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Home My WebLink About06-11-12 (2)J 1505610105 REV-1500 ~I°'- ""F° ' PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes "'°'"°" '°"°^°' Counh Code Year Flle Number f INHERITANCE TAX RETURN Po Boxz8o6ot ~ Harrisburg, PA tytz8-o6D1 RESIDENT DECEDENT ~ ~~ ~ ~ ~ ~ '.. ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth AIlvIDDYYYY Decedent's Last Name Suffx Decedent's First Name _ MI _ Wirth Carolyn M '. __..__ (If Applicable) Enter Surviving Spouse's Information Below Spouses Last Name Suffx Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLIICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW m 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) m 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 Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name _. Daytime Telephone Number Adam R. Deluca (7171 X49-1177 First Line of Address 61 West Lowther Street Second Llne of Address City or Post Office Carlisle Correspondent's e-mail address: Under penalties of perjury, I it is true. correct and compl SIGNATURE OF PERSON REGISTER OF WILLS USE ONLY n7 ter N ~ t` , ; ~ 37' - t. x t ~ ~r ~ A r C'C-i!-..i 'Q ~,-~^ ci ' r' ; +" i t 33 `: (-+ ~~ t'i T •- F-j ~`v-n °~ care that I have examined this return, including accompanying schedules and statements, aid to the best of my knowledge and belief, Deciaraticn of preparer other than the personal representative is based on all information of which preparer has any knowledge. iPONSIBLE FOR FILING RETURN DATE ADDRESS -' ~ 152 Creekside Drive, Eno a, PA 17025 SICyyAT~1RE OF PR~Pry~RErjr$TktER TF/AN REPRESENTATIVE r..4~ 61 West Louther Street, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 15056101[]5 15175610105 J J REV-1500 EX (FI) Decedent's Name: CBfOYD Mae Wlrth RECAPITULATION 1505610205 1. Real Estate (Schedule A) ............................................. i. Decedent's Social Security Number 193-36-4871 0.00 2. Stocks and Bonds (Schedule B) .................................... ... 2. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 0.00'. 4. Mortgages and Notes Receivable (Schedule D) ........................ ... 4. 0.00 '. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. ' 66,875.97 ~ 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. ' 0.00 ~'. 7. Inter-Vivos Transfers & Miscellaneous Nan-Probate Property `"~~"~~"" " """ ""~ ~~` ~ -' (Schedule G) O Separate Billing Requested...... .. 7. 130,895.70 '. 8. Total Gross Assets (total Lines 1 through 7) ..... ........ e _._ 197,771.67. 9. Funeral Expenses and Administrative Costs (Schedule H) _ ............... .. 9. I ...._.-- 8,407.14 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule Ij.. ......... ~ ..-. 10 _. __,.. ..._ e .v ._. ...,.w 23 665.91 11. Total Deductions (total Lines 9 and 10) ......... ......... ......... . 11 a.:_..- ... _, __._ 32,073.06 12. Net Value of Estate (Line a minus Line 11) .............................. 12. 165,698.62 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 - 165,698.62 ' TAX CALCULATION - $EE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rete, or transfers under Sec. 9176 ~ 0 00 '. (a)(1.2) X .0_ 15 16. Amount of Line 14 taxable ~ "" """" "'~~ °-~°" ~--°~ ~ -- - ~- at lineal rate X.0_ 0.00'! 16 17. Amount of Line 14 taxable at sibling rate X .12 165,698.62 ! 17. 18. Amount of Line l4 taxable ~~ ~~~~ ~~~~ at collateral rate X .15 I 0.00 ' 18 19. TAX DUE ........................... ............................ .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 150561205 O Side 2 1~i05610205 J 0.00 0.00 ' 19,883.83 , 0.00 19,883.83 REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number ~ Q ~' -- V O l ~~ DECEDENT'S NAME Carolyn Mae Wirth STREET ADDRESS 1000 Claremont Road CITY Carlisle STATE 21P PA 17015 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 10,225.23 B. Discount 538.15 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. (1) 19, 883.83 Total Credits (A+ 13) (2) 10,763.38 (3) 0.00 (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 9,120.45 Make check payable to: REGISTER OF WILLS, AGENT gin. f ~ k~ ,~..w~'.~1°&`~.~t..FC I r i Ia° t }.:NI Lfi r4 U6 ~ D §' ' . x e .- xe . . t4 , ,... 4} 3 .~ avl..x , il x d~.. Ati r . ... 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 lransierred ................................................................................... ....... ^ 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, benefits or care? ............................................................... ....... