HomeMy WebLinkAbout01-04-131505610101
REV-1500 ~` ~°'-1O' 4~1
PA Department of Revenue pennsylvattia
OEP~NTNENT OF PEVENUF
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO BOX 28o6oi
Harrisburg, PA 1'7128-o6oi RESIDENT DECEDENT
OFFICIAL USE ONLY
Code Year File Number
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
! 7 / ~ 3(c / /~o/ / / 1 19'3/
Decedent's Last Name Suffix Decedent's First Name MI
R ~4GEL :~.. ~,,
~ Lo~SE
L
~,~
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
J ~N GEL ~ ~.S
.~,,.,. , , ~ r ._. -.,
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death
prior to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 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 Nu,~ber
Cpl-r~~~/L~~ E ~: ~h-~ 1 ~ F L1.~~ I .~ l /,.E __
Firsllmmt ~~line of address
Se~co~Jnd line of address
City or Post Office State
~~ Ch'.4~~/'C`SxB~U~I~G P~
l~al3'1tE~ F VIR~3 U$~(~k1f
:x7 ;~-.. r" .~..p C:J
I.,, ~ a ,.1 r'el
~ tr'7
ti .. , R._a ~~ Q
DATE~ED ~
ZIP Code
~.
Correspondent's a-mail address: Cesh;gilds 3(~ Carn~asfi net'
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.
SIGNATUR PERS PAMST6LE FOR FILING RE RN l Z' ~E
ADDRESS S (/~N L .~E1Q/~//~'~z ~ Sfl~p F/CST /FrENIl /VDT/ I -~ ~
LEW/ sTq/I/, /19~sS 9 ~z ~--
SIGNATURE EPA ER O~R T A EP ENT~IVE ~
X ~ DATE
i~ 3/Z
ADDRESS CHI¢IQL~S ~' SH/EI.~S ~ !(SE.Z -r-
- ~/E-r~~rN~CS.es u~. pig !loss
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610101 1505610101
J
1505610105
REV 1500 EX
G~ T ~ ~~d~ Decedent's Social Security Number
Decedent's Name: ~L~~.SG L . /s.~F~r~,/~VT(.s~ l 7 ' ~ ~;, a6 ~¢ [~u ~ ~ 7j ¢ ,~ a G
RECAPRULATION
1. Real Estate (Schedule A) ............................................. 1. ~ ~ 0 A Q :<
e
2. Stocks and Bonds (Schedule B) ....................................... 2. ' ,, v°~
~~ ~
~ --
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. D ~ D
6. Jointly Owned Property (Schedule F} O Separate Bring Requested ....... 6. Q~ O ,
7. Inter-Verbs Transfers 8 Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7. ~ =, 6 ~ S Q O D
:.. _
................... 8.
8_ Total Grose Asaets (total Lines 1 through 7) .......... ~ b , 0
9. Funeral Ex nses and Administrative Costs Schedule H ..............
~ ( ) .
.... s ~
.'~ b { _ }
fl ~~
J ~ ~~~ -; ~ r~ ~,tiP` ~4
~
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ......... ..... 10. A
: ~';
,r{ ~
+: 4 ~:
11. Total Deductions (fatal Lines 9 and 10) ............................ ..... 11. a
_.+5~~` ~.~~ P
12. Net Yalue of Estate (Line 8 minus Line 11) ......................... ..... 12. ~ / '' ~ 6 ~ 3 0
13. Charitable and t.,ovemmental Bequests/Sec 9113 Trusts for which - "` '~'~""~`
an election to tax has not been made (Schedule J) ................... ..... 13. { ~ ~x ~ O tl
14. Net Value Subiect to Tax (Line 12 minus Line 13) ................... ..... 14. / a ^ ~ ~ 3 ` D
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 ~ ~ ~ ~ ~ "~
16. Amount of Line 14 taxable
at lineal rate X .0 }~' ~ a 16.
17 Amount of Line 14 taxable
. at sibling. rate X .12 { ~
~ D Li ~ 17.
18. Amount of Line 14 taxable p
~
at collateral rate X .15 18.
