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HomeMy WebLinkAbout11-26-12 (2)1505611185 REV-1500 EX (02-11)(FI) PA Department of Revenue OFFICIAL USE ONLY Bureau of Intlivitlual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN 21 12 0584 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MM DDYYVV Date Of Birth MMDDYYri 10272011 12211922 Decedent's Last Name Suffix Decedent's First Name M I SMITH LOUISE A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffiz Spouse's First Name M I Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE - - REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (Date of Death ^ 4 Limited Estate ^ 4 Prior to 12-13-82) ^ . a. Future Interest Compromise (date of 5. Federal Estate Tax Return Requiretl © 6 Decedent Died Testate ^ death after 12-12-82) 7 D d t M i . (Attach Copy of Will) . ece en a ntained a Living Trust (Attach Copy of Trust.) _ 8. Total Number of Sate Deposit Boxes ^ 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 Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JEFFREY A• ERNICO, ES4• 717-232-5000 First Line of Address 3401 NORTH FRONT STREET Second Line of Address PO BOX 5950 City or Post Office State ZIP Code HARRISBURG PA 1711~095~ REGISTER OF WILLS USE ONLY n r ('1 !moo rV u-. n ~_. T Uzi -n =5 C T) correspondent'se-malt address: JAERNICOaMETTE•COM Under penalties of perjury, I declare that I have exeminetl this return, including accompanying schedules entl statements, and to the bast N my knowledge and belief, it is true, correct and complete. Declaration of preperer other than the personal representative is based on~ll infyrtnation of which preparer has any knowledge. K• SMITH 10206 DAYLILY COURT M 110 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DA E METTE, EVANS 8 WOODSIDE a-I I~ ADDRESS 3401 N• FRONT STREET., PO BOX 5950 HARRISBURG, PA 17110-095 PLEASE USE ORIGINAL FORM ONLY 1505611185 Side 1 OM4647 3.000 1505611185 1505611285 REV-1500 EX (FI) Decedent's Social Security Number Decedent's Name: SMITH 0 ITC p RECAPITULATION 1. Real Estate (Schedule A) .. .. , ~ Q 0 2. Stocks and Bonds (Schedule B) ... .. .. 2 12 , 3 8 8.5 4 3. Closely Heltl Corporation, Partnership or Sole-Proprietorship (Schedule C), g ~ • 0 Q 4. Mortgages and Notes Receivable (Schedule D) 4 a • O Q 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) 5, 1 ~ 2 , 7 2 9.6 0 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested g 0 • OO 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested 7. ~ , ~ ~ 8. Total Gross Assets (total Lines 1 through 7) 8 115 , 118 • 14 9. Funeral Expenses antl Administrative Costs (Schedule H). .. g_ 7 , 9 7 8 • 7 4 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) 10 1 , 324 • 50 11. Total Deductions (total Lines 9 and 10), . „ 9 , 303.2 4 12. Net Value of Estate (Line 8 minus Line 11) . 1 z. 1 O 5 , 814.9 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) , .. , 3 1 O ,181.5 0 14. Net Value SubjeettoTax (Line 12 minus Line 13) 14. 95, 633.40 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers un er Sec. 9116 (a)(1.z)x.o 0.00 ts. 0.00 i6. Amount of Line 14 xable 4~ at lineal ratex.o 95, 633.41 1s. 4 , 303.50 17. Amount of Line 14 taxable at sibling rateX.12 ~•~~ 17 ~•~0 18. Amount of Line 14 taxable at collateral rateX.15 x•00 t8. o•aa 1s. TAxouE 1s. 4,303.50 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505611285 1505611285 OM4846 3.000 REV-1500 EX (FI) Page 3 DECerten4's Cnm nlefe Add~nac• File Number ___ LJr LC LIJ09 DECEDENTS NAME STREET ADDRESS CITY 5iATE ZIP Tax Payments and Credits: 1. TaxDUe(Page2,Line19) (1) 4,303.50 2. Credits/Payments A. Prior Payments p , p p B. Discount p , p p Total Cretlits (A + B) (2> p . p p 3. Interest (3) - 40.9 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refuntl. (4) p . p p 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 4 a 4 4 - 4 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 ........................... ^ ...... d. receive the promise for life of either payments, benefits or care? .................. ^ 2. If death occurretl after Dec. 12, 1982, did decedent transfer property within one year of tleath without receiving atlequate consideration? .................... ^ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? . ^ 4. Ditl 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 O AND FILE IT AS PART OF THE RETURN. For tlates of death on or after July 1, 1994, antl before Jan. 1, 1995, the tax rate imposetl 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)]. Far dates of tleath 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 imposetl on the net value of transfers from a tleceasetl 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 chiltl is 0 percent [72 P.S. §9116(a)(1.2)]. • The taz rate imposetl on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as notetl 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 tlefinetl, untler Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or atloption. omasri z.aoo REV-1503 E%~ 1698) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERRANCETAX RETURN RESIDENT DECEDENT NUMBER Louise A. Smith 1 1 0 84 All property jointly-owned with right