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer propedy within one year of death without receiving adequate consideration? ....................................................................................................... ....... ^ 3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her df:ath? ....... ....... ^ 4. Did decedent own an individual retirement account, annuity or other non-prohate property, which contains a benefciary designation? ................................................................................................................. ....... ~ ^ IF THE ANSWER TO ANY OF THE A80VE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. -_ - E 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 lax 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 staWte does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and fling a tax return are still applicable even if the surviving spouse is the only benefciary. For dales 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 df:ath 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 indivitlual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX+(u-iD) ~ . Pennsylvania DEPARTMENT OF REVENGE INHERITANCE TAX RETURN RESIDEM DECEDENT SCHEDULE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Carolyn Mae Wirth 2011-00982 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. Well Fargo Checking Account #3114731296 Well Fargo Bank, N.A., P.O. Box 6995, Portland, OR 97228 34,401.45 2, Wells Far c Savi g ngs Account #3114733201 Wells Fargo Bank, N.A., P.O. Box 6995, Portland, OR 97228 30,005.26 3. Misc. Jewelry antl Pins 500.00 ' 4, All Clothing 250.00 5. HP Widescreen laptop 600.00 6. Kindle eBook reader 75.00 7, Remaining retainer balance from litigation that began prior to decedent's death and resulted in settlement 1,044.26 ' TOTAL (Also enter on Line 5, Recapitulation) $ 66,875.97 If mare space is needed, use additional sheets of paper of the same size. _ __ REV-151D EX: (OB-D9) ~ pennsylvania SCHEDULE G DEenRTn ENT OE REVENUE INTER-VIVOS TRANSFERS AND cN"ERR""cer"xRETUR" MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Carolyn Mae Wirth 2011-00982 finis schetlule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPIION OF PROPERTY trvaucE ixE ~NaNE Or ixE T0.nrvsEEREE, IMEIR aeunaxswc TO OECEOExr axo THE Daieor rMxsEFR arenancow alHE DEm FDR afro ESrarE. DATE OF DEATH VALUE OF ASSET °/a OF DECD'S INTEREST EXCLUSION OFnwuuetE) TAXABLE VALUE 1. American Funds CB&T CUST IRA Charlotte W 8er es Transferee/siste f , . g , ro decendent, transfer on 9/14/11 130,895.70 100 ' 130,895.7( TOTAL (Also enter on Line 7, Recapitulation) $ I 130,895.70 '~ If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (LO-09) TOTAL (Also enter on Line 9, A.ecapitulation) $ 8,407.14 ~ Ipennsylvania SCHEDULE H DavaRTNENr oERavENUE INHERffANCE TA%RETURN RES[DEM DECEDENT FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE Of FILE NUMBER Carolyn Mae Wirth 2011-00982 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERALEXPEN$ES: L B. ADMINISTRATIVE'COSTS: 1. Personal Repres@ntative Commissions: - 4,012.56 Name(s) qF Personal Representative(s) Charlotte W. Berges street Address 152 Creekside Drive City Enpla Btate?A ztP 17025 Year(s) Commission Paid: 2012 Z~ Attorney Fees: 4,012.56 B. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Addrtess City State _ ZIP _ Relationship of Claimant to Decedent 4. Prohate Fees: S~ Accountant Fees: 130.00 6. Tax Return PreparBr Fees: ~ Patriot News Adviertisement 177 02 a Cumbedand Couhty Law Journal Advertisement 75.00 ',I If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) ~ ' Pennsylvania DEPARTMENT OF REVENpE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER Carolyn Mae Wirth 2011-00982 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 DESCRIPIION OF DEATH 1' Claremont Nursing and Rehabilitation Center 8,040.00 2. Advantage Ambulance Medical Transport 994.64 3. Mobile X-Ray Imaging, Inc. 828.60 4. Special Events Emergency Medical Services, Inc. 1 950.55 5. Cumbedand Goodwill Emergency Medical Services 465.96 6. W.L. SchneiderASsociates 886 02 7. Bank of America, Inc. credit card closing service charge 281.02 e. Wells Fargo account service charge 200.00 9. Spring Creek Rehabilitation and Health Care Center 10,000.00 10. Verizon phone bill'. 19 12 TOTAL (Also enter on Line 10, Recapitulation) $ 23,665.91 ' If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (Ol-SOj ~ pennsylvania SCHEDULE 7 INHERITANCE TAX RETURN BENEFICIARIES RESIDEM DECEDENT ESTATE OF. FILE NUMBER: Carolyn Mae Wirth 2011-00982 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME A D ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUT10N5 [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1 Charlotte W. Berges, 152 Creekside Dr., Enola, PA 17025 sister 100% ENTER DOLLAR AMOU TS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGN 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRI UTIONB A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECIION TO TAX IS NOT TAKEN: 8. CHARITABLE AND GOVERNMENTAL DISTRIBUTONS: t TOTAL OF PART I$ -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, use additional sheets of paper of the same size. WILL of Carolyn M. Wirth I, Carolyn M. Wirth, of PA, Pennsylvania, declare that this is my will. I revok@ all prior wills and codicils. ARTICLE ONE DECLARATIONS CONCERNING FAMILY 1.1 Family. I am not married. I have no chil,'dren. r~ `~ l AND PROPERTY ~ ?