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Home My WebLink About09-25-12 (2).~ REV-1500 Ex `01-1°' 1505610143 OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Vear File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE Po Box.2sosot INHERITANCE TAX RETURN 2 1 ~Q ~~g Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 02 05 2008 09 29 1955 Decedent's Last Name Suffix Decedent's First Name MI KEMPER TERRY M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI KEMPER JULIE M 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 ^ 2. Supplemental Retum ^ 3. Remainder Return (date of death prior to t2-13-82) ^ 4 Limited Estate ^ qa, Future Interest Compromise ^ 5. Federal Estate Tax Return Required (date or death after 12-12-82) ^ 8 Decedent Died Testate ^ 7. Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes - (Attach Copy of Wilp (Attach Copy of Trust) ^ 9. Litigation Proceeds Received ^ ~ p. Spousal Poverty Credit (date of death ^ ~ ~ _ Election to tax under Sec. 9113(A) between 12-31-91 end 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number TERRENCE J KERWIN 717 362 3215 First line of address 4245 STATE ROUTE 209 Second line of address City or Post Office ELIZABETHVILLE REGISTER OFy,I(ILLS USE O~Y N 'v !n r*~ ~ c4, ~ 7D ' N r--~ f U;:, ~ ~ C/1 ::3~ G:"7 ~ ~..,, C ~ ~ _ r~ '"r'l C DATE F D - = , . State ZIP Code r , `,7 PA 17023 ~ ~- Correspondent'se-mail address: tjk~kerWinlaWl`irm.COm 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. Julie M. Kemper Argali Lane, Mechanicsburg, PA 17055 `/- /fs ~/ a-- SIGNATURE OF PREPARER O ER T N EPRESENTATIVE DATE ~ ~//'/"~~„~ Terrence J Kerwin ~~- f ~ - ~ a-- ADDRESS - 4245 State ute 209, Elizabethville, PA 17023 Side 1 1505610143 1505610143 1505610243 REV-1500 EX Decedent's Social Security Number oeoecen~sNeme KEMPER, TERRY M. 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 & Notes Receivable (Schedule D) ........................................................ .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... . 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............ . 6. 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ............ . 7. 8. Total Gross Assets (total Lines 1-7) ...................................................................... . 8. 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... .. 9. 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) .............................. .. 10. 11. Total Deductions (total Lines 9 & 10) .................................................................... .. 11. 12. Net Value of Estate (Line 8 minus Line 11) ........................................................... .. 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............................................... .. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ............................................... .. 14. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 2 '] 1 3 0 2 2 15 , (a)(1.2) X .00 , 16. Amount of Line 14 taxable at lineal rate X .045 16. 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. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 27,274.22 27,274.22 _ _ _..-- _ 144.00 144.00 27,130.22 27,130.22 0.00 0.00 Side 2 1505610243 1505610243 REV-1500 EX Page 3 File Number 21 Decedent's Complete Address: Kemper, Terry M. ___ STREET ADDRESS 46 Argali Lane CITY STATE ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount (1) 0.00 Total Credits (A + B) (2) 3. Interest (g) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2 Line 20 to request a refund 0.00 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.0 ~ 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; or .................................................................................................................. ~ 0 d. receive the promise for life of either payments, benefits or care? .............................................................. ~_] ~_ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........................................................................................ ' x ............................... I 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 abeneficiary designation? ...................................................................................................................... x 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 Januarryy 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 stafute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retturn 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 1.2) [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) . A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, wFether by bloo~ or adoption. SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY INHERRANCE TAX RETURN RESIDENT DECEDENT - - -- - - - FILE NUMBER -- - ESTATE OF Kemper, Terry M. 21 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE OF NUMBER DESCRIPTION DEATH 1 Medical professional liability litigation docketed to Cumberland County Civil Action No. 10-0494. 27,274.22 $27,274.22 of the gross settlement pertains to the survival action. Settlement approved August 6, 2012 by Order of Court (see attached) TOTAL (Also enter on Line 5, Recapitulation) 27,274.22 SC:FEDULE H FUNERAL. EXPENSES 8~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ,~A~~CT T~e~ RESIDENT DECEDENT ~~w~ wv ~ ~ v-~ ESTATE OF Kemper, Terry M. ----_ . _ _ _ _ _- - --- P --------- Debts of decedent must be re orted on Schedule I. ITEM DESCRIPTION NUMBER I FUNERAL EXPENSES: A. B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) FILE NUMBER 21 AMOUNT Street Address II City State Zip Year(s) Commission paid 2 ' Attorney's Fees 3. ', Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant __ - Street Address City Relationship of Claimant to Decedent 4. ; Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. i Other Administrative Costs 1 I Register of Wills -additional probate fee --- _ -I'----_ _ _ - -------- State Zip ' I i TOTAL (Also enter on line 9, Recapitulation) 39.00 70.00 144.00 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Kemper, Terry M ScheckAe H w~~F,u~>le~ralME~er>ISes ~ /"~1^1~YpY~~ 2 Register of Wills -filing fee for inheritance tax return & inventory 3 ', Register of Wills -Release FILE NUMBER 21 ---- - --~ ii i 30.00 5.00 Page 2 of Schedule H REV-1617 EX+ (11 AB) SCHEDULE) COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT -- ----- ESTATE OF Kemper, Terry M. NUMBER ' NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I~ ',TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)) 1 j Julie M. Kemper it 46 Argali Road ~, Mechanicsburg, PA 17055 II. RELATIONSHIP TO DECEDENT Do Not Ust Trustee(s) spouse FILE NUMBER 21 SHARE OF ESTATE (Words) 100% Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet, as appropriate. AMOUNT OF ESTATE ($$$) NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON L-NE 13 OF REV-1500 COVER SHEET' - - ---- 0.00