of survivorship must be tlisclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1.1,161-063 Shares Praxis Intermediate Income Fund C1 A CUSIP: MI IAX 12,368.54 1,161.063 shares at $10.67 per share Held in Keystone Financial Associates Investment Account #72028451; see attached valuation. TOTAL (Also enter on line 2, Recaphulation) $ 12 388 54 3wasss toot (If more space is needetl, insert atltldional sheets of the same size) REV-~ sce EX. (~ taol Pennsylvania SCHEDULE E oERARTntENroF REVENUE I CASH, BANK DEPOSITS & MISC NHERITANCE TAX RETURN RESIOENi DECEDENT , . PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Louise A. Smith 21 12 0584 Inclutle the proceeds of litigation and the dale the proceeds were received by the estate . All orooertv jointly nwnod with d.,ra ..r ~.~..n.....~r,:.. ....._. ~_ .:__~___ __ .._~ _.... _ ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH t. 3,000 Par Alliance Development Fund Certificate o£ Deposit 4635 3 000.00 2 PNC Money Market Account #51-1300-8415 37,305.06 Interest accrued to 10/27/2011 1.23 3 PNC Checking Account #50-7010-2099 6,435.07 4 PNC Checking Account #50-7009-8966 5,110.32 5 Wells Fargo Savings Account #6861975560 50,713.46 6 Refund, Messiah Village 164.46 TorAL (Also enter on line 5 Recapitulation) S ~ 102 owa6AD 2.ooD If more space is needed, use additional sheets of paper of the same s¢e. REV-1511 EX~ Doa9) Pennsylvania DEPARTMEMOF REVENUE INHERITANCE TAX RETURN RESIDEM DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Louisa A. Smith t ~ naan Decedent's debts must be reported on Schetlule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL F~(PENSES: t_ Miscellaneous funeral expenses 600.00 B. 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City __ State ZIP 2. Attorney Fees: 3. Family Exemption: (If decetlenl's adtlress is not the same as claimant's, attach explanation.) Claimant Street Address 4. 5. s. 7. 1 2 Year(s) Commission Paitl: City State ZIP Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Taz Return Preparer Fees: Cumberland Law Journal Legal advertisement The Patriot News Legal advertisement Total from continuation schedules 6,500.00 361.50 285.00 75.00 137.24 20.00 9 W48AG 2 Ono TOTAL (Also enter on Line 9, Recaplt If more space is needetl, use additional sheets of paper of the same size. 978 REV-1512 E%~ ry2-~) Pennsylvania SCHEDULE I oEPPRTMENI'OF REVENUE DEBTS OF DECEDENT RNEe RsmErr~oEC DENT~RN , MORTGAGE LIABILITIES & LIENS `~ ~ ~ ~ ` `~~ FILE NUMBER Louise A. Smith 21 12 0584 Report tlebts incurred by the decedent prior to tleath that remained unpaid at the date of death, inclutling unreimbureed metlical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~~ Alert Pharmacy Pharmacy bills 1,135.10 2 AF6L Insurance Company Automatic deduction for insurance premium 68.80 3 Sanford Roumm Acharya Rheumatology LLC Medical bill 100.60 swasAN z.ooo If more space is needed, insert adtlitional sheets of the same size. REV-1513 EX+(01-10) Pennsylvania DEPRRTMENTOF REVENUE INHERRANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ° '"~"' 21 1 2 0564 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 pnUude outright spousal daMbulions antl transfers under Sec. 9116 (a) (1.2).] 1. David K. Smith 10206 Daylily Court Manassas, VA 20110 30$ of Residue: 30,544.47 Son 30,544.47 2 Douglas Smith 1135 Deep Canyon Drive Clayton, NC 27520 30$ of Residue: 30,544.47 Son 30,544.47 3 Karen Roberts 731 Woodbine Avenue Rochester, NY 14619 30~ of Residue: 30,544.47 Daughter 30,544.47 ENTER DOLLAR AMOUNTS FOR DISTRIBUTONS SHOWN ABOVE ON LINES 15 THROUGH 1 8 OF REV-1500 COVER SHEET, AS APP ROPRIATE. II NON-TAXABLE DISTRIBUTONS A. SPOUSAL DISTRIBU110NS UNDER SECl1ON 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARRABLE AND GOVERNMENTAL DISTRIBUTIONS: 1~ See Attached 1 TOTAL OF PART II • ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 10 , 181.50 SCHEDULE J BENEFICIARIES swasni z.ooo ° ~~~~~= way= ~~ ~~~_~_~, u~c eumuvnai sneers or paper or me same aze. Estate of: Louise A. Smith Schedule J Part 1 (Page 2) Item No. Description 4 Lisa Marie Weaber 132 Granby Park Norfolk, VA 23505 Specific monetary bequest 1,000.00 5 Angela L. Cabrera 100 Robin Street Rochester, NY 14613-2130 Specific monetary bequest 1,000.00 6 Andrea L. Schamberger 127 State Street Seneca Falls, NY 13148 Specific monetary bequest 1,000.00 7 Todd D. Smith 84 Brentwood Drive Selma, NC 27576 Specific monetary bequest 1,000.00 Relation Granddaughter Granddaughter Granddaughter Grandson 21 12 0584 Amount 1,000.00 1,000.00 1,000.00 1,000.00 Estate o£: Louise A. Smith 21 12 0584 Schedule J Part 2B (Page 1) Item No. Description Amount 1 Oil City Community Christian and Missionary Alliance Church 411 Seneca Street PO Box 945 Oil City, PA 16301 29 of Residue: 2,036.30 2 The Christian and Missionary Alliance, The Orchard Foundation PO Box 35660 Colorado Springs, CO 80935-3566 3$ of Residue: 3,054.45 3 Grantham Brethren in Christ Church 421 Grantham Road Mechanicsburg, PA 17055 2$ of Residue: 2,036.30 4 Messiah Village Endowment Fund 100 Mount Allen Drive Mechanicsburg, PA 17055 38 of Residue: 3,054.45 2,036.30 3,054.45 2,036.30 3,054.45