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Home My WebLink About06-25-121505611180 J REV-1500 Ex l°2-,,) (FI) Pennsylvania OFFICIAL USE ONLY PA Department of Revenue oeanRrmeNroF Rever+ue Cou~}tY Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN ---Z I I ~ I K ~~ y PO BOX 280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT 21-11-1194 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 10162011 10251974 Decedent's Last Name Suffix Decedent's First Name MI FALK JUSTIN E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE BOXES BELOW ~x 1. Original Return 4. Limited Estate 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 0 2. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12-82) 0 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 0 10. Spousal Poverty Credit (Date of Death Between 12-31-91 and 1-1-95) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number STEPHEN D. TILEY 717-243-5838 First Line of Address 5 SOUTH HANOVER STREE Second Line of Address City or Post Office CARLISLE Correspondent's a-mail address: State ZIP Code PA 17013 3. Remainder Return (Date of Death Prior to 12-13-82) 0 5. Federal Estate Tax Return Required 0 8. Total Number of Safe Deposit Boxes 0 11. Election to Tax under Sec. 9113(A) (Attach Schedule O) REGISTER OF WILLS USE ON6Y C = `~ Tt'~ a =L, _ c, ~::~ r~ "- ~ "A' zv: , ;._, CJ ~_ -r~ C7 ~-- =~ : ' Q ~.T ~::: ._ r=" DAiE .. D fi t-" Cf. a Cft rt ~_- "f' l t"Tl 1 -Tl 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 com lete. Declar ti f re arer other than the ersonal re resentative is based on all information of which re arer has an knowled e. SI ATU E ER O O S L FOR FILING RETURN DATA.-. ADDRESS DALE J. FALK 14 INDEPENDENCE DRIVE MT. HOLLY SPRINGS PA 17065 SIGN R 'QTNER TH~p( REPRESENTATIVE ~qT / ADD ESS STEPHEN D. TILEY, 5 SOUTH HANOVER STREET, CARLISLE, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505611180 1505611,180 J 150561128D REV-1500 EX (FI) Decedent's Social Security Number Decedent's Name. JUSTIN E FALK RECAPITULATION 1. Real Estate (Schedule A) . . ... .. . 1. N 0 N E 2. Stocks and Bonds (Schedule B) ............... ... 2. NON E 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. . 3. N 0 N E 4. Mortgages and Notes Receivable (Schedule D) .......... .. 4. N 0 N E 5 Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) .. 5. 112 O 4 . 0 0 6. Jointly Owned Property (Schedule F) OSeparate Billing Requested .. 6. N 0 N E 7 Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested .. .. .. 7. 0 , 00 8. Total Gross Assets (total Lines 1 through 7) ........................ .. 8. 112 0 4 . 0 0 9. Funeral Expenses and Administrative Costs (Schedule H) .. .. ......... . 9 10 3 61.0 0 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) .. 10 10.0 0 11. Total Deductions (total Lines 9 and 10) ............ ...... 11. 10 3 71.0 0 12. Net Value of Estate (Line 8 minus Line 11) ....................... .. 12. 8 3 ~ . 0 0 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) .. .... ........... 13. 0 . 0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) .................... .. 14. 8 3 3 . 0 0 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 D 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate x o 4 5 8 3 3. 0 0 16 3 7. 4 9 17. Amount of Line 14 taxable at sibling rate X # # #I 17 0 , 0 0 18. Amount of Line 14 taxable at collateral rate X # # #I 18. 0 . 0 0 19. TAX DUE .......................... ............... 19. 37.49 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ Side 2 L 1505611280 150561,1280 J REV-1500 EX (FI) Page 3 Decedent's Complete Address: 21-11-1194 File Number 079-68-6206 DECEDENT'S NAME JUSTIN E FALK _ STREET ADDRESS 14 INDEPENDENCE DRIVE CITY MOUNT HOLLY SPRINGS STATE PA ZIP 17065 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount 3. Interest (1) Total Credits (A + B) (2) 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. (3) (4} 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 37.49 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 ....................._._................................................... ..... ^ 0 b. retain the right to designate who shall use the property transferred or its income .......................... _..... ...... ^ Q c. retain a reversionary interest ......................._..................................................... ,.. .... _ ......... . __. ^ ^X d. receive the promise for life of either payments, benefits or care? ............................... ^ ^X 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? ...... .... ^ ^X 4. Did decedent own an individual retirement account, annuity or other non-probate property which , contains a beneficiary designation? .......................... C~ ^ 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 'm [72 P.S. §9116(x)(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(x)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. 