HomeMy WebLinkAbout08-08-12 (4)1505610105
REV-1500 ~ (oz-ii) (FI) j!,
enns lvania OFFICIAL USE ONLY
PA Department of Revenue P Y County Code Year
Bureau of Individual Taxes OEPAAT4CNT O~RCVCNUC
PO BOX z8o6oi INHERITANCE TAX RETURN ~ j
Harrisbur , PA 1~1z8-o6o1 RESIDENT DECEDENT `
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYW
149-14-0008 05/16/2012 12/15/1923
Decedent's Last Name Suffix Decedent's First Name
Wik Thomas
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
C~ 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)
~ 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}
MI
J
MI
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
Dale Wik (717) 423-6806
First Line of Address
33 Byers Road
Second Line of Address
City or Post Office
Shippensburg
Correspondent's a-mail address:
State ZIP Code
PA 17257
REGISTER OF W~S USE ONLY t„
_
,
C~7 =~; ~.
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~ ~-
C'? C ~
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DATE FEED
b. • •
.t-
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` O~F-PERS N RESPONS_ LE FOR FILING RETURN DATE
`~-~ ~ ~~
ADDRESS
33 Byers Road, Shippensburg, PA 17257
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
L 1505610105
Side 1
1505610105 J
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File Number
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1505610205
REV-1500 EX (FI)
Decedent's Social Security Number
Decedent's Name:
149-14-0008
RECAPITULATION
1. Real Estate (Schedule A) ........................................ ..... 1. 158,000.00
2. Stocks and Bonds (Schedule B) .......... . ....................... ..... 2. 0.00
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00
4. Mort a es and Notes Receivable Schedule D
9 9 ( ) ......................
.....
4. 0.00
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).. ..... 5. 17,199.77
6. Jointly Owned Property (Schedule F) O Separate Billing Requested .. ..... 6. 0.00
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested... ..... 7. 75,050.00
8. Total Gross Assets total Lines 1 throw h 7
( 9 ) ........................ 8.
..... 250,249.77
9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 24,626.29
10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) .......... ..... 10. 728.17
11. Total Deductions (total Lines 9 and 10) ............................ ..... 11. 25,354.46
12. Net Value of Estate (Line 8 minus Line 11) ......................... ..... 12. 224,895.31
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ................... ..... 13. 0.00
14. Net Value Subject to Tax (Line 12 minus Line 13) ................... ..... 14. 224,895.31
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 4 224,895.31 16_ 8,995.81
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19. TAX DUE .................................................... .....19. 8,995.81
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
1505610205 1505610205
REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Thomas J. VVik
---- - - --
STREET ADDRESS
33 Byers Road
CITY STATE !ZIP
Shippensburg PA ; 17257
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) 9,097.14
2. Credits/Payments
A. Prior Payments ---- -- - --- - --- -- -- --- --- -_
B. Discount
Total Credits (A + B) (2) 0.00
3. Interest
(3) Q.00
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. (4) 0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 9,097.14
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 transfen-ed 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 "in trust 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 fT 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-1502 EX+ (ll-OS)
~ pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Thomas J. Wik 21-12-572
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
If more space is needed, insert additional sheets of the same size.
y~Z-1'~NrOR
_~ 9 ~~~~~~~~ Q~~~= A. Settlement Statement (HUD-1)
SRN oaJti~~
B. Type of Loan
OMB Approval No. 2502-0265
1. ~ FHA 2. QX RHS 3. ~ Conv. Unins.
4. ~ VA 5. ~ Conv Ins. 6. File Number:
12-0103 7. Loan Number:
7700370245 8. Mortgage Insurance Case Number:
C. Note: This form is furnished to give you a statement of actual settlement costs. Amounts paid fo and by the settlement agenf are shown.
Items marked "(p.o.c.)"were paid outside the closing; they are shown here for informational purposes and are not included in the fota/s.
D. Name and Address of Borrower:
Garrido R. Davis
Kristina M. Davis
1576 Lindsey Lot Road
Shippensburg, PA 17257 E. Name and Address of Seller:
Dale J. Wik, Executor
33 Byers Road
Shippensburg, PA 17257 F. Name and Address of Lender:
Mortgage Network, Inc.
