Requested ... ... 7. 8. Total Grose Assets (total Lines 1 through 7) ......................... ... B. 6 $ , 9 8 4 •17 ~ • ~ ~ 9. P ( ............... Funeral Ex eases and Administrative Costs Schedule H) ... 9. ~ • ~ ~ t0. Debts of Decedent, Mortgage Uabilities, and Liens (Schedule I) .......... ... 10. 11. Total Deductlons (total Lines 9 and 10) ........................... ... 11. 0 ' ~ 0 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. 1a. Net Value Sub(eet to~ Tax (Une 12 minus Line 13) ............. ......... . 14. TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount o} Line 14 taxable at the spousal tax rate, or [rarisfers under Sec. 9116 65,984.17 (aK1.2>x.oo 1s. 16. Amount of Line 14 taxable ~ • 0 0 at lineal rate X .045 16. 17. Amount of Line 14 taxable a • O ~ ar sibling rate X .12 17. 18. Amount of Line 1a taxable O • 0 ~ at collateral rate X .15 18. 19. TAX DUE .................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Slde 2 65,984.17 o•oo 65,984.17 o•oo 0•~~ o•oo o.ao o.ao O 1505611288 1505611288 J Rev-1500 EX (Fl) Page 3 Decedent's Complete Address: Flle Number 21 12 0352 DECEDENTS NAME E. Blanche Seliens STREET ADDRESS 8 Moore Circle CITY Carlisle STATE PA ZIP 17015 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Qedits/Paymerns A. Prior Paymems B. Discount Total Credits (A+ B) (2) 3. Imerest 4. If Line 2 is greater than Line 1.+ Line 3, emer the difference. This is the OVERPAYMENT. Fill In oval on Page 2, lJne ZO to request a refund. 5. If Line 1 + Line 3 is greater th8n Line 2, emer the difference. This is the TAX DUE. (1) 0.00 (3) 0.00 (4) (s) 0.00 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedem make a [raruier 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 paymems, benefits or care? ~ ~ ~ ~ ~ ~ ~ ~ • ~ ~ ~ • ~ • • • • • • • • • ~ • ~ ~ ^ 2. If death occurred aher Dec. 12, 1982, did decedem transfer property within one year of death without receiving adequate consideration? ...................................... . ^ 3. Did decedem own an "intrust for' orpayable-upon-death bank accoum or security at his or f~er death? ~ . ^ 4. Did decedem own an individual retiremem account, annuity or other non-probate property, which comains 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 i5 3 peroem [72 P.S. Sect. 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 oT the surviving spouse is 0 peroem [72 P.S. Sect 9116(a)(1.1)(ii)]. The statue does not exempt a transfer to a surviving spouse from tax, and the statutory requiremerns for disclosure of assets and filing a tax return are s[ill'~ 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 stepparen4 of the child is 0 peroem [72 P.S. Sect. 9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedem's lineal beneficiades is 4.5 peroem, except as rated in [72 P.S. Sect 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 peroem [72 P.S. Sect. 9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parern in common with the decedem, whether by blood or adoption. REV-1503 EX+18-98) SCHEDULE B COMMONW EALTH OF PENNSYLVANIA STOCKS & BONDS INR E RITANC E TAX R ETU RN RESIDENTOECEOENT ESTATE OF FILE NUMBER E. Blanche Sellens 21 12 0352 (Ii more space is needed, insen additional sheets of the same size) REV-1508 EX~Itt-10) Pennsylvania SCHEDULE E ~l 0(VAPIMk NY O4 NfV£NUf CASH, BANK DEPOSITS, & MISC. INH ERITANCE TAX RETURN PERSONAL PROPERTY RESIDENTDECEDENT ESTATE OF: FILE NUMBER: E. Blanche Sellens 21 12 0352 Include the proceeds of litigation and the dale the proceeds were received by the estate. All properly Iolntly owned with right of survivorship must tie tllsclosed on Schedule F. 1 Great-West Life, Policy #1204331, life insurance policy on the life of the 20,493.30 Decedent's husband, Morley E. Sellens, valued according to its date of death cash value (Canadian $20,436.17 = $20,493.30). This policy wars owned by the Decedent. TOTAL (Also erner on line 5, Recapitulazion) 20,493.30 If more space is needed, insert additional sheets of the same size REV-1513 