HomeMy WebLinkAbout11-07-12 (2)1505610140
REV-1500 ~` `°'-'°'
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
Po Box2aosot INHERITANCE TAX RETURN 2 1 1 2 0 9 3 6
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Secudty Number Date of Death MMDDVYYY Date of Birth MMDDVYYY
Decedent's last Name Suffix Decedent's First Name MI
J O hN N S O N W I L L I A M M
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
^X 1. Odginal Retum ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
pdorto 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Retum Required
death after 12-12-82)
^X 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 ~ 111. 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:
Nam e Da~rtime Telephone Number
M
U R, R E L W A L
T E
R S I I I ESQ r~~
7 1 7 6 ~~ 4 6~ 0_ =L~
First line of address
5 4 E M A I N S T R E E T
Second line of address
City or Posy Offce
M E C H A N I C S B U R G
State ZIP Code ~
P A 1 7 0 5 5
E
t0 USE ON =-~~
- ~
C
- I i
-
._ -r
`J
DATE FILED
Correspondent's a-mail adtlress:
Under penalties of penury, I declafe that I have examined this return, iricluding accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, coned and complete. Odclapd5~ of praparer other than the personal representative is based on all Information d which preparer has env knowledge.
Z
MECHANICSBURG
SIGNATURE OF
REPRESENTATIVE
III 54 E. MAIN ST.
FORM ONLY
Side 1
1505610190 L505610140
REV-1500 EX
WILLIAM M. JOHNSON
1505610240
RECAPITULATION
1. Real Estate (Schedule A) ......................................... .. 1.
2. StocM~.s 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.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .... ... 6.
7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property
(Schedule G) ~ Separate Billing Requested .... ... 7.
8. Total Gross Assets (total Lines 1 through 7) ........................ ... 8.
9. Funeral Expenses andAdministrative Costs (Schedule H) ............... ... 9.
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .......... ... 10.
11. Total) Deductions (total Lines 9 and 10) ............................ ... 11.
12. Net Value of Estate (Line 8 minus Line 11) ......................... ... 12.
13. Charxtabla and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has mot been made (Schedule J) ................... ... 13.
Decedent's Social Security Number
47862,49
47862,49
3 5 0 5.3 2
1181.99
4 6 8 7.3 1
4 3 1 7 5. 1 8
2 0 0 0 0.0 0
14. Net Value Subject to .Tax (Line 12 minus Line 13) .. ............. ..... .. 14. 2 3 1 7 5 . 1 8
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal taz rate; or
transfers under Sec. 9116
(a)(1.z)x.o _ 0. 0 0 15. 0, 0 0
16. Amount of Line 14 taxable
at lineal rate X .045 16. O , O O
17. Amount of Line 14 taxable
al sibling rate X .12 O. O O 17. O. O O
18. Amount of Line 14 taxable
2 3
1 7 5
1
8
3 4 7 6
2
8
at coulateral rate x .15 . 16. .
19. TAX DUE ...................................................... 19.
20. FILL IN THE OVAL IF'YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610240
3 4 7 6.2 8
1505610290 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 12 0936
DECEDENT'S NAME
WILLIAM M. JOHNSON
STREET ADDRESS
5225 WILSON LANE
_ _ _
CITY
MECHANICSBUF2G STATE
PA ZIP
17055
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Pdor Payments
B. Discount 0.00
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 R, Llne 20 to request a refund.
(1) 3,476.28
Total Credits (A + B) (2) 0.00
(3)
(4) 0.00
5. If Line 1 +Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 3,476.28
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent makes transfer and: Yes No
zi. retain the use or income of the property transferred : ................................................................ ...... ^
t.. retain the right to designate who shall use the property transferred or its income : ......................... ...... ^ ^X
c.. retain a reversionary interest, or .......................................................................................... ...... ^
cl. receive the promise for life of either payments, benefits or care? ................................................. ...... ^ ^X
2. 11` death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? ................................................................................. ...... ^ ^X
3, Did decedent own an "intrust for" orpayable-upon-0eath 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 a beneficiary designaiion? ............................................................................................ ...... ^
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 fhe use of the surviving spouse is 0 percent
p2 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
f ling 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(1.2) [72 P.S. §9116(a)(1)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-1508 EX+ (71-10)
pennsylvania ~ SCHEDULE E
DEPARTMENT OF REVENUE
CASH, BANK DEPOSITS, & MISC.
