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HomeMy WebLinkAbout06-19-121505611185 REV-1500 EX (02-11)(FI) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes PO BOX 280801 INHERITANCE TAX RETURN 21 12 0 4 0 0 Harrisburg, PA 1 7 1 28-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date Of Blrth MMDDYYYY 03232012 06151927 Decedent's Last Name Suffix Decedent's First Name MI COOK ("IARGARET E (If Applicable) Enter Surviving Spous e'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 6 Decedent Died Testate death after 12-12-82) ^ 7 D d t M i i t d Li i T ~ 8 . . ece en n ne a a a v ng rust . 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 ^ 1 1. 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 KEITH 0• BRENNEf1AN 71,7-697-R5~8 __ First Line of Address 44 WEST f1AIN STREET Second Line of Address City or Post Office State ZIP Code MECHANICSBURG PA 17055 REGISTE~~ USE ONL'1° ~} ~ ,~ ~ ~I f~7"I L ~ ~ :its ( r r .' ~ 1 c; ~,-, " f .~, - ..T`3 ~ ~ .~ -1 ~, .. r ~./~ G1 DATE FILED .~" Correspondent's a-mail address: Under penalties of perjury, I 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 representative is based on all information of which nranarar nac a~~ v„n~.no~~e Side 1 1505611185 OM46473000 1505611185 J 7 (. f"'1 ~. ~, ~; --r-t !"fit ~vlvlvit L• GKAL1tK, tXt~UTRIX P•0• BOX 697, MILLHEIM, PA 16854 SIG URE OF PREPARER OTHER THAN REPRESENTATIVE DATE G -sac - 2ci~ ADDRESS 44 WEST MAIN STREET MECHANICSBURG, PA 17055 PLEASE USE ORIGINAL FORM ONLY 1505611285 REV-1500 FCC (FI) Decedent's Social Security Number Decedent's Name: COOK MARGARET E RECAPITULATION 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) ~ Separate Billing Requested g 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested 7. 8. Total Gross Assets I;total Lines 1 through 7) 8 Side 2 9. Funeral Expenses and Administrative Costs (Schedule H). g, 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) 10 11. Total Deductions (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 un~er Sec. 9116 16. Amount of Line 14 t• xable ~ at lineal rate x 0 4 . 717 , 5 0 9 •1, 8 1 s. 17. Amount of Line 14 taxable at sibling rate X .12 0 • o 0 17 18. Amount of Line 14 taxable at collateral rate X .15 0 . o 0 18. 19. TAX DUE 19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1505611285 ],505611285 4,770.39 0.00 o•oo 402,752.95 o•oo 324,407.19 731,930.53 11,077.41 3,343.94 14, 42], • 35 71?,509.18 0.00 717,509.18 o•oo 32,287.91 o.oo o•Oo 32,287.91 DM4648 3. D00 REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number 21 L2 040 DECEDENTS NAME COOK MARGARET E _ STREET ADDRESS CUMBERLAND COUNTY CITY MECHANICSBURG STATE PA ZIP 17055- Tax Payments and Credits: 1 Tax Due (Page 2, Line 19) (1) 2. Credits/Payments A. Prior Payments 0 • 0 0 B. Discount 1, 614 •3 9 Total Credits (A + B) (2) 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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. 32,287• 1, 614 •39 (3) 0.00 0.00 (5) 30,673.52 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. OM4671 2.000 REV-1503 EX+ (8-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT 'ATE OF FILE NUMBER Margaret E. Cook 21 12 0400 All property jointly-owned with right of survivorship must be disclosed on Schedule F. swasss i o00 (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (11-10) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS, & MISC. RESIDENT DECE DENTTURN PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Margaret E. Cook 21 12 0400 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Sovereign Bank 2,528.37 Checking account No. 1681703777 2 Sovereign Bank 250.02 Club account No. 1684001876 3 Sovereign Bank 19,952.46 Money