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REV-1500 Ex t°'-'°' 1505610101
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania -
Bureau of Individual Taxes D-FT"E"T OFRFIE"UE County Code Year File Number
PO BOX28o6oi INHERITANCE TAX RETURN
Harrisburg, PA 17128-o6o1 RESIDENT DECEDENT r I
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth NY
I8y Llo (pq Og0q)o1 z 031 L, I50
Der,( dents Last Name Suffix D,,,edenCs First Name MI
LEES 0BEPT L
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse,, Fiat Na~ie' Ml
Spouse s Social security N,.mber
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
M 1. Original Return Q 2. Supplemental Return Q 3. Remainder Return (date of death
prior to 12-13-82)
Q 4. Limited Estate Q 4a. Future Interest Compromise (date of Q 5. Federal Estate Tax Return Required
death after 12-12-82)
6. Decedent Died Testate Q 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
Q 9. Litigation Proceeds Received Q 10. Spousal Poverty Credit (date of death Q 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 TO:
Name Davtif; Telephone Irwlber
-JOI CE I REMP~_KL`( 74 5 3
$f220FWILLS EICWLY
> .z" M
~C3st.)
First line of address
33 DT LLEk D R J V E °C-
Second line of address m { r' a P-
~a0„ Ci ~ Ct`~ C:3
City or Post Office State ZIP Code DATE FILED
Sfl IPPENSBUR6 PA I r7a5
Correspondent's e-mail address: hem2fr1V 0 2riAdenta l h0n x?sale. ccryL
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.
SIG RE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
'
, e 5
AD S A7 / ! ~OA
Dil~r Dr►ye~Shi bu , PA 17d5? ; Ia 7N0 DrIVe ~~ht`.aoi~ns , Tr) odS7
SIGNATURE OF PREPARER OTH THAN REP ENTATIVE ATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610101 1505610101 J
J 1505610105
REV-1500 EX
De)cedQent's( Social Security N~u)mber Q
Decedent's Name: RQ~-+ L. Lees t~ q D
1 & `T 4 V'
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 and Notes Receivable (Schedule D) 4. II'' .
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. `4 `i . 4 U
6. Jointly Owned Property (Schedule F) p Separate Billing Requested 6. .
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) p Separate Billing Requested........ 7.
8. Total Gross Assets (total Lines 1 through 7) 8. H L $ .4
9. Funeral Expenses and Administrative Costs (Schedule H) 9. i O .50
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule 1) 10. , W 2 -3_5
11. Total Deductions (total Lines 9 and 10). 11. j LA .85
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. a, 5 0 . l7
14. Net Value Subject to Tax (Line 12 minus Line 13) 14. 4 3 . lD 3
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 t a
at lineal rate X .0 N~ y L 16. (0 LP 3
17. Amount of Line 14 taxable r/ ~1 p
at sibling rate X .12 `-t 1 • Z., I 17. !
18. Amount of Line 14 taxable
at collateral rate X .15 18. •
19. TAX DUE 19. . -5
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
1505610105 1505610105 J
RI=VT1500 EX Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NA E
STREET ADDRESS
P0 16r T~ -
~ )
CITY r STATEn~ - ZIP
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) ~J
2. Credits/Payments
A. Prior Payments _
B. Discount
Total Credits ( A + B) (2) °1• I
3. Interest
(3) 0
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. (4) 0
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 9 1
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 ❑
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? ❑ N
3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ❑ [~t]
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.
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 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 beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) 172 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, whether by blood or adoption.
'EV-1508 EX + (117)
4& SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE RN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Igo bu } L. Lees C90 I a I 159
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
NUMBER DESCRIPTION OF DEATH
CCnSh i n C~ ,~n 01_ - lours fi qy y S. qS
C~
TOTAL (Also enter on line 5, Recapitulation) $ L ` t4 b, 8a
(If more space is needed, insert additional sheets of the same size)
REV-1,511 EX+ (10-06)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Pp bcrt L _ Lees Q>?c)J a - 1)) 16 0)
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
t.
ire paI°cby hts mc+h) r. 2ero cost tD
t.
k1DbeC+- D- K-S CSiVie .
B. ADMINISTRATIVE CASTS: _ DID
1. Personal Representative's Commissions
Name of Personal Representative(s) Jvye Ke l~ f dde_Ki'rby_
Street Address,33.00 ler DYVP's'. [9 - TrV l1 Pl v_(^I7~ e _
City ~?U I, p pe~t~SbLA V-Q State M Zip /,)5
r
Year(s) Commission Paid: 15w.O _ Adele t500. 00
2. 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 of
6. Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $ 6 0
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX+(12-03)
SCHEDULE I
COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
kobc-t L _ Lees e , 01 I'S I
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
Med~`caI~ses lea, ~s
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX+ (11-08)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
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 spousal distributions and transfers under
Sec. 2116 (a) (1.2).]