19. TAX DUE .............. ................................ ........... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610105 1505610105
O
J
REV-tStOIX ~ ItAg
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE G
INTER-VIVOS TRANSFERS ~
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
~'~o~ s~ L . Td.ern,c~~l a/-/o //9D
This schedule must be completed and filed 'rf the answer to any of questions t through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
'"~1-°~T"E"^~°FT'~Tra"s~eREF.TMeRREtATaHSwaTOOECroEnrta+~TMEU+TEOETRAHSFER.
ATTACHACOPY OF THE DEFO FOR REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET 96 OF
DECD'S
INTEREST
EXCLUSION
~r APPLICABLE
TAXABLE VALUE
t ~ ?R~ i4~ou~ f l~elc~ ark 111 em bu-s ~sf
~;~P,rr,, ~ Cn;cl, ~ Uh i on , /'h BGGt ~.» ~ Csb u rnJ
!vt ~ ')Za>~a.) ulhoun~' e~ /6~ DS p, oo , .
c,.Jo le tM ~ Sin T n a rl '~
~ ase sf' c~eeeclent
TOTAL (Also enter on line 7, Recapitulation) I t l~, DSO, ~°
(tf more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (10-06}
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES ~
INHERITANCE TAX RETURN ADMINISTRATIVE CC>STS
RESIDENT DECEDENT
ESTATE OF ~. FILE NUMBER
~loi5~ L. 1 ~ut-na gel ~/_ ~ a _ ~j~-o
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
~.
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s) ~n ~ ~'nQ 9U WQ~ ~~
Street Address y J
City State Zip
Year(s) Commission Paid:
2- Attorney Fees Cliotr~CS ~, df1~~Gt5 ~ ~(l7L~Lr ~'j'•MII'IG~
3• Family Exemption: (If decedents address is not the same as daimant's, attach explanation) ~~ti~
Claimant _ NDT ~ApUC'/l,BLE ~ Pi~ESEN7• C//PG'!{A1S ?JlfN~
Street Address
City State Zip
Relationship of Claimant to Decedent t
4. Probate Fees ~ 0-' I GihQ~ i SSf~1G df ~rf CP,/' ~~ 17 Ct~~Ls ~ ~ ~~ sd
t! ~f
5• Accountant's Fees
6• Tax Return Preparer's Fees
Q ,rte /S. O~
~~//(/~p /V4T~: See ~4i~U~ P~~/a~a1~o~ ~i~ilt~~+/~
TOTAL (Also enter on tine 9, Recapitulation) $ `l ~ ~, 5Q
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX+ (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF ~ - FILE NUMBER
~Jo i se L . /~e~ha ye/ a~-/o- /! yv
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RE Do Not LfstTrust CEDENT AMOUNT OR SHARE
ee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
,. 2~~mL1g, S~ fur- as A~ay ba/ r~pvan~, ~~.s
~r!~ !4 S~DO U Se ~t'~/~ 4~Cd /~C Sc1 rvi r/e 5 ~ s~Jv U S G /00 f d
16o days, ~.~Yi~Gli he tiQS:
Svcs ~ ~erna9el
YSfO ~r5f ~~. N,o~I~~ ~c~r .2~/
1.ew;s~n, /~yid .ssys.~.
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-15(10 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART Il -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET ( $
(If more space is needed, insert additional sheets of the same size)
J
j~'~ WILL AND TESTAMENT
Z, EIAIBE L. TJERNAGEL, currently residing at 47'~
Wood Cre t
Drive, Mechanicsburg, Pennsylvania 19055, and being o~ jsound mi d
and memory, do hereby make, declare and publish this t ~e my Let t
Will and Testament, hereby revoking any and all Wills n~d Codici s
i
heretofore made by me. `
ITEM I. I direct pay personal repreaantative to p all of m
debts, funeral and administrative expanses as soon as c,nvenien
after my decease.