300 Rosewood Drive
Danvers, MA 01923
G. Property Location:
959 Ridge Road
Shippensburg, PA 17257
Cumberland County, Pennsylvania H. Settlement Agent: 20-2339545
AbstrailAmerica Real Estate Settlement Solutions
65 Ken-Mar Drive
Shermansdale, PA 17090 Ph. (717)514-4114 I. Settlement Date:
August 3, 2012
Place of Settlement:
128 East King Street
Shippensburg, PA 17257
J. Summary of Borrowers transaction K. Summary of Seller's transaction
100. GrossAmount Due from Borrower: 400. Gross Amount Due to Seller:
101. Contrail sales rice 158,000.00 401. Contrail sales price 158
000
00
102. Personal ropert 402. Personal ro e ,
.
103. Settlement Char es to Borrower (Line 1400 9,695.27 403.
104. 404.
105. 405.
Ad'ustments for items aid b Seller in advance Ad'ustments for items aid b Seller in advance
106. Co/Town Taxes to 406. Co/Town Taxes to
107. School Taxes to 407. School Taxes to
108. Assessments to 408. Assessments to
109. 409.
110. 410.
111. 411.
112. 412.
120. Gross Amount Due from Borrower 167,695.27 420. Gross Amount Due to Seller 158
000.00
200. Amounts Paid b or in Behalf of Borrower 500. Reductions in Amount Due Seller: ,
201. De osit or earnest mone 1,000.00 501. Excess de osit (see instruilions
202. Princpal amount of new loan(s) 161,224.00 502. Settlement char es to Seller (Line 1400) 11
003
20
203. Existin loan(s) taken sub'eil to 503. Existin loan(s) taken sub'eil to ,
.
204. 504. Payoff First Mortgage
205. 505. Pa off Second Mort a e
206. 506.
207• 507. De osit disb. as proceeds
208. 508.
209. Seller Paid Closin Costs 5,530.00 509. Seller Paid Closin Costs 5
530
00
Ad'ustments for items un aid b Seller Ad'ustments for items un aid b Seller ,
.
210. Co/Town Taxes to 510. ColTown Taxes to
211. School Taxes to 511. School Taxes to
212. Assessments to 512. Assessments to
213. 513.
214. 514.
215. 515.
216. 516.
217. 517.
218. 518.
219. 519.
220. Total Paid by/for Borrower 167,754.00 520. Total Reduction Amount Due Seller 16
533
20
300. Cash at Settlement from/to Borrower 600. Cash at settlement to/from Seller ,
.
301. Gross amount due from Borrower (line 120 167,695.27 601. Gross amount due to Seller line 420 158
000
00
302. Less amount paid by/for Borrower (line 220) ( 167,754.00) 602. Less reductions due Seller (line 520) ,
.
( 16
533
20)
303. Cash ~ From ~ To Borrower 58.73 603. Cash ^X To ~ From Seller ,
.
141,466.80
The undersigned hereby acknowledge receipt of a completed copy of this statement ~ any attachments referred to herein
Borrower y~~ ~~~~ Seller ;' ~ ~~~. ~,L,,-~~'
ll~~~~ ~
Ga~dc R. D vis !~" ~~`_,.,_ Dale J. Wik, Execu ~ r
Kri tins M. Davis
The Public Reporting &rdenfor this cdlection of irformation is estimated at 35 minutes per response for cdlecting, reviewing, and reporting the data This agency may not cdlect this irformation, and you are not required to complete
this form, unless it displays a arrer>tly valid OIvB contrd amber. No confidentiality is assureo; this dsclosure is marx~cry. This is designed to provide the parties to a RESPAcovered transaction wih information during the settlement
process.
Page 1 of 3 HUD-1
(12-0103. PF D/12-0103/28)
L. Settlement Charges
700. Total Real Estate Broker Fees $ 9,208.20
Division of commission (line 700) as follows:
701. $ 9,108.20 to JA/Lex Real Estate Services, LLC
Note: Line 701 IndudesAd'ustment of -100.00 For Commission Credit
702. $ to JA/Lex Real Estate Services LLC
703. Commission aid at settlement
704.
705.
800. Items Payable in Connection with Loan
Paid From Pad From
Borrower's Seller's
Finds at Fuds at
Settlement Settlemerrt
20
801. Our on ination char e $ 974.00 from GFE #1) `~ ~ " ""~"''"
802. Your credit or charge (points) for the specific interest rate chosen $ -1,551.40 (from GFE #2) c„~; ~~'
3,. ; ~ \ ' ~ u, a
,. :..