Market account No. 1684070422 4 Sovereign Bank 10,022.10 Certificate of Deposit, account No. 1665551499 5 Comprehensive Financial Associates 321,560.67 Investment account No. 5CR360602 6 Susquehanna Conference 20,000.00 Certificate of Deposit No. 16461 7 Susquehanna Conference 20,000.00 Certificate of Deposit No. 19544 B 1999 Honda Accord LX 6,525.00 9 Optum Health 312.71 insurance refund 10 United States Treasury 655.00 2011 Federal income tax refund 11 PA Department of Revenue 108.00 2011 State income tax refund 12 Stonebridge Life Insurance 734.90 long term care insurance refund 13 Novitas 89 92 medicare refund 14 United Healthcare 13.80 refund O W46AD 2 000 TOTAL (Also enter on line 5, Recap If more space is needed, use additional sheets of paper of the same size. S 402,752.95 REV-1510 EX + (08-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Margaret E. Cook 21 12 0400 This schedule 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 NUMBS DESCRIPTION OF PROPERTY irr~~oE7FEru~nn=_oFTr~TaAr~sFEREETr~EiRREwnonisr+iProDeceoenrrAND TFE DATE OFTRMSFER ATTAG IACAPV OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD'S INTEREST EXCLUSION IF PPPLJCABLE TAXABLE VALUE ~ Prudential Life Insurance 2,000.00 100.0000 2,000.00 0.00 Claim No. 11245613. Beneficiaries: Connie L. Grazier and Darlene A. Bruner, daughters of the Decedent. Transfer upon death. 2 Nationwide Insurance 4,764.14 100.0000 4,764.14 0.00 Policy No. L001076190. Beneficiaries: Connie L. Grazier and Darlene A. Bruner, daughters of the Decedent. Transfer upon death 3 MetLife 135,011.46 100.0000 0.00 135,011.46 Annuity contract No. 540009966. Beneficiaries: Connie L. Grazier and Darlene A. Bruner, ~~ daughters of the Decedent. Transfer upon death 4 Pioneer Equity Fund A 8,571.92 100.0000 O.OOi 8,571.92 Annuity account No. 00621310326. Benefiaries: I Connie L. Grazier and Darlene A. Bruner, daughters of the Decedent. Transfer upon death 5 New York Life 50,563.00 100.0000 0.00 50,563.00 Policy No. 53028094. Beneficiaries: Connie L. Grazier and Darlene A. Bruner, daughters of the Decedent. Transfer upon death 6 Pacific Life Annuity 91,329.69 100.0000 0.00 91,329.69 Policy No. FA09028890. Beneficiaries: Connie L. Grazier and Darlene A. Bruner, daughters of the Decedent. Transfer upon death Total from continuation sched les 38,931.12 TOTAL (Also enter on line 7, Recapitulation) $ 324,907.19 Ii more space is needed, use additional sheets of paper of the same size. 9 W46AF 2.000 Estate of: Margaret E. Cook 21 12 0400 Schedule G (Page 2) Item DOD Value Taxable No. Description of Asset ~ Interest Exclusion Value 7 Security Benefit 25,815.60 100.0000 0.00 25,815.60 Annity contract No. 8017220. Beneficiaries: Connie L. Grazier and Darlene A. Bruner, daughters of the Decedent. Transfer upon death 8 Principal Life Insurance Company 13,115.52 100.0000 0.00 13,115.52 Annuity Contract No. 9210788. Beneficiaries: Connie L. Grazier and Darlene A. Bruner, daughters of the Decedent. Transfer upon death Total (Carry forward to main schedule) 38,931.12 REV-,5„ EX+I,o-o9, SCHEDULE H Pennsylvania DEPARTMENT DF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Margaret E. Cook 21 12 0400 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Malpezzi Funeral Home, Inc. balance due 2,912.84 Total from continuation schedules ~ 389.67 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Walved Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2. Attorney Fees: Snelbaker & Brenneman, P. C. 5,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent a. Probate Fees: $113.50 plus additional probate fee of $365.00 478.50 5. Accountant Fees: 1,000.00 6. Tax ReturnPreparerFees: Miscellaneous filing fees and expenses, Reserve 1,000.00 7. 