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Home My WebLink About08-31-12 1505610105 REV-1500 EX (oz- u) (Fq PA Department of Revenue OFFICIAL USE ONLY Pennsylvania Bureau of Individual Taxes Coun Code Year File Number °"""`"`"`°`"`"`""` ty INHERITANCE TAX RETURN PO BOx z8o6oi S ~ Harrisburg, PA 1128-0601 ~ ~ (~ f RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 201-03-8373 01/04/2005 ' 09/16/1919 Decedent's Last Name Suffix Decedent's First Name MI Fox Martha M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Nama Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 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 0 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 ry John C Oszustowicz 717 n 2 g - ~'i ( ) .> 43-743 ~ __ _ ~ _ p. ~ ; rn C`3 ~~ REGISTER S'DSE ON14'17 <./"." First Line of Address U' ~ ~ ~-, 104 S Hanover St ~ ` ~ -» <„ ~ Second Line of Address - ~ W ~ p ~ f s ~r F City or Post Office State ZIP Code . DATE FILED Carlisle PA 17013 Cortespondent'a e-mail address: jOhnO@CarII51epa18W.COm Under penalties of perjury, I declare that I have examined this return, inducting awornpanying schedules and statements, and to Ne best of my knowledge and belief, lt b We, correct and complete. Dedaratan of preparer other then the personal representative is based on all information of which preparer has any knowledge. NATURE OF PERSON RESPONSI LE FOR FI G RETURN ~^^ DATE 900 Rid ., Carlisle, PA 17013 SIGNATUR OF P E AN REPRESENTATIVE DATE ADDRESS ~/3///~ 104 S Hanover St., Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 `„~ 1505610105 1505610105 J 1505610205 REV-1500 EX (FI) Decedent's Social Security Number Dacedent'sName: Martha M Fox 201-03-8373 RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule 8) ....................................... 2 599.00 3. Closely Held Corporation, Partnership or Sole-Propdetorship (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) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 6. Total Gross Assets (total Lines 1 through 7) ............................. g, _. 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9, 599.00 8,033.70 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) .......... ..... 10. 11. Total Deductions (total Lines 9 and 10) ............................ ..... 11. ' 8,033.70 12. Net Value of Estate (Line 8 minus Line 11) ......................... ..... 12. 0.00 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) . . ................. ..... 13. 14. Net Value SubJeet to Tax (Line 12 minus Line 13) ................... ..... 14. 0.00 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- 16 17. Amount of Line 14 taxable at sibling rate X .12 ', 17. 18. Amount of Line l4 taxable - at collateral rate X .15 18 19. TAX DUE .................................................... ..... 19. ' ._ 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 1505610205 1505610205 REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number DECEDENTS NAME Martha M Fox STREET ADDRESS -- --------- - ---- 900 Ridge Rd. CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. FIII in oval on Page 2, Llne 20 to request a refund. 5. Ii Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) 0.00 (3) (4) (5) Make check payable to: REGISTER OF WILLS, AGENT. w a $.~t', >:'~~- a n ~# rv n - i } a,~ it sax x.Aw„,,. . u :a .a ... _ ,., ~;- ~ - ,~x ,.. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a Uansfer and: Yes No a. retain the use or income of the property Vansferred .................................................................................. ........ ^ 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 'in Vust 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. 3 Y ~'.r h 'a~~> 9k" ~ x ry ~ ci E, x °:x . ~ la n ryea. .6 i{G3 v t.. -. (1 "~' a f For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the nett 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 benefiaaries 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. Total Credits (A + B) (2) REV-15o3 IX+(y-ii) ~ pennsylvania DERARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDI~LE B STOCKS & BONDS ESTATE OF FILE NUMBER Martha M Fox 21-05-0618 All property jointly owned with right of survivorship must he disclosed nn a.,~,ea~~m a .~ ~DD~C ,ya~e ., neeaea, insert aaa¢ionai sneets of the same size REV-1511 EX+ (SO-09~ ~ ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAx RETllRN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Martha M. Fox 21-05-0618 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' O'Donnell Funeral Home 908 Hanover Ave, Allentown, PA 18109 7,312.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) ____ _ _ __ __ Street Address City State ZIP Year(s) Commission Paid: Z• Attorney Fees: 3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address_ Gty _____ State ZIP Relationship of Claimant to Decedent 4. Probate Fees: S• Accountant Fees: 6• Tax Return Preparer Fees: ~• The Sentinel -legal advertising B Cumberland County Legal Journal -legal advertising 9 TOTAL (Also enter on line 9 Recapitulation) I ~ If more space is needed, use additional sheets of paper of the same size. 425.00 106.50 115.20 75.00 8,033.70