4~;.
803. Your adjusted origination charges
from GFE #A
-577.40 `"
~.. ~< .
;:.
,~~;
~~
804. Appraisal fee to Ro ersAp raisal Services, Inc. (from GFE #3) 440.00 ~. .~~
805. Credit Re ort to Birchwood Credi Services, Inc. (from GFE #3) 60.00 < ~~>
806. Tax service to
807. Flood certification to
LPS National Flood (from GFE #3)
(from GFE #3) :•'~'
~' w:
10.00 •;; ~ a
u
808. Final Inspection to Rogers Appraisal Services, Inc. (from GFE #3) 75.00 ~~
809. FNMA LQI Update to Birchwood Credit Services, Inc. (from GFE #3) 50.00 <;
810. (from GFE #3)
811 •
9M Itnme Rcn~~ircrl by 1 nnrlnrfn Rn Doirl in Arlv~nne (from GFE #3)
vMM v~ MVI VV vv 1 PIM 111 /'1Y ~QIIV~'i
901. Daily interest charges from 08/03/12 to 09/01/12 29 @ $16.560000/day (from GFE #10) 480.24 .,.off
902. Mort a e insurance remium for months to RHDA-Guarantee Fee (from GFE #3) 3,224 48
903. Homeowner's insurance for 1.0 ears to Erie Insurance (from GFE #11) 631.00
904. from GFE #11
905. (from GFE #11)
1000. Reserves Deposited with Lender
1001. Initial deposit for your escrow account (from GFE #9) 507.04
omeowner s insurance 4. mont s 5 .5 per mont ~ ~ ~ ~ ~ ~° ~~
1003. Mort a e insurance 2.000 months $ 39.97 per month $ 79.94 ~ ~,
1004. Pro ert taxes $
~ '
1005. $
_ ,b~.
:fin'..{...
•~
• ~~~. ~~ ~ ~ ~~, ~ ~•r• ~ o.. c~.vw i i iii iu w Lw ~ G! .J I der mOrtin ~ CI t5.4t5
1007. 2013-2014 School Tax 3.000 months at7 ~ 133 FiFi nPr mnnth ~ dnn raR
1008. $ ~ ~ ' . 3 ~,~~~ ~„
1009. $ -402.68
JJ AA T!il_ /~1_______
1 y{.J
1101. Title services and lender's title insurance (from GFE #4) 1,460.00 15.00
1102. Settlement or dosin fee $ ~°,~.,, `: ~ ,, ,,;~ :,,nT,.:
1103. Owner's title insurance to Fidelity National Title Insurance Co. from GFE #5 5.00
1104. Lender's title insurance to Fidelity National Title Insurance Co. $ 1,340.00 ?- °' 3 `
,• ` ., 2.
1105. Lender's title oli limit $ 161,224.00 ~ \~ •~' ~ \~~~
1106. Owner's title poli limit $ 158,000.00 •~ ~ ~ ~ `
~ ... ~~
..
1107. A ent's ortion of the total title insurance remium to ABSTRACT AMERICA REAL ESTATE SE $ 1,143 25 ' ~
1108. Underwriter's portion of the total title insurance premium to Fidelit National Title Insurance Co. $ 201.75 ~ ~° ~;~,•r,z;_° n~ ~~
1109.
1110.
1111.
1112.
1113.
1200. Government Recording and Transfer Charges
1201. Government recordln char es to Cumberland Coun Recorder of Deeds from GFE #7) 146.00 '°~~~~~~~~ ~~~ F~
1202. Deed $ 62.00 Mortgage $ 84.00 Releases $ Other $ ~::
<:4.:.:...<
,
1203. Transfe r taxes to Cumberland County Recorder of Deeds (from GFE #8) 1,580.00 •" .~ '~' * `°`~~~~~-
1204. City/County tax/stamps Deed $ 1,580.00 Mortgage $ ,., ;.
~_, `; ; , . _ ~•
1205. State tax/stamps Deed $ 1,580.00 Mort a e $ ., ;~` .~~:,,,>:.:;; ;,. _; 1,580.00
1206.
1207.
