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Home My WebLink About12-05-12 1505611185 REV-1500 EX (02-11) (FI) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes PO BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 198-20-5693 05272012 06151929 Decedent's Last Name Suffix Decedent's First Name MI EVANS WARREN D (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI EVANS FAYNELLE N Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW F 7x 1. Original Return ❑ 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 Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number VICKY ANN TRIMMER 717-620-244:5 Cl> E2 OL9rER OF WILLS USMNJ;J CIO ~ C7 CS3 w°~~ First Line of Address 1a r,a r T A~~ CIS PERSUN & HEIM, PC -M c~ c, --t1 -,-y t Second Line of Address C> p ry PO BOX 659 r'-v f- r n DATE ED Cf City or Post Office State ZIP Code F--~ MECHANICSBURG PA 170550659 Correspondent's e-mail address: VATRIMMER@PERSUNHEIM • 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. SIGN RE OF PERSON RESPONSJBtEjFOR FILING R TURN DATE ADDRE,116 FAYNELLE N• EVANS 518 E WINDING HILL RD, MECH• 17055 SIGNATURE OF PREPARER OTHER THAN REPRESE E DATE PERSUN & HEIM, P•C• NTAT 12.1 ADDRESS PO BOX 659 MECHANICSBURG PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 1505611185 OM46473.000 1505611185 z _J 1505611285 REV-1500 EX (Fl) Decedent's Social Security Number 198-20-5693 Decedent's Name: E V A N S WARREN D RECAPITULATION 1. Real Estate (Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0.00 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . 2 3,758-00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . , . . 3. 0 • 00 4. Mortgages and Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . q 0 • 00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) . . . . . 5. 0 • 00 6. Jointly Owned Property (Schedule F) ❑ Separate Billing Requested . . . . g 0 . 00 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested . . . . 7. 1661975 . 00 8. Total Gross Assets (total Lines 1 through 7) . . . . . . . . . . . . . . . . . . 8 170,733 • 00 9. Funeral Expenses and Administrative Costs (Schedule H) . . . . . . . . . . . . . 9. 0 • 00 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule 1) . . . . . , . . . 10 0 • 00 11. Total Deductions (total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . 1 1 0 • 00 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . 12 1 7 0 , 7 3 3 • 00 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . 11 0 • 00 14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . 14. 170,733 • 00 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)(1.2)X.0 1701733-00 15. 0.00 16. Amount of Line 14 t xable at lineal rate X .0 4 9 0.00 16. 0.00 17. Amount of Line 14 taxable at sibling rate X .12 0.00 17 0.00 18. Amount of Line 14 taxable at collateral rate X .15 0.00 18. 0.00 19. TAX DUE ...................................19. 0.00 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ Side 2 1505611285 1505611285 OM4648 1000 REV-1500 ESC (FI) Page 3 File Number DecQdent's Complete Address: DECEDENTS NAME EVANS WARREN D STREET ADDRESS 518 EAST WINDING HILL ROAD CUMBERLAND CITY STATE ZIP MECHANICSBURG PA 17055- Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 0. 00 2. Credits/Payments A. Prior Payments 0.00 B. Discount 0.00 Total Credits ( A + B ) (2) 0.00 3. Interest (3) 0.00 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 refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 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 . . . . . . . . . . . . . . . . . . . . . . . . 