~ ' _~ r ~ ' n -- `c,~ ~' ~~ ~~ :, '~ ~., i .. I intentionalli~y leave nothing to anyone claiming t:o be a child'bf mine regardlesls of the validity of their claim. T) i~~~ ,. _. -~ ~.7 ~ --, 1.2 Personal Wishes. It is my desire that my executor follow any written directions left with this will regarding memorial services. My remains shall be cremated and under no circumstances shall my remains be embalmed. ARTICLE TWO GIFTS OF PROPERTY 2.1 Tangible P~rsonal Property. I direct my executor to distribute all of my tangible personal property to myl,relative Charlotte Berges. I may also lease a non-testamentary letter addressed to the executor requesting that certain of my personal possessions be delivered to n$med individuals. Although such letter shall not be interpreted as'a testamentary writing, I request that my beneficiaries end executor carry out the requests made in the letter. If a minor child is to receive personal property it may be delivered to tN~e child or their guardian or parent as the executor sees fit. 2.2 Residue ofllEstate. I leave the residue of my e:;tate to the Trustee(s) of tlhe Carolyn M. Wirth Revocable Trust to be added to the trust and t1o be held, administered and distributed according to the terms of that trust and any amendments properly made to it. ARTICLE THREE APPOINTMENT OF FIDUCIARIES - Page 1 - 3.1 Executor. I nominate Charlotte Bereges to act as my executor. If Charlotte Bereges cannot serve then Stephanie Bower is to serve as the executor of my will. No bond shall be required of any executor under this will. 3.2. Executors Authority. In addition to any powers and elective rights conferred by statute or federal law or by other provisions of this will, I grant my executor the authority to administer my estate under any procedure for informal or unsupervised administratiorn, or any other available procedure :Eor avoidance of administration or reduction of its burdens. On ~ I~~ 20a1D at L,~'~~, i~ I hereby sign (date} (town and state) this docum(e~nt an~(d~'~declare it to be my will. Carol~yno~~ rthl ~R~ This document '(consisting of pages including this one) was signed and declared to be her will by Carolyn M. Iti!irth in our joint presence. At her request, in her presence, and in the presence of each other, we!hereby sign as witnesses to the execution of this will, believin that she is of sound mind and under no undue influence. Eac~i of us observed the signing of this will by Carolyn M. Wirth and etch other subscribing witness and knows that each signature is t~e true signature of the person whose name was signed. Each off us is now more than eighteen years of age and a competent witness and resides at the address set forth after our name. We declare under penalty of perjury that the foregoing is true and cor'r1ect and 1th~t this declamation was executed on rt I ~ Q~t% ' at F-~l CZ~e~' (date} (town) L~ ~~a t te) ~ residing fitness-sign ture) (town and ;>tate) - Pa qe 2 - - residing at (wi*_ess signa ure} (town and state} ', - Paqe 3 - WILL AFFIDAVIT for the WILL of Carolyn M. Wirth State of ~~~~~ ~~~~~ ~ County of ~C~' ~' I, the undersigned, an officer authorized to administer oaths, certify that Clarolyn M. Wirth, 17,o,.rt D W , ~ ~Q,y~, /h~ (Print name of Witness) and /I~nn~i/ ~}. _~~,,,.,~ r (Print Name of Witness) the witnesses,', whose names are signed to the attached or foregoing instrument and whose signatures appear below, having appeared together before me and having been first duly sworn, each then declared to me'that: 1) the attached or foregoing instrument is the last will of the testator; 2) the testator willingly and voluntarily declared, signed and executed the wji11 in the presence of the witnesses; 3) the witnesses signed the will upon request by the testator, in the presence and hearing of the testator, and in the presence of each other; 4) to the best''. knowledge of each witness the testator was, at that time of the signing, of the age of majority (or otherwise legally competent to m$ke a will), of sound mind, and under no constraint or undue influence; and 5) each witnes$ was and is competent, and of the proper age to witness a will, Testator: (Testator signature Witness: -a;~g Witness signature} Address : ~ . ~'( pu ~,~,QO ~ ~ r, - Page 4 - Witne:>s Address: Subscribed, sworn and a Notary Puhlc, by Carolyn M. Wirth, the r~ ~~ the witnesses,) this Signed: v (Official C,pacity of Officer) acknowledged before me, ~~,,;,, ~ ~~z,,~Z , testator, and by and b rn 2 ~ Ca' 17 x F-~~ , ~~ ('-fa'` day of ~ ~ 20 06 (Notary Seal) Commonwealth of Pennsylvania NOTARIAL SEAL SHAWN S. HENTZ, Notary Public Lancaster City, Lancaster County My Commission Ezoires Mar. 14, 2010 - Pa qe 5 -