E%+10/-10) t `„~' Pennsylvania SCHEDULE J p(PA9IMFNT Ot NEVENUE INH ERITANCE TA%RETURN BENEFICIARIES RESIDENT DECED ENT ESTATE OF: FILE NUMBER: E. Blanche Sellens 21 12 0352 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NuMBE NAME AND DRESS OF PERSONS RECEIVING PROPERTY Do Not Llst Trustees OF ESTATE t TAXABLE DISTRIBUTIONS [Include outright spousal distributions, and trar:sfers under Sec. 9116(a)(1.2).] Morley E. Sellens Surviving spouse 65,984.17 8 Moore Circle Carlisle, PA 17015 ENTER DOLLAR AMOU TS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES15TH ROUG H 190E REV-15001:OVER SH EET, AS APPROPRIATE. TT NON-TAXABLE DISTRIBUTIONS: A SPOUSAL DISTAIIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 GJVER SHEET. If more space is needed, use additional sheets of paper of the same size. Estate Valuation Date of Death: 09/i2/201i Valuation Date: 09/12/2011 Processing Da t.e: 05/15/2012 Shares Security or Par Description 1) 481.1557 CHEVRON CORP NEW (166769100) COM New York Stock Exchange 09/12/2011 Total Value: Total Accrual: Total: 595,490.87 Estate of: Elizabeth Blanche Sellens Estate Account: 62810 Report Type: Date of Death Number of Securities: File ID: Sellens EState Mean and/or Div and Int Security High/Ask Low/eid Adjustments Accruals Value 95.93000 93.16000 H/L 99.595000 45,49G.Bi 595,490_67 SC. OG Page 1 This report was protluced with EstateVal, a product of Estate Valuations 6 Pricing Systems, Inc. If you have questions, please codtact EVP Systems at (818) 313-6300 or www.evpsys.com. (Revision 7.1.1) May I5, 2012 KEEFER WOOD ALLEN & RAHAL, LLP 210 WALNUT STREET PO BOX 11963 HARRISBURG PA 17108 - 1963 Attention: Robert R Church Dear Sir: Re: Policy 1204331 Life Insured: Morley E Sellens Policyowner: The Estate of Elizabeth Blanche Sellens THE Great-West Life ASSU RAIVCE ~~ COMPANY Administrative Service Centre 255 Dufferin Avenue London, Ontario Canada N6A 4K.1 Toll Free: 1-800-665-0551 Thank you for your letter dated April 3Q 2012 regarding the above mentioned policy submitted with a Short Certificate of the Letters Testamentary. The current beneficiary designation is The Estate of Elizabeth Blanche Sellens. The cash surrender value of policy 1204331 effiective September 12, 2011 is $20,436.17 (CN). In order to transfer the ownership from the Estate and to adjust the beneficiary eve require the following: 1) A copy of the Death Certificate; 2) A copy of the Last Wil] and Testament; 3) The enclosed K315 Transfer of ownership form completed, dated and signed by Mr Sellens as the Executor of the Estate 4) The enclosed'K863 Designation of beneficiary form dated one day afrer the Ownership form and signed by the new Owner Should you have any further questions or concerns, please do not hesitate to contact your Great-West Life financial advisor or contact us by calling the toll free number indicated above. Sincerely, Panayese Fragiskatos Panayese Fragiskatos Great-West Life Client Service, Individual Insurance c.c. WPGAD HEAD OFFICE AND CANADIAN REGION HEADQUARTERS: GREAT-WEST LIFE CENTRE, WINNIPEG. MANITOBA Page 1 of 1 ~ OANDP: Currency Converter CAD/USD for the 24-hour perintl entlinp Suntlay, Sap tt, 2011 22'.00 UTC @~ +r- 0°io Currency I Have: Currency I Want: 20,436.1 T CAD 20,493.3 usD CAD/USD Details CND(USCI for tho 2M1-hour petlod ending Suntlay, Sep 11, 2011 22:00 U7C L +i- 0"/° Selling 20,436.2 C~1D ~ you get 20,493.3 USD Buying 20,436.2 C14D ~ you pay 20,513.9 USD Rate Details CAD/USD for the 24-hour period entling Suntlay, Sep 11, 2011 22:OG UTC Bid Ask Sell t GAD Huy 1 QAD MIN 1.00105 1.00286 Avc 1.00280 1.00380 MAx ~ 1.003G7 1.00468 Recent Trends CADIUSD average tlally bitl prices Les: 90 days Take trusted OANDA Ratesr. with you on your travels CADIUSD Interbank Rate +F 0°/ Sep 12, 2011 OANDP; CAD USD CAa USD CAD USD 1 ~ 1.00 15' r 15.04 45 45.13 2 r 2.01 20' r 20.06 50 r 50.14 3 r 3.01 25 r 25.07 100 r 100.28 4 ~ 4.01 30 r 30.08 250 r 250.70 5 ~ 5.01 35 r 35.10 500 r 501.40 10 r 10.03 40 ~ 40.11 1,000 ~ 1,002:80 !~ ~innm ~