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J 1505610105
REV-1500 °"°~-"' `~''
M Wltda OFFBCIAL USE ONLY
PA Department of Revenue P
Bureau of IndividuaLTaxes `°°°` County Cade Yrer File Number
Po Box 260601 INHERITANCE TAX RETURN
Harrisburg, PA 1y128-0601 RESIDENT DECEDENT ~ ~ ~ ~ ~~~
Social Security Numher Date of Death MMDDYYYY Date of Bitth MMDDYYYY
Decedents Last Name Suffer Decedent s First Narne MI
SEYMORE SR CHARLES B
(N Applicable) Enter SurviWng Spouse's Information Bebw _ _.....
Spouse's Last Name Suffix Spouse's First Narrrr! MI
Spouses Socal Secunty Number
THIS RETURN MUST BE FlLED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Retum O 2. Supplemental Retum O :3. Remainder Retum (Date of Death
Prior to 12-1362)
O 4. Limded Estate O 4a. Fuhxe Interest Compromise (date of O !i. Federal Estate Tax Retum Required
death after 12-12-82)
O 6. Decedent Died Testate O 7. Decedent Maintairred a Living Trust 6. Total Numher of Safe Deposit Boxes
(Attach Copy of Wdi) (Attach Copy of Trust.)
O 9. litigation Proceeds Received O 10. Spousal Poverty CredR (Dale 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 CORRE,SPOIOBiCE AND CONRDENTAL TAX INFOIt11A710N SFIOUID BE DIRECTED T0:
Name Daytime Teleptlone Number
STEPHEN SEYMORE, EXE (717) 766-7085
iffGISTER OF WILLS USE ONLY
rV
m
Frst Line of Address ~r"rTl -
908 ALLENVIEW DRIVE ~ ` r ~,
rr, _,
r t
Second Llne of Address Gi°,. O -
-1
City or Post Ofiice State ZIP Code FILED ~
MECHANICSBURG PA :.17055 ~ y, -_
W
CorrespondeM'a e-mail address:
Under penattles M perjury, I dednam_ Jt-h~at ,I ~hav,e examined tlis return, Iridudrg eanrrgarrying ard~fles aM statement:, arxl to Ste nest of my knowledge and belief,
it is true, corr~G ant{ complete. w`~°"`TM prepamr oMer man the parsmrel rapreserrtatlve's based on all imarmatlon d wFUCh preparer has any knowledge.
THAN
ADDRESS
DATE
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 1505610105 J
J
1505610205
REV-1500 EX (Fi)
Decedents Social Security Numher
oecedenrs Name; ; 177-26$956
RECAPITULATION
1. Real Estate (Schedule A) ........................................... .. L
2. Stocks and Bonds (Schedule B) ..................................... .. 2. '. 113,806.93
3. Closely Held Corporatbn, 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. 25,828.30
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6.
7. Inter-Vrvos Transfers 8 Miscetlaneous NorrProba[e Property
(Schedule G) O Separate BilFrg Requested...... .. Z
8. Total Gross Assets (total Lines 1 through 7) ...... ......... ......... .. 8. '.. 139,633.23 ;.
9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. 17,311.57
10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I)....... _ _ .. , . 10. 8,832.07
1 t. Total Deductions (total lines 9 and 10) ............................... .. 1i. ', 23,943.84 I
12. Net Value of Fatale (Line 8 minus Line 11) ............................ .. 12. 115,689.59
13. CharRable and Governmental BequestslSec 9113 Trusts for which '
an election to tax has not been made (Schedule J) ...................... .. 13.
14. Net Value Subject to Tax (Une 12 minus Lme 13) ...................... .. 14. 175,689.59
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_ 15.
16. Amount of line 14 taxable
at lineal rate x .0 45 115,689.59 ' tfi. 5,206.57
17. Amount of Line t4 taxable '
at sibling rate X .12 17.
18. Amount of Line l4 taxable
at collateral rate X .15 18.
79. TAX DUE ......................................................... 14
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
O
Side 2
150561025 1~SU5610205
REV-1500 IX (Fq Page 3
Decedent's Complete Address:
File NumMr
DECEDENTS NAME
CHARLES B SEYMORE
STREET ADDRESS
908 ALLENVIEW DRIVE
CrrY .-.______- __- -- STATE SIP
MECHANICSBURG PA 77055
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. CrediCslPaymen6
A. Prior Payments
B. Discount
3. Interest
TatalCredBs(A+B) (2)
(3)
4, ti Line 2 is greater than Line 1 + Line 3, en~r the ditTerence. Th's is the OVETiPAYMt3R.
Fill in oval on Page 2, Llne 20 to request a refund. (4)
5. If Line 1 + Line 3 is greater than Line 2, elr~r the dd(erence. Th6 is the SAX OBE (5)
(1)
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 ard: Ves No
a. retain the use or income of the property transferred .................................................................................... ...... ^
b. retain the fight to desgnate who shall use the property transferred or its income ............................_........ ...... ^
c. retaM a roversbnary interest ........................................................................................................................ ...... ^
d. receive the promise for life of eRfler payments, benefits or are? ............................................................... ....... ^
2. fi death occurred after Dec. 12, 1982, did decedent trarrsFer propedy within one year of death
without receiving adequate consideration? ........................................................................................................ ...... ^
3. Did decedent own an'in Wst for or payable-upon-0eath bank acaunt ar setaaity at his ar her rieaN? ........ ...... ^
4. Did decedent own an ilxlividual retirement account annuity or abler non-probak property, wtech
conhains a beneficiary designation? .................................................................................................................. ...... ~ ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COI~LEfE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
~.