1 Advertise grant of Letters Testamentary: A. Cumberland Law Journal: $75.00 B. The Sentinel: $221.40 296.40 TOTAL (Also enter on Line 9, Recapitulation) ~$ _ 11 , 077.41 swasA~ z o0o If more space is needed, use additional sheets of paper of the same size. Estate of: Margaret E. Cook Schedule H Part 1 (Page 2) Item No. Description 2 First United Methodist Church alter flowers 3 Caroline Brown funeral luncheon 21 12 0400 Amount 64.00 325.67 Total (Carry forward to main schedule) 389.67 REV-1512 EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES 8~ LIENS ESTATE OF FILE NUMBER Margaret E. Cook 21 12 0400 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' Optium Health Insurance _ payment on account 524.00 2 PPL Electric payment on account 85.51 3 Messiah Lifeways payments on account: $864.00 and $835.20 1,699.20 4 Pinnacle Health Cardiovascular payment on account 111.31 5 Heritage Medical Group payment on account 26.16 6 Spirit Physican Services, Inc. payment on account 767.38 7 Verizon payments on account: $16.23 and $36.96 53.19 8 Quantum Imaging & Therapeutic Associates payment on account 2 07 9 Boscov's payment on account 9 99 10 AT&T payment on account 65.13 TOTAL (Also enter on Line 10 Recapitulation) $ 3 , 343.94 ewasAH z o0o If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsylvania DEPPF2TMEN7 OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: FILE NUMBER: ~i i ~ nnnn a-1Ql d1CL C~ ~.V V/~ -- -- - --- 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. Todd A. Grazier 5332 Caleb Drive Columbus, OH 43220 Grandson 5~ of Estate 2 Steven A. Grazier P.O. Box 346 Millheim, PA 16854 Grandson 5~ of Estate 3 Daniel R. Grazier 57905 Desert Gold Drive Yucca Valley, CA 92284 Grandson 5~ of Estate NTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH I I 18 OF REV-1500 COVER SHEET, AS APP I ROPRIATE. [I NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 0.00 swami z o0o rr more space Is neeoea, use aaalttonal sneers of paper of the same size. Estate of: Margaret E. Cook 21 12 0400 Schedule J Part 1 (Page 2) Item No. Description Relation Amount 4 Karen R. Noble 20711 Citation Drive Ashburn, VA 20147 Granddaughter 5% Of Estate 5 Connie L. Grazier P.O. Box 697 Millheim, PA 16854 Daughter 40% of Estate 6 Darlene A. Bruner 4982 Patillo Church Road Burlington, NC 27217 Daughter 40% of Estate LAST WILL AND TESTAty1EN7' 1. 1~~lARGARET E. COOK, of the Borough of Mechanicsburg, County of Cumberland, and Commomveal[h of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this as and Cor my Last Will and Testament, hereby revoking and making vuid all Cornier wills and codicils by meat anytime heretofore made. FIRST. 1 order and direct that all my just debts and funeral expenses be paid by my Executrices or Executrix, as the case may be, hereinafter named, as soon as eouveniently may be done after ^iy decease. SF,COND. I give and bequeath a suns of money equal to five per cen[um (5%) of my neC distributable estate unto my grandson, namely, "TODD A. GIZALIER, absolutely, if he survives me. THIRD. I give and bequeath a sum of money equal to five per centum (5°~0) of my net distributable estate unto my grandson, namely, STEVEN A. GRAZIER, absolutely, if he Stt l'V ROCS Ill e. rni)I?TII. i give :u:d b~qu~ath a spun of more}-~ equ ;i tc t;ve Ter cenhml (5%,j of m-y nEt distributable estate unto my grandson, namely, D 1NIEL R. GRAZIER, absolutely, if he survives uie. F[F"I'H. l give and bequeath a sum of money equal to five per centum (5%) of my net disU ibutabtc estate unto my granddaughter, namely, KAREiv R. NOL~LE, absolutely, if she survives uie. SIlT[I. I give, devise