37.49 0. REV-1508 EX+(11-10) SCHEDULE E Pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OF REVENUE PERSONAL PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Justin E. Falk 21-11-1194 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 2002 Dodge Neon Sedan (See Exhibit "A") 1,905 2 M&T Checking Account #951162187 (See Exhibit "B") 7,592 Accrued Interest to the Date of Death 0 3 Refund - Highmark 195 4 Refund -Carlisle Regional Medical Center 1,000 5 Refund -Carlisle Regional Medical Center 100 6 Pennsylvania Income Tax Refund -Year 2011 133 7 Federal Income 'ra Refund -Year 2011 245 8 Refund -Penn State Hershey Medical Center 34 TOTAL (Also enter on line 5, Recapitulation) $ I 11,204 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+ (08-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Justin E. Falk 21-11-1194 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 NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF TFIE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT.4ND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION ~ FAPPLICABLE) TAXABLE VALUE 1. IRA With M&T Investment Group 0 See Exhibit "C" 0 188.802 Shares Franklin Templeton Founding Allocation Class A 0 Value per share on October 16, 2011 = $9.89 0 Total Value 1,867 0.00% 0 Decedent's Interest zero as less than age 59.5 and not 0 disabled such that could withdraw the IRA without penalty. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TOTAL (Also enter on Line 7 Recapitulation) $I 0 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX + (10-09) pennsylvania DEPARTMENT OFREVENUE INHERITANCE TAX RE~rURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Justin E. Falk 21-11-1194 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRfPTION AMOUNT A. FUNERAL EXPENSES; 1. Hollinger Funeral Home & Crematory, Inc. 3,990 B. 1 ADMINISTRATI~/E COSTS' Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: State ZIP 2. Attorney Fees. 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Dale J. Falk and Mary R. Falk street address 14 Independence Drive city Mount Holly Springs state PA zIP 17065 Relationship of Claimant to Decedent Father and Mother 4. Probate Fees: 5. Accountant Fees: Frey & Tiley 6. Tax Return PreparerFees: Frey & Tlley 7 Register of Wills -Filing Fees for Letters of Administration 8. Advertising -The Sentinel 9. Advertising -Cumberland Law Journal 10 Register of Wills -Filing Fee for Inheritance Tax Return TOTAL (Also enter on Line 9, Recapitulati If more space is needed, use additional sheets of paper of the same size. 2, 500 3,500 Included Above Included Above 102 179 75 15 $ 10.361 REV-1512 EX+(12-OS) pennsylvania DEPARTMENT OF REVENUE'. INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES 8~ LIENS ESTATE OF FILE NUMBER Justin E. Falk __ 21-11-1194 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ~~ iiwic space is neeaea, inseR aaanionai sneers or the same size. REV-1513 EX+ (01-10) Pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Justin E. Falk ~, „ „n~ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] Dale J. Falk and Mary R. Falk 1 14 Independence Drive Mount Holly Springs, PA 17065 Father and Mother 100 Percent ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUG H 18 OF REV-1500 COVER SH EET. AS APPROPRIATE. 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 IT more space is needed, use additional sheets of paper of the same size. 2002 Dodge Neon Sedan SXT What Your Car is Worth I j 4r;_.E J c!~ ~3C5 i :C ~ `'ta~ ~ q iv.~.` ~Fr_. ,. ~ .I ,3R> ?5 '1f IEi1 .t~r15 > ~ __.., r.7 ,. ., _...if5 YEb .'7iEA9ER^IAN L3E7 ~:a+W ~E is ftM AS:trC ~T.y3; ri?lr`T:5 "Y~I.R 1tr'TQf' CcmeaTe tha cost cfi buv~^c - ir_h ~ :.m=r~ c=_. =-_ ---_-- -c~,er - _---_-_ new vs seC = t' . ~ _: ~ r: a - . . _na _..