1300. Additional Settlement Charges
1301. Required services that ou can sho for (from GFE #6 ~, ~ ;~
bl ~~
1302. Harr E. Killian to Har E. Killian 1 603.91
1303.
1304. Se tic Pum in to Sunda Se tic 200.00
1305. See addit'I disb. exhibit to 100.00
1400. Total Settlement Char es (enter on lines 103, Section J and 502, Section K) 9,695.27 11,003.20
f^ / /" .. ~ /
By sigiing page 1 of this statement, the sigrgtories acknaMedge receipt of a completed copy of page 2 & 3 of tf~is three slat ~ _, ? ~~
/ /F
AbstractAmerica eal Estate Settlement Solutions, Settlement Agent
Page 2 of 3 HUD-1
(12-0103.PFD/12-0103/28)
Comparison of Good Faith Estimate (GFE) and HUD-1 Charges Good Faith Estimate HUD-1
Charged That Cannot Increase HUD-1 Line Number
Our origination charge # 801 974.00 974.00
Your credit or charge (points) for the spedfic interest rate chosen # 802 -1,551.40 -1,551.40
Your adjusted origination charges # 803 -577.40 -577.40
Transfer taxes #1203 1,580.00 1,580.00
Charges That in Total Cannot Increase More than 10% Good Faith Estimate HUD-1
Government recording charges #1201 175.00 146.00
Appraisal fee # 804
440.00
440.00
Credit report # 805 60.00 60.00
Flood cert~cation # 807 21.00 10.00
Final Inspection # 808 75.00
FNMALQI Update # 809 25.00 50.00
Mortgage Insurance Premium # 902 3,224.48 3,224.48
Title services and lender's title insurance # 1101 1,613.00 1,460.00
Owner's title insurance to Fidelity National Title Insurance Co. #1103 5.00 5.00
Total 5,563.48 5,470.48
Increase between GFE and HUD-1 Charges $ -93.00 or -1.67°/
Charges That Can Change Good Faith Estimate HUD-1
Initial deposit for your escrow account #1001 1,664.26 507.04
Daily interest charges # 901 $ 16.560000/day 480.00 480.24
Homeowner's insurance # 903 600.00 631.00
Loan Terms
Your initial loan amount is $ 161,224.00
Your loan term is 30 years
Your initial interest rate is 3.7500
Your initial monthly amount owed for principal, interest and $ 786.62 indudes
any mortgage insurance is ~ Prindpal
a Interest
^X Mortgage Insurance
Can your interest rate rise? ^X No ^ Yes, it can rise to a maximum of %. The first
change will be on and can change again every _ months after
. Every change date, your interest rate can increase or decrease
by %. Over the life of the loan, your interest rate is guaranteed
to never be lower than % or higher than %.
Even if you make payments on time, can your loan balance rise? ^X No ^ Yes, it can rise to a maximum of $
Even if you make payments on time, can your monthly ^X No ^ Yes, the first increase can be on and the monthly
amount owed for principal, interest, and mortgage insurance rise? amount owed can rise to $
The maximum it can ever rise to is $
Does your loan have a prepayment penalty? X No Yes, our maximum re a
^ ^ y p p yment penalty is $
Does your loan have a balloon payment? Q No ^ Yes, you have a balloon payment of $
due in _ years on
Total monthly amount owed including escrow account payments ^ You do not have a monthly escrow payment for items, such as property
taxes and homeowner's insurance. You must pay these items directly
yourself.
^X You have an additional monthly escrow payment of $213.55 that results
in a total initial monthly amount owed of $1,000.17. This indudes
principal, interest, any mortgage insurance and any items checked below:
^X Property taxes ^X Homeowner's insurance
^ Flood insurance ^
^ ^
Note: If you have any questions about the Settlement Charges and Loan Terms listed on this form, please contact your lender.
Page 3 of 3 HUD-1
(12-0103. PFD/12-0103/28)
HUD-1 Attachment
Borrower(s): Garrick R. Davis and Kristina M. Davis Seller(s): Dale J. Wik, Executor
1576 Lindsey Lot Road 33 Byers Road
Shippensburg, PA 17257 Shippensburg, PA 17257
Lender: Mortgage Network, Inc.