and bequeath all the rest, residi.ie and remainder of my Estate, real, personal and mixed, whatsoever mid wheresoever situated, in equal charas unto my two (2) daughters, namely, CONN[E L,. GRAZIER and DARLENE f1. BR[JNT'R, share and share alike, absolutely and in fee simple, if they survive me. il~mv daughter, CONNfF, I,. GRAZIER, should predecease me, l order and direct that her Lnvv oF~iccs SNELB AK ER Lk BR~NtJEM AN, P.C. share of my residuary estate afuresaid shall be distributed in equal shares unto her then living children, share and share alike. I t my daughter, DARLENE A. BRUNP.R. predecease me, I order and direct that her share of my residuary estate aforesaid shall be distributed in equal shares unto her then living children. share and share alike. [F my said daughter should leave no children to survive her, then and in that evc nt, {order and direct that her share of my~ residuary estate aforesaid shall be distributed in equal shares unto the then living children of my other daughter, Connie L. Grazier, share and shm~e alike. 1_~STL~'. 1 nominate, constitute and appoint my daughters, namely, CONML L. GKALIER and DnRLf?NL' A. 13R~UM~EZ to be the Executrices. of this, my Last Will and I'cstament, but if for any reason either of said daughters should fail to qualify as said Executrix or cease so tv serve, then and in that event, 1 nominate, constitute and appoinC the daughter so quali)~ying ur surviving to be the sole Executrix hereof: each and both to serve without bond or other security as a condition of quali(`icatio^ hereunder. iN Whl~Nl?SS V~~H~REOP, 1, M~\RGAI2ET E. COOK, have hereunto set my hand and seal to this m~ Last Will and Testament, which consists of three (3) typewritten pages to each of which I have af6xe d my signanire this 9"' day of October, A.ll., 'Two "Thousand Six (2006). 4ARG~~RLT E. COOK ELP.AKER Y~ NEMl1 N. P.C. ('he preceding instrun~eut, consisting of this and two (2) other typewritten pages, each identilied by the signature of the "Testatrix, was on the date thereof signed, scaled, published and declared by NIARUARET F.. COOK, the Testatrix therein named, as and for her Last Will and Testament, in the presence of us, who, at her request, in her presence and in the presence of each other, have subscribed our names as witnesses hereto ..-`_ -~ ~_-, '7 CONIIvIONWI'.AI:I'FI t?F YENI~SYLVANL~1 SS. C(?Ui~l"f'Y OF CUMI3LRLAND 1h'e. 1v-ftARGAKE?T 1:. COOK, R[CItARll C. SNI;LBAI<ER and JANE J. GOONEY, the Testatrix and the witnesses, respectively, whose names are sig~ted to the attached or foregoing instrument. being first duly sworn. do hereby diciare to the undersigned authority that the Testatrix sirued and eseruted the instrument as her 1 ast Will and Testament and that she had signed willingly, and that she executed it as her ii-ee and voluntary act for the purposes therein e~pressed. and that each of the witnesses. in the presence and hearing of the Testatrix, signed the Will as a witness and that to the best of his or her knowlcd~e, the Testatrix was at that time eighteen years oY aze or older, of sound mind and under no constraint or undue influence. I'es trix 1tneSS -{( ~Vitnes~ ~__ V OFFICES L ©r11(E~! & ~F-h,aN. P.C. Subscribed, sworn to and acknowledged before me by MARGARE"h E. COOK, the Testatrix, and subscribed and sworn to before nle by RICHARD C. SNELBf1KER and JANE J. GOONEY, tl~c xitnesses, this 9°i day of October. 2Q06. C.C?t~1iV;QtJWEALTH QE PENNSYLVAPi6`. %~~ r Nota_da! Seal i / Susan L. Malr`a. Notary Public ~ _._ ~~'~~_. `~_ Yeciianicsburgflore,CurnbedandCounty jVptal-5' I'UbI1C msy C~ornmissien Expires Nov. 24, 2007 4 h4ember, Penngylvznia Association Of Notaries _~_