1. Joyce -:1. H~r"PCr1y Sisitr
Hary-itf L. Lees mclfher 1
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1 ChnafnWr- Cm- ribufiba 5D.00
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 050. 00
If more space is needed, insert additional sheets of the same size.
REGISTER OF WILLS CERTIFICATE OF
CUMBERLAND COUNTY GRANT OF LETTERS
PENNSYLVANIA
No. 2012-01159 PA No. 21-12-1159
Estate Of: ROBERT LESLIE LEES
(First, Middle, Lastl
a/k/a : ROBERT L LEES
Late Of: SOUTHAMPTON TOWNSHIP
CUMBERLAND COUNTY
0 Deceased
Social Security No : 184-40-6448
WHEREAS, on the 9th day of November 2012 an instrument dated
November 22nd 2002 was admitted to probate as the last will of
ROBERT LESLIE LEES
(First, Middle, Last)
a/k/a ROBERT L LEES
late of SOUTHAMPTON TOWNSHIP, CUMBERLAND County,
who died on the 9th day of September 2012 and
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, GLENDA FARNER STRASBAUGH , Register of Wills in and
for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby
certify that I have this day granted Letters TESTAMENTARY to:
JOYCE I HEMPERLY and ADELE C KIRBY
who have duly qualified as EXECUTOR(RIX)
and have agreed to administer the estate according to law, all of which
fully appears of record in my office at CUMBERLAND COUNTY COURTHOUSE,
CARLISLE, PENNSYL VA NIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixe e eal
of my offi ce on the 9th day of November 2012.
y(s o Iii
Deputy
**NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)
LAST WILL AND TESTAMENT
KNOW ALL MEN BY THESE PRESENTS, that I, ROBERT LESLIE LEES, of
16 Irvin Drive, Shippensburg, Pennsylvania being of sound and disposing mind,
memory and understanding, do make, publish and declare this my Last Will and
Testament, hereby revoking all prior wills and codicils by me at any time
heretofore made.
FIRST: I direct the payment of all my legal debts, funeral expenses
including my grave marker and all expenses of my last illness, state, federal
estate and inheritance taxes and administration costs shall be paid from my
residuary estate and shall not be charged or apportioned to any other legatee,
donee, beneficiary or joining tenant as soon as may be conveniently done
following my decease leaving all specific bequests free of tax to the legatee.
SECOND: I give and bequeath my 30:06 Springfield rifle to Tucker
Clayton Kirby. If Tucker Clayton Kirby is under the age of 18 years at the time of
my death, I direct that Terry Kirby keep and maintain the said rifle for Tucker
Clayton Kirby and to deliver it to Tucker Clayton Kirby when he attains the age o
18 years.
THIRD: I give and bequeath any vehicle that I own at the time of my
death to my friend Stephen Shaffer, of Toms River, New Jersey.
FOURTH: I give and bequeath my tools (whether they are hand Lb8s,
shop tools or power tools) in kind, equally according to value, to JeffreVT,-
1' ` rv 7 t..._
Hemperly, Brian Hemperly and Terry Kirby, share and share alike.
• -1
D
fl
hY
FIFTH: The rest and residue of my estate, I give, devise and bequeath to
Harriet Lees and Joyce Hemperly, in equal shares, share and share alike, per
stirpes.
SIXTH: I nominate and appoint Joyce Kemperly and Adele Kirby, as the
Executrices of this my Last Will and Testament. No bond shall be required of
any nature or kind.
IN WITNESS WHEREOF, I, ROBERT LESLIE LEES, to this my Last Will and
Testament set my hand and official seal this-a~- day of 2002.
,C.; 4,-r- (SEAL)
Robert Leslie Lees
Sworn to and subscribed, declared and
Published by Robert Leslie Lees, as
His Last Will and Testament, and so
Done in the presence of we the
Witnesses, who sign at his request,
And in his presence, and in the presence
Of each other.
x2c
~ c
COMMONWEALTH OF PENNSYLVANIA:
:SS
COUNTY OF CUMBERLAND
I, Robert Leslie Lees, whose name is signed to the foregoing instrument,
having been duly qualified according to law, do hereby acknowledge that I
signed it willingly; and that I signed it as my free and voluntary act for the
purpose therein expressed.