SettlementAgent: Abstract America Real Estate Settlement Solutions
(717)514-4114
Place of Settlement: 128 East King Street
Shippensburg, PA 17257
Settlement Date: August 3, 2012
Property Location: 959 Ridge Road
Shippensburg, PA 17257
Cumberland County, Pennsylvania
Additional Disbursements
Payee/Description Note/Ref No. Borrower Seller
Bob Eckenrode Builder 100.00
Repairs
Total Additional Disbursements shown on Line 1305 $ 0.00 $ 100.00
Adjusted Origination Charge Details
Origination Charge
974.00
to Mortgage Network, Inc.
Total $ 974.00
Origination Credit/Charge (points) for the specific interest rate chosen
Credit/Charge -1,551.40
to Mortgage Network, Inc.
Total $ -1,551.40
Adjusted Origination Charges $ -577.40
Reserves Deposited with Lender
Homeowner's Insurance 210.32
4.000 at 52.58 per month
Mortgage Insurance 79 94
2.000 at 39.97 per month
2013 Co/Twp. Tax 218.48
8.000 at 27.31 per month
2013-2014 School Tax 400.98
3.000 at133.66 per month
-402.68
month
Total $ 507.04
Title Services and Lender's Title Insurance Details BORROWER SELLER
Closing Protection Letter
to Fidelity National Title Insurance Co.
Overnight Delivery
to USPS
75.00
45.00
WARNING: It is a crime to knowingly make false statements to the United States on this or any similar form. Penalties upon conviction can
include a fine and imprisonment. For details see: Title 18 U.S. Code Section 1001 and Section 1010.
(12-0103. PFD/12-0103/28)
HUD-1 Attachment - Continued
Tax Certification Fee 15.00
to Abstract America Real Estate Settlement Solutions
Lender's title insurance 1,340.00
to Fidelity National Title Insurance Co.
Total $ 1,460.00 $ 15.00
Owner's Title Insurance BORROWER SELLER
Owner's Policy Premium 5.00
to Fidelity National Title Insurance Co.
Total $ 5.00 $ 0.00
Lender's Title Insurance
'"fees also shown above in Title Services and Lender's Title Insurance Details BORROWER SELLER
Lender's Policy Premium
to Fidelity National Title Insurance Co.
Lender's Endorsement Charges
Endorsement Endorsement Charge
ALTA Endorsement Form 100 50.00
ALTA Endorsement Form 300 50.00
ALTA Endorsement Form 8.1 (Environmental Protection Lien) 50.00
Tota I
1,190.00
150.00
$ 1,340.00 $ 0.00
WARNING: It is a crime to knowingly make false statements to the United States on this or any similar form. Penalties upon conviction can
include a fine and imprisonment. For details see: Title 18 U.S. Code Section 1001 and Section 1010.
(12-0103.PFD/12-0103/28)
REV-15o8 EX+ (ii-io)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Thomas J. Wik 21-12-572
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.
If more space is needed, use additional sheets of paper of the same size.
REV-1510 EX+ (08-0°)
~ pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Thomas J. Wk 21-12-572
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.
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE] VALUE
1. Thomas Wik -Son - 05/15/2012 13,000.00 13,000.00
2 Janet Colondrillo -Daughter - 05/15/2012 13,000.00 13,000.00
3 Gerald Wik -Son - 05/15/2012 13,000.00 13,000.00
4 Dale Wik -Son - 05/15/2012 13,000.00 13,000.00
5 Carol Linn -Daughter - 05/15/2012 13,000.00 13,000.00
6 Doris Wik -Daughter-in-law - 05/15/2012 10,050.00 10,050.00
TOTAL (Also enter on Line 7, Recapitulation) $ I 75,050.00
If more space is needed, use additions! 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
Thomas J. Wik 21-12-572
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
~' Fogelsanger-Bricker Funeral Home 7,185.00
2 Ministry 100.00
3 Shipwrech Restaurant 484.59
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City -- - _ __ - __ -- - _ _ _ State _ _ ZIP _ _
Year(s) Commission Paid:
2. Attorney Fees:
3. Fami{y 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:
5. Accountant Fees:
6. Tax Return Preparer Fees:
~• Fee's for Sale of House
TOTAL (Also enter on Line 9, Recapitulation) I $
If more space is needed, use additional sheets of paper of the same size.
323.50
16, 533.20
24,626.29
hEU-1512 EX+ (1Z-08)
~ pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Thomas J. Wk 21-12-572
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
If more space is needed, insert additional sheets of the same size.