1:1 X b. retain the right to designate who shall use the property transferred or its income . . . . . . . . . . ❑ EK c. retain a reversionary interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. receive the promise for life of either payments, benefits or care? . . . . . . . . . . . . . . . . . . ❑ FX1 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? . ❑ Fil 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(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. OM4671 2.000 REV-1503 EX -16-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Warren D Evans All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1.121 Shares Met Life Stock 3,758 TOTAL (Also enter on line 2, Recapitulation) $ 3 , 758 3W4696 1 000 (If more space is needed, insert additional sheets of the same size) REV-1510 EX ~ (os-os) SCHEDULE G pennsylvania DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Warren D Evans This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INCLLDETFE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE NUMBS TI-EDATEOFTRANSFER ATTACH ACOPY OF THE DEED FOR REAL ESTATE VALUE OF ASSET INTEREST IF APPLICABLE VALUE 1. PSECU Roth IRA 12,033 100.0000 0 12,033 Payable to spouse 2 TIAA-CREFF IRA 25,650 100.0000 0 25,650 Payable to spouse 3 PSERS Pension 0 100.0000 0 0 Payable to spouse Exempt for PA 4 PSECU IRA 129,292 100.0000 0 129,292 Payable to spouse TOTAL (Also enter on line 7, Recapitulation) $ 166,975 If more space is needed, use additional sheets of paper of the same size. 9W46AF 2.000 REV-1513 EX,, (01-10) SCHEDULE J Pennsylvania DEPARTMENTOF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Warren D Evans RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. Faynelle N. Evans 518 East Winding Hill Road Mechanicsburg, PA 17055 PSECU IRA Inventory Value: 129,292 PSECU Roth IRA Inventory Value: 12,033 PSERS Pension TIAA-CREFF IRA Inventory Value: 25,650 Met Life Stock 100% of Residue: 3,758 Surviving Spouse 170,733 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 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 0 9W46AI 2 000 If more space is needed, use additional sheets of paper of the same size. . Persun & Heim, P.C. Attorneys at Law IRS NO. 26-3786257 LLOYD R. PERSUN 1700 Bent Creek Boulevard GARY J. HEIM Suite 160 JACK M. HARTMAN Mechanicsburg, PA 17050 MATTHEW E. HAMLIN* VICKY ANN TRIMMER** Please reply to: (717) 620-2440 JENNIFER DENCHAK WETZEL PO Box 659 FAX: (717) 620-2442 Mechanicsburg, PA 17055-0659 *ALSO NEW YORK BAR HTTP://WWW.PERSUNHEIM.COM vatrimmer@persunheim.com ALSO A CPA December 4, 2012 Cumberland County Register of Wills Cumberland Courthouse 1 Courthouse Square, I" Floor Carlisle, PA 17013-3387 Certified Mail, Return Receipt Requested Re: Estate of Warren D. Evans Dear Sir or Madam: Enclosed for filing are the following: 1. Original and one copy of an Inventory; 2. Original and one copy of a Pennsylvania Inheritance Tax Return, along with a copy of the tax return to be time stamped; 3. A check made out to the Register of Wills in the amount of $58.50 for filing fees; 4. A self-addressed, postage prepaid envelope for return mail. Please file the original Inventory and Inheritance Tax Return. Please forward a copy of the Inheritance Tax Return to the Pennsylvania Department of Revenue. Please return a date-stamped copy of the Inventory and the cover page of the tax return to my attention in the enclosed envelope. Please do not hesitate to call with any questions. Thank you for your assistance. Very truly yours, Vicky Ann Trimmer 3`O r41~ VAT:slb co 4? , ~~j Enclosures = X, r- cc : Faynelle Evans, w/o encl. r Z rm cr1 CO LD r> .nom rv t ~ 30399v1 co -r1 i__A i z b vOi o ~ a o ~ a to croz~'r ~z z a rn ~o zo a tsi a ~ o H z r ~ y r. J 9 V O N ~ C7 N O G~ N Q L fU r r_ C3 O ~ n~nn Q O O PD n ' Y O ~ z o ~CD nn a o M !ter V) o o ~ o a a t way ~ b a Z r Ir L,J co N can z g z 20 o Ir v rt (D arc, z o [b 0 m" o C) rri 17D 4D N °a' 71) M C7 c-D sf) a C/ a u, ~ ;P , C-.5 ....g : _3;:. M. fV 16. "e o o UNI »G7N -R w '7A C7 ~ ~ `~mOv z -n - m