INHERITANCE TA%RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
FILE NUMBER:
WILLIAM M. JOHNSON 21 12 0936
Include the proceeds of litigation and the date the proceeds were received by the estate.
All orooerly ioindv owned with right of survivorshlo must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. SOVEREIGN BANK 47,528.49
CHECKING
2. HIGHMARK 334.00
INSURANCE REFUND
TOTAL (Also enter on Line 5,
If more space is needed, insed 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
WILLIAM M. JOHNSON 21 12 0936
Decedent's debts must be reported on Schedule 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. HOFFMAN-ROTH FUNERAL HOME -CARLISLE, PA 192.11
2. BETHANY VILLAGE -FUNERAL LUNCHEON 756.71
B. ADMINISTRATIVE COSTS:
1. Personal Represerilative Commissions:
Name(s)otPersonalRepresentative(s) WILLIAM C. RANGE
street Address 62 LONGWOOD DRIVE
city MECrHANICSBURG state PA ZIP
Year(s)CommissionPaid: (RENOUNCED)
p. AttomeyFees: MURREL R. WALTERS, III
3. Family Exemption: (Ildecedenl'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: CUMBERLAND COUNTY REGISTER OF WILLS
5, I Accountant Fees:
6. I Taz Retum Preparerfees:
7
TOTAL (Also enter on Line 9, Recapitulation) I E
If more space is needed, use addilional sheets of paper of the same size.
2,400.00
156.50
REV-1512 EX+ (12-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
WILLIAM M. JOHNSON 21 12 0936
Reparl debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. WEST SHORE EMS 102.44
AMBULANCE
2. BETHANY VILLAGE 1,029.55
R',ESIDENTIAL CARE
3. HAMPDEN PHYSICIANS ASSOCIATION 50.00
MEDICAL
TOTAL (Also enter on Line 10, Recapitulation) I S 1 1
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
OEPAftTMENT OF REVENUE BENEFICIARIES
INHERITANCE TA%RETURN
RESIDENT DECEDENT
FILE NUMBER:
WILLIAM M. JOHNSON 21 12 0936
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLEE DISTRIBUTIONS pnclude ouMght spousal distributions and Vansfers under
Sec. 9116 (a)(1.2).)
1. STEPHEN SMITH Collateral
427 CAMINO HERMOSO
SAN MARCOS, CA 92078
2. DIANE: RANDOLPH Collateral
294 BISHOP'S FOREST DRIVE
WALTHAM, MA 024'54
3. ROSALIND SMITH Collateral
427 CAMINO HERMOSO
SAN h1ARCOS, CA 92078
4. ARTHUR E. DAVIS Collateral
58 BURWICK DRIVE
MECHIANICSBURG, PA 17050
5. KENNETH MOOR Collateral
83 W. VINE STREET
SHIRE:MANSTOWN, PA 17011
6. CHASE MICHAEL FUNK Collateral
SU:>ANNE E. FUNK, 3773 DERRY STREET
HARRISBURG, PA 17111
7. WILLhAM & KAY Rf~NGE Collateral
62 LONGWOOD Df~IVE
MECHIANICSBURG; PA 17050
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-Tf~XABLE DISTRIBU IONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1. GETTYSBURG COLLEGE, MAJOR PLAN GIVING, ATTN: BRIAN SALEK 10,000.00
P.O. BOX 423
GETTYSBURG, PA 17325
2. BETHANY VILLAGE NURSING SCHOLARSHIP, ATTN: J.D. SHURMAN 10,000.00
325 WESLEY DRIVE
MECHANICSBURG,PA17055
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S 20 000.00
If more space is needed, use additional sheets of paper of the same size.