Robert Leslie Lees Notarial Seal
H. Anthony Adams, Notary Public
Shippensburg Boro, Cumberland County
My Commission Expires May 15, 2006
Member, Pennsylvania Assoaiatim01 Notaries
Sworn to and acknowledged, before me,
By Robert Leslie Lees, the Testator,
This day of !,v. 2002.
Notary Public Notarial Seat
H. Anthony Adams, Notary Public
Shippensburg Boro, Cumberland County
My Commission Expires May 15, 2006
Member, Pennsylvania Association of notaries
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND :~v
WE, Darlene M. Bigler and Sharon Coleman Adams, the witnesses whose
names are signed to the foregoing instrument, being duly qualified according to
law, do depose and say that we saw the Testator sign and execute the
instrument as his Last Will and Testament; that he signed willingly and that he
executed it as his free and voluntary act for the purposes therein expressed; that
each of us in the hearing and sight of the Testator signed the Will as witnesses,
and that to the best of our knowledge the Testator was at the time at least
eighteen (18) or more years of age and of sound mind and under no constraint
or undue influence.
f I i
l
i
Sworn to and subscribed before me by,
Darlene M. 13igler and Sharon Colem n Adams,
The witnesses, this . day of Jz), 2002
Notary Public
Notarial Seal
H. Anthony Adams, Notary Public
Shippensburg Boro, Cumberland County
My Commission Expires May 15, 2006
Member, Pennsylvania Association of Notaries
T0: Whom it may concern Estate of Robert Leslie Lees
AFFIDAVIT
I, H. Anthony Adams, being duly sworn according to law, do depose and state that I
made a typographical error in drafting the "SIXTH" paragraph of the Last Will and
Testament of Robert Leslie Lees in that I incorrectly spelled Joyce Hemperly's last name
as "Kemperly".
H. Anthony Adams, Esquire
Sworn to and subscribed
This day of September, 2012.
A
Notary Publi
My Commission Expires:
NOTARIAL SEAL
CHRISSY A ZUKAUCKAS
OUTHAMPTON TWP.. CUb1B ANNOOD COUM
my Commissm E>n UK 20. t1
4; J CD
C) C -i
1.1 r7
~-t
4a`
TO: Whom it may concern Estate of Robert Leslie Lees
AFFIDAVIT
I, Joyce Hemperly, being duly sworn according to law, do depose and state that I am
the sister of the decedent, Robert Leslie Lees, and that I am the same individual whose
last name was misspelled as "Kemperly" in the "SIXTH" paragraph of the Last Will and
Testament of Robert Leslie Lees.
J,o, ce emperly
Sworn to and subscribed
This day of Qcr j o 9t it- , 2012.
Notary `dot,rml Qv,,
ry Publi Then~as i Coyne, Noia y
My Commission Expire .'enn'v~~',t"''
A1yComn:,s5~Ls~~e 3tx: ,
Member, Pe s c iviinl
ACCOUNT NO. ACCOUNT TYPE STATEMENT PERIOD PAGE
9859922628 FREE CHECKING OCT.05-NOV.05,2012 1 OF 1
00 0 06825H NM 017
000004793 FIDS1549D01111051211 02 000000 13926
ESTATE OF ROBERT L LEES
L ~s JOYCE I HEMPERLY, EXEC
ADELE C KIRBY, EXEC
33 DILLER DR
SHIPPENSBURG PA 17257
INTEREST EARNED FOR STATEMENT PERIOD 0.00 WALNUT BOTTOM
ACCOUNT SUMMARY
BEGINNING DEPOSITS & OTHER CURRENT ENDING
BALANCE OTHER. ADDITIONS CHECKS PAID SUBTRACTIONS INTEREST PD BALANCE
K. AMOUNT NO. AMOUNT NO. AMOUNT
0.00 3 4,448.48 3 363.83 0 0.00 0.00 4,084.65
ACCOUNT ACTIVITY
POSTING DEPOSITS,INTEREST CHECKS 9 OTHER' DAILY
DATE TRANSACTION DESCRIPTION & OTHER ADDITIONS SUBTRACTIONS BALANCE'
10-05-12 BEGINNING BALANCE 80.00
10-09-12 DEPOSIT 4,290.00 4,290.00
10-15-12 CHECK 97.04 4,192.96
10-16-12 CHECK NUMBER 1001 250.00
10-16-12 CHECK NUMBER 0096
16.79 3,926.17
10-29-12 DEPOSIT 1.37 3,927.54
11-01-12 DEPOSIT 157.11
4,084.65
ENDING BALANCE $4,084.65
i
CHECKS PAID SUMMARY
10-15-12 97.04 96* 10-16-12 16.79 1001* 10-16-12 250.00
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