-, T - _ True Market Value's 2002 Dodge Neon Sedan -What Your Car is Worth 17013 uP4ATE Pncing for Carlisle, PA True Market Value® Trade-in De'cler ?te*ai! $1,380 $2,828 Prvate Party Sale $2,9(15 Customized True Market Values Prices Trade-Zn Arivate Party Dealer Retail ;vafsonai 5ase ?T~c_ $1,481 $2,155 $3,278 CaGOnal Equipment $264 $320 $457 AM/FM/Cassette Audio System $14 $17 $25 Power Glass Sunroof $76 $92 $131 Power Door Locks $47 $57 $81 4-Speed Automatic Transmission $127 $154 $220 Cal~rr ~.~~us?ment - R c $4 $6 $9 ~.Zyf.,r:c's ;rtd, ~s .,. n£ ~~r Z z .. n_~ _ .,_.. $8 $11 $17 Mltea~e ,=.d)usi„+e:^I - -r'!3_ $95 $95 $95 C~ndaicn ;ie?~ ._~.~ .,. ~~aez $-472 $-682 $-1,028 Total Buying a Certified Used Vehicle Ceatariastaii _ _. _~:=~± ~s~*~ "''c' Vehicle not eligible for certification. 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Enter VIN ADVERTISEMENT ADVERTISEMENT Tips and Advice 1!7 SiecS `n ?uy',nr, a "! ~s v~_a- i0 SteosT.D 5<l9ina Yh~:r~ar f•1P_'N i_at r+fiV inip `Je)Ef?e!'s Fue3 E~onomv mar ~afen~ _ M1, ,SDVERTTSEMENr find o~ vs~ith Edmunds Af#ardab>i~~ty Cal+cuia~s~~ Tel{ us your desired monthly payment, and we'1! give you a pd~ range faryo~ next car. - I ~'J ~t211tIf011d5 ~°i~19SUi;4i57~'Y C:lict:.iat~~r~, _,._ a www.edmunds.com{dodge/neon/2002Itmv-appraise-results. htm i 712 F.pi., ~ s/f e. ~ 3 f Pricing Details fora 2002 Dodge Neon sedan SXT 4d r Ca r Q M~ Bank 499 Mitchell Road, Millsboro, DE 19966 Adjustment Services Phone 888-502-4349 F ax (302) 934-2955 November 21., 20l I Frey and Tiley 5 South Hanover Street Carlisle, PA 17013 Re: Estate of Justin E Falk Social Security: 079-68-6206 Date of Death: October 25 2011 Dear Sir or Madam.: Per your inquiry on November 11, 2011, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Account Number Ownership (Names of) Opening Date Balance on Date of Death Accrued Interest Total Checking Account 951162187 Justin E Falk Dale J Falk (POA) Mary R Falk (POA) 12/05/02 $7, 592.25 $ .OU __ $7,592.25._._ __ For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, please call the Bishop Street Oflice at #814-355-6420. We were unable to locate any safe deposit box for the above-mentioned decedent. 'This letter does not include any aceounts in which the deceased may have been listed as Power of Attorney, Custodian of Uniform Transfers, Representative Payee, or Trustee under a Written Agreement Sincerely, s ~~ 1 Tammy Spencer Adjustment Services &T ~~v~st~.~nt ~r~u~ 285 Delaware Avenue. Suite 2000, Buffalo, NY 14202-1885 M&T Securities, Inc. December 5, 201.1 Justin E. Falk AZR367584 Date of Death: 10/16/2011 Description of Security Quantity in Shares Price per share on 10/1.6/2011 FRANKLIN TEMPLETON FOUNDING 188.802 Low: $ 9.89 ALLOCATION CLASS A High: $ 9.89 Close: $ 9.89 We have received the information presented above from sources, which we believe t:o be accurate. However, we do not guarantee their accuracy. The stock price per share on valuation date is the closing price on that date. The mutual fund price per share is the low/nav price on that date. Previous business day price is used if DOD falls on a weekend or holiday. Please contact Client Solutions with any further questions, or if we may be of further assistance to you at 1-800-724-7788, Option #l. Thank you. Sincerely, / ~' ' v,~~i Brokerage Operations Specialist M&T Securities, hic. ~ Investment and !nsuran,;e Products: • Are NOT Deposits * Are NOT FDIC-Insured • Are NOT Insured By Any Federal Gcvernment Agency • Have NO Bank Guarantee • May Go Down In Value M&T Investment Group"" is a service mark of M&T Bank Corporation and consists of NI&T Securities, Ina, the investment-related areas of Nt&T Bank and the investment advisory firm MTB Investment Advisors, Inc. Brokerage services and insurance products are offered by M&T Securities, Inc. (member FINRA~'SIPC), not by Nl&T Bank. M&T Securities, Inc. is licensed as an insurance agent and acts as agent for insurers. Insurance policies are obligations of the insurers !hat issue the policies. Insurance products may not be available in all states. °> s N 0 O 0 0 ~ ~~ ~~ I rt A n I'! m ~ `z N ~ '. i~~~ ~ m ~ o >F N~ O O O i ~ 0 o n ~ n m ono ! x ~ ~ ~ o i z °-' f ;. ~ F 7 00 ' O -^ J d ~O p C to ,' v Q A c --~ i ;, a o o `c ~ 0 T s=y ~ O a. !" 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