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Home My WebLink About07-26-121505610105 REV-1500 EX (02-11) (FI) 5 PA Department of Revenue pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes UEFxR,FFxTUPREVFxxF County Code Year File Number PO BOX 28o6oi INHERITANCE TAX RETURN Harrisbur , PA iyi28-o6oi RESIDENT DECEDENT ~, I ~ 0~~~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 03092012 12151920 Decedent's Last Name Suffix Decedent's First Name MI Chaney John J (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Chaney Betty J Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 175242495 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) O 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 T0: Name Daytime Telephone Number Timothy S. Sponseller 717-264-1100 First Line of Address 223 Lincoln Way East Second Line of Address City or Post Office Chambersburg Correspondent's a-mail address: State ZIP Code PA 17201 REGISTER OF WILLS USE ONLY t" 7 ~'' P. ~.~ ~? ~~ ` ~ te' ~, T ~' r f'~i C L C p-y r , x. Q ~ " f " ~ ~ a ~-. DRTE &ItED -'~ n _-_ 4~ tV 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 preparer has any knowledge. SIGNATURE OF PERSON RESPONSI LE FOR G RETURN Gloria J. Ashway ~ .n/`Jj_L~ ~ ~/~~~ /~DATE~j ADDRESS "7". il~=~ / '°r ~`~ SIGNATURE OF PREPARER OTHER THAN RE RESENT Timothy S. Sponseller DA ~0 ADDRESS 7~A I inrnln lA/ v F^ct CRh^mhPrchurn PA 177(11 PLEASE USE ORIGINAL FORM ONLY 1505610105 Side 1 1505610105 J 4 i i; {~'"~ ~~~ ~i < ~ r .,. "!'1 ~~ J REV-1500 EX (FI) 1505610205 Decedent's Social Security Number Decedent's Name: 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. 3,100..00 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 7,51.3.77 (Schedule G) O Separate Billing Requested..... ... 7. 8. Total Gross Assets (total Lines 1 through 7) .......................... ... 8. 10 613.77 9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. 12,850.00 10. Debts of Decedent. Mortgage Liabilities and Liens (Schedule I) ............. .. 10. 11. Total Deductions (total Lines 9 and 10) ............................... .. 11. 12,850.00 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 7,51.3.77 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 7 513.77 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 .O~r 7 513 77 16. 17. , . Amount of Line 14 taxable 338..12 at sibling rate X .12 17 18. Amount of Line 14 taxable at collateral rate X .15 18 19. TAX DUE ......................................................... 19. 338.12 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 1505610205 1505610205 J REV-1500 EX (FI) Page 3 Decedent's Complete Address: STREET ADDRESS File Number CITY _ . _ _... _._ _ STATE ZIP Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 2. Credits/Payments ~~R ~~ A. Prior Payments ___ B. Discount 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. (3) Fill in oval 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. (5) 44R 17 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 ...................................... ...... ^ ^ 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 "intrust for" orpayable-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. REV-i5o8 EX+ (il->.o) ,~ Pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: John) Chanev ?1 1~ nay Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivnrahin ~,.~~~+ do a:~..~..~ea .._ ~_~_.,..~_ - •••-•~ ..r...... ~~ ~~~~~~~, we auuiu~iia miee~s or paper or me same size. fREV-i5o9 EX+ (oi-lo) ,j i~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: .Inhn .I rhaney ~1 17 nd7R If an asset became~omtly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A,Betty J. Chaney 10321 Mowersville Road, Newburg, PA 17240-9706 wife B.Gloria J. Ashway C. JOINTLY OWNED PROPERTY: 1031 Mowersville Road, Newville, PA 17240-9706 I daughter LETTER DATE DESC rrEM NUMBER FOR JOIN TENANT T MADE JOINT RIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE DATE OF DEATH DECEDENT' S DAVALUE OFTM 1 . VALUE OF ASSET INTERESr DECEDENT'S INTEREST . B 2009 Orrstown BankAcct.# 103008487 26,922.45 16.66 4,487.16 2. B 2009 Orrstown Bank Acct. # 4000031971 6,215.18 16.6 6 1, 035.88 3. B 2009 Orrstown Bank Acct. # - 400031658 11,944.17 16.6 6 1, 990.73 TOTAL (Also enter on Line 6, Recapitulation) I # 7 513 77 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) ~: pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER .Inhn .l C:hanav ~ 1 OA7Fi Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A• FUNERAL EXPENSES: 1. Fogelsanger-Bricker Funeral Home B. i ADMINISTRATIVE COSTS; Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: State ZIP z• Attorney Fees: Sponseller/Graham, LLC 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 4• Probate Fees: Register of Wills - Cumberland County 5• Accountant Fees: 6• Tax Return Preparer Fees: ~' Pastor Dale Miller s. Eveready Sunday School Class TOTAL (Also enter on Line 9, Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. 10, 786.50 1,650.00 113.50 150.00 150.00 REV-1737-7 EX + (6-08) REVERSE Pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN NONRESIDENT DECEDENT ESTATE OF FILE NUMBER John J. Chaney 21-12-0476 When flat rate method is elected, list the beneficiaries of the Pennsylvania property When proportionate method is elected, list all beneficiaries. RELATIONSHIP TO ITEM 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 Vansfers under Sec. 2116 (a)(1.2)] 1. Betty J. Chaney - 10321 Mowersville Road, Newburg, PA 17240 wife ( 100% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON REV-1737 COVER SHEET OR THE PROPORTIONATE METHOD WORKSHEET ON THE REVERSE SIDE OF REV-1737 COVER SHEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 TOTAL OF PART II (Enter total non-taxable distributions on Line 13 of REV-1737 cover sheet ) (If more space is needed, use additional sheets of paper of the same size)