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Home My WebLink About10-15-12 (2) 15056041125 REV-1500 EX (06-05) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number ,i PO BOX 280601 INHERITANCE TAX RETURN %~ Hamsburg, PA 17128-0601 RESIDENT DECEDENT d ~ I ~ ~O~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 0 5 0 2 2 0 1 2 1 2 3 1 1 9 2 3 Decedent's Last Name L E W I S TIVE (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number MI A MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return ^X 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number W I L L I A M D O U G L A S 7 1 7 2 4 3 1 7 9 0 Firm Name (If Applicable) _. I REGISTE~F WILLS US~£}NLY D O U G L A S L A W O F F I C E `~,O rw Ca r•- C`1 First line of address ~~ ~ ~ C"~ ~ - ~-ti 4 3 W S O U T H S T Second line of address City or Post Office C A R L I S L E Correspondent's a-mail address Suffix Decedent's First Name D E L I A State ZIP Code - P A 1 7 0 1 3 ~ ~ .' ~' -~r G v, ;, cn Dom-," , ~~ -~14fE FILED . _.~ C..' ~__- r"t i t-~ r_ _ ,- ,,.- -r; r- ~~ O 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, coned and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. 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(l l aull snulw g aull) a3eaS3;o anleA~aN 'Z6 0 0 5 T ' L L .. ..... .. ..... ............. (0 L '8 6 scull le;o;) suol;onpad le;ol ' L L 'OL .. ..... .. ... (I alnPa4oS) suall +g 'sal;lllge1l a6e6yoy~ ';uapaoa4;o s;qaa 'Ol .6 ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' (H alnpayoS) s;so0 and;e~;siulwpy ~ sasuadx3 le~aun~ 'g 0 0 5 T 8 T ~ 8 T 6 6 .8 .. ......................... (L-1 sau!l leiol) sassy sso~0 le~ol '8 8 T b 8 T 6 6 •L ~ ~ ~ ' ' ' ' Pa;sanbaa 6u!II!8 a;e~edag ~ (O alnpayoS) " ~(~adad a;egad-uoN snoauellaoslW +g spa;sued son!A-~aaul L •g • • • ~ • • • pa;sanbaa 6u!II!9 a;e~edag ~ (d alnpayog) ~}~adad paum0 ~1;u!of '9 •g • ~ • ~ ~ ~ ~ (3 alnpayog) ~fpadad leuos~ad snoauel~aoslW ~ s;lsodaa ~lueg 'yse~ .5 .b .. ...................... (d alnPa4oS) algenlaoaH sa;oN ~ sa6e6}~ow 'q .£ .. ... (O alnpayog) d!4s~o;al~dad-clog ~o dlys~au~ed 'uol;e~od~o0 PIaH ~(lasol0 '£ .Z .. ................................ (e alnPa4oS) spuog pue s~loo~S ~Z . ` .. ...................................... (y alnpayog) a;e;sa leab ~ ~ NOllt/lfllld110321 8 T E S 6 8 5 0~ S I M'3'I ' K K I'Z ~Q aweN s,tuapaaaa ~agwnN ~(;unoag leloog s,;uapaoaa X3 0051-A32i 9ZTZb0950ST R,EV-1500 ESC Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME DELIA A. LEWIS _ _ _ -- - _ _ --- STREET ADDRESS CITY STATE ZIP Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit _ B. Prior Payments _ C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty (1) $14,125.38 Total Credits (A + B + C) (2) $0.00 Total Interest/Penalty (D + E ) 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. (3) $0.00 (4) $0.00 (5) $14,125.38 (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) $14,125.38 Make Check Payab/e to: REG/STER OF W/LLS, 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 : ...................................................................... ^ X^ b. retain the right to designate who shall use the property transferred or its income; ............................... ^ X^ c. retain a reversionary interest; or ................................................................................................ ^ X^ d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ Q 3. Did decedent own an "in trust 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? .................................................................................................. ^ 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 January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (O) 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 twenty-one 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 zero (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 four and one-half (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 twelve (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. LAST WILL AND TESTAMENT I, DELIA ANN LEWIS, of Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, declare the following to be my last will and testament, hereby revoking any and all wills heretofore made by me. Item I. I direct my executrix hereinafter named to pay all my just debts and funeral expenses. Item III. I give, devise and bequeath all my property, both real and personal, to be divided as follows: A. Fifteen (15%) percent to Bonalee Winkler B. All the rest, residue and remainder of my estate to my niece, Glenna Taylor Cox. However, if Glenna Taylor Cox should predecease me, the remainder of said property (after the above-mentioned portion given to Bonalee Winkler) is to go to the heirs and assigns of Glenna Taylor Cox. Item IV. I nominate, constitute and appoint my iece, Glenna Taylor Cox, as my executrix, and direct that she shall serve without bond. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ', h____day of September, 2006, -, ~ DELIA ANN LEWIS Signed, sealed, published and declared by the above named testatrix, as and for her last will and testament, who at her request, in her presence, in our presence, and in the presence of each other have hereunto subscribed our names as attesting witnesses: /r/ ///~"J i; / k`~ COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ~ r ., We, ~,~;~ ~ ' . -~ and C ~-„~f_~ ~ ~~.~ i ,/att.." ~~ whose names are signed to the attached or for oing inst~ ment, being duly qualified according to law, do depose and say that were present and saw testatrix sign and execute the instrument as her last will, and that she signed willingly and that she executed it as her free and voluntary act for the purposes therein contained, that each of us in the hearing and sight of the testatrix signed the will as witnesses; .and that to the best of our knowledge, the testatrix was at that time 18 or more years of age, of sound mind and der no c s into ndue influence. . ~, Sworn to and subscribed before me th1_s 1 ~,~' day of ptember, 2006. NotHiai sai Anne M. Cox, Notary Public Ca~ia 8orou~h, Cumbe~iand County My ConNNinbn Expi~s June 3, 2005 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND I, DELIA ANN LEWIS, whose name is signed to the attached or foregoing instrument, having been duly qualified according to Iaw, do hereby acknowledge that I signed and executed the instrument as my last will, that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. -; ~ , ; , Delia Ann Lewis Sworn to and subscribed before me this the ~` day of September, 2006 ,v~~ ~-~~I,~L~ ~,~~'~_ otar Y lrotarisi Seal AmN M. Cox, Nohry Public Care 8oro~ph, Cumberland County MY CommNtion Expires June 3, ~0! REV-1510 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER DELTA A. LEWIS This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIRRELATIONSHIPTODECEDENTAND THE DATE OF TRANSFER ATTACHACOPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD'S INTEREST EXCLUSION QFAPPLICABLE) TAXABLE VALUE 1. SOVEREIGN BANK CD $47,187.69 100. $47,187.69 Account Number 1675541476 2. SOVEREIGN BANK CD $46,996.49 100. $46,996.49 Account Number 59543.76 TOTAL (Also enter on line 7 Recapitulation) 13 94 184 18 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8r INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER DELTA A. LEWIS Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. 1. FUNERAL EXPENSES: B. ADMINISTRATIVE COSTS: ~, Personal Representative's Commissions Name of Personal Representative (s) Soaal Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: p, Attorney Fees 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 5 Accountant's Fees 6. Tax Return Preparers Fees 7, Filing Fee $15.00 TOTAL (Also enter on line 9, Recapitulation) I $ 1 (If more space is needed, insert additional sheets of the same size) REV-1513 EX + (9-00) SCHEDULE) COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER DELIA A. LEWIS RELATIONSHIP TO 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 sppoousal distributions, and transfers under Sec. 9116 (a) (1.2)j 1. Glenna Cox Collateral $94,169.18 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET S (It more space is needed, insert additional sheets of the same size) Sovereign Bank ESTATE OF Delia A. Lewis __ SOCIAL SECURITY #: 405-34-5318 DATE OF DEATH: May 2, 2012 Account #: 1671077903 Type: Checking Open date: 10/27/2006 In the name of: Delia A Lewis (Glenna T Cox POA) Date of Death Balance: $300.81 Int.(YTD) from 1/1/2012 to 4/24/2012 $0.01 Accrued interest to date of death: $0.00 Other Info: Account #: 1675541476 Type: CD In the name of: Delia A Lewis ITF Glenna T Cox BENEF Open date: 10/27/2006 Date of Death Balance: $47,187.69 Int.(YTD) from 1/1/2012 to 4/30/2012 Accrued interest to date of death: $2.33 Otherlnfo: Account #: 1675541484 Type: CD In the name of: Delia A Lewis ITF Glenna T Cox BENEF $93.76 Open date: 10/27/2006 Date of Death Balance: $59,543.76 Int.(YTD) from 1/1/2012 to 4/30/2012 Accrued interest to date of death: $12.33 Other Info: $495.34 Page 1 of 1 ~ nv6~c9 t~ ~-I ~ ~Q ~ ~ ~. cso