For dates of death on or after July 1,1994, anti before Jan. 1, 1995, the tax rek imposed tm the net value of transfers to or fir the use of the surviving spouse
is 3 percent [/2 P.S. §9116 (a) (1.1) (i)).
For dates of death on or after Jan. 1, 1995, the tax rate knposed on the net vahre at transfers to or far the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does no[ exempt a transfer to a survivng spouse iron tax, and the sfapuhory requirements for disclosure of assets and
Kling a tax return are still applicable even if the surviving sptxrse 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 [/2 P.S. §9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to tx for fire use ofthe decedent's lineal beneficiaries is 4.5 i~ercent, except as noted in [/2 P.S. §9116(a)(1)].
• The tax rata imposed on the net value of transfers 90 tx iw 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 m rxxnman witlr the decedent, whether by blood or adoption.
REY-a5N3 EXt (7-v)
~~~ penr~sylvarria SCMEpYLE B
OEPPRTNENT OF REVENUE
INHERITANCE TAX RETURN
STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
CHARLES B SEYMORE 2011-01072
All propMy jointly owned sdlh right d suMvorshb must ba diaclaetl on Sfiedule F.
REM VALUE AT DATE
NUMBER DESCRIPRON QF DEATH
1' .BERKSHIRE HATHAWAY INC DEL 7,269.00
2 OPPENHEIMER INTL DNERSIFIED FD 3,734.56
g ' PIONEER GLOBAL HIGH YIELD FD 293.08 ':
4 CAPITAL INCOME BLDR FD 18,535.37
5 AMERICAN HIGH INCOME TR 9,122.57
g INCOME FD AMER INC 18,456.05 ;
7 LINCOLN CP ASSUR BSHARE 56,396.30
TOTAL (Also enter on Line 2, Rerapitulation) S ; 113,806.93',
If mare space is needed, insert addtional sheets of the same size
REV-i5D8 EX+ (v-1o)
~ ° pennsylvarria SCNEp11LE E
~~~ OEPARTNENT OP REVENUE CASHr BANK DEPOSITS St MISC.
INHERITANCE TpX RETURN PERSONAL PROPERTY
RESIDENT DECEDFM
ESTATE OF: FILE NUMBER:
CHARLES B. SEYMORE 2011-01072
Include the proceeds of Ktigation and the date the proceeds was received by the estate.
All prapert~ 1oiMiy owned rMth right of wrrvirraship nwat 6e an Solted,rle F.
ITEM
1, CASH 5,515.09.
2. 2009 HYUNDAI SANTA FE 20,000.00
3, S29 ACCOUNT 311.21
TOTAL {Also enter an Line 5, Recapitulation) ; 25,826.30 -:
[f more space is needed, use additional sheets of paper of the same size
.EV-1513 E7:+ (1C-091
~ '- Pennsylvania
~~ DEPARTMENT DE REVENUE
INRER(TANCE TA% RET00.N
RESIDEM DKEDENt
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
CHARLES B SEYMORE
2011-01072
Deaederd's debts most 6e reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' FUNERAL AND BURIAL EXPENSES 13,488.07
e. ADMINISTRATIVE COSTS:
L Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City __ ____ _____.._ .._.. _.._...___ __. _.- ___ ____- ___-State __- _ ZIP _-_ ___-
Year(s) Commission Paid:
2. Attorney Fees:
3. Family Exemption: ([f decedent's address is not the same as daimam's, attach explanation J 3,500.00
claimant STEPHEN SEYMORE
Street Address 908 ALLENVIEW DRIVE
city MECHANICSBURG____ __ _ _ state_PA,ZIp17055__.__
RHationship of Claimant to Decedent SON _ _ _
4. Probate Fees: 323.50
E. Accountant Fees:
6. Tax Return Preparer Fees:
7.
TOTAL (Also enter on Line 9~, Rerapitulatlon) ;' 17,311.57
If more space is needed, use additional sheets of paper of the same size
REV 1512 E%~ (12-98j
~`_ Pennsylvania SCHEDULE I
DerARTWENT DG REVervue DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DKEDENT
ESTATE OF FILE NUMBER
Report debts incurred by the decedent pray to death that remained unpaid at the date of deaM, induding unreimburxd medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIpTIDN OF DEATH
t. AUTO LOAN 5,551.64
2 CREDIT CARD 466.04'
3 UNREIMBURSED MEDICAL EXPENSES 614.39
TOTAL (Nso enter on Line 10, Re:apitulation} S 6,632.07
If mare space is needed, insert addi[ional sheets of Me same size
REV-1513 EX+ (DI-10)
~~" Pennsylvania SCHEDULE 7
DEPARTMENT or REVENGE
INHERRANCE TAX RETU0.N BENEFICIARIES
RESIDENT DKEDENT
ESTATE OF: FILE NUMBER:
CHARLES B SEYMORE 2011-01072
RELATIONSHIP TCI DECEDENT AMOUNT OR SHARE
NUMBER NANE AND ADDRESS Of PERSON(S) RECEIVING PROPERTY Do Not Lkt Trsstaa(s) Of ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal diNtibutnNES aM transfers under
Sec. 9116 (a) (1.2).j
1. (AURASEYMORE. DAUGHTER. 50%'
2 STEPHEN SEYMORE SON 50%
II
1.
ENTER DOLLAR AMOUNTS TOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 Of REV-1500 COVER SHEET, AS APPROPRIATE.
NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRLBUTIONS UNDER SECTION 9113 FOR WHICH AN EtFCTION TO TAX LS NOT TAKEN:
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II - ENTER TOTAL NON•TAXABI-E DLSIRIBIliI0N5 ON L[NE 13 OF REV-1500 OVER SHEEP. ;
If more space n needed, use a~Rional sheets Dt paper of Uie same tee.