STEM II. I give and bequeath certain items of t~ible
personal property to those persons designated in a se a~ate
writing, if such a writing is in existence at the tim ~f my
death, signed by me and attached to this will, descri i~q those
items and recipients of them as required by law. If u~h a
writing is not so attached, then this gift shall lapse a~d becom
a part of my residuary estate. {
ITEM III. All the rest, residue and remainder of m property
real and personal, I give, devise and bequeath to my p~use, Sv
L. Tjernagel.
i
ITEM IV. In the event my spouse should predeceas ~e or fa
to survive me by a period of sixty (60) days, I give n~t bequea
all my tangible personal property to my spouse's chil e~, namel
Steven L. Tjernagel, Susan Lorraine Tjernagel Crowe an ~,aurie Ari
Tjernagel, in equal shares, share and share alike.
ITEM V. In the event my spouse should predeceas ~e or fai
to survive me by a period of sixty (60) ys, then, in h~t event,
ELOI E L. TJERN
w a
~ ~ M F'
$$ as
a
ooW°~~
A ~~z
o ~ ~~
~~`~ °~
v
__ _ i
I give and bequeath all the rest, residue and rema skier of y
estate to the SVEN L. TJERNAGEL and ELOISE L. TJERNAG L~REVOCAB E
LIVING TRUST. This property shall be distributed by h~ Truste
separate and apart from this nY Last Wiil and Testamen .i If for
any reason this bequest is not operative or is invalid br if th
aforesaid Trust fails or has been revoked, I give ,residua
estate to the TRUSTEE named to mct in the aforesaid rust, and I
direct said TRUSTEB to divide, ad~ainister, hold and di t~ibute t
trust estate pursuant to the provisions of the aforesa d'Trust,
hereinbefore reterred.to, as such provisions now exist tp the sa
extent and in the same manner as though the aforesai trust we
herein set forth in full. The TRUSTEE, or any SUCCE S~R TRUST
named in the aforesaid Trust shall serve without bond.
i
ITEM VI. I authorize and empower my personal rep e~entativ
to sell any real and/or personal property owned by me a1~ my deat
and not specitically devised or bequeathed herein, at a tl~er publi
or private sale or sales. and to give good and suff client dee
and/or bills of sale therefore, in !ee simple, as I ojuld do i
living. My representative is authorized and empowered o~engage i
any business in which I may be engaged at my death, for s~ch perio
of time after my death as seems expedient to said rep tentative
i
ITEM vli. I nominate and appoint my spouse to bet eipersonal
representative,of my estate, to serve without bond. I for any
reason my spouse cannot or does not serve, then I~appo rjt m
Y
ELOISE L. TJ GEL
i
2
i
_.. .._ -
sister, Kay Lane Gray, currently residing in Canandaigu ,New York
to be the substitute personal representative without e;filinq a
any bond. and within the ease powers.
IN WITNESS WHEREOF, I have hereunto set ay hand at _
Pennsylvania, this ~L~ day of
in the year One Thousand Nine Hundred Ninety-One.
I
~ ~ i
ELOISE L. TJ
i
i
The within and foregoing instruaent consisting of ~s and two
(2~ other pages was at the date hereof signed and s,aled any
published and declared to ba her Last Will and Testame in ~
our presence.
~ ~
We have hereto subscribed our Haase in her presen ~ and
in the presence of each other and at her r est, a
Pennsylvania, this ,~~~ day of
fn the year One Thousand Nine Hundred Ninety-One.
/~
n A [ 1 v~
Address S/~j
.? ~!
W tneas
I
Address 5~/<) (-~~~ .'~ .
_.
Address
r
COPlMONWBALTH OF ~
~
8Y1,~r
~
~
D~ ) To-wit:
COUNTY/CITY OF ~!/F~I~C~ ~ 1'y~
.
Before me, the undersigned authorit
appeared ELOI3B L. TJEitNAagi, Y• on this da
~ersonal]
own to sae to ,and
e Tes a rix an e w messes, r
whose naaes era signed to the attached or f
s ~ '
ct vely
oregoing ins
all of these persons being by me first duly sworn,
TJERNAGBL, the Testatri r men nc~
LOISE L
x, declared to me and to the wit
presence that s~-id instrument is he a sas in m
r Last Will and T
that she had willingly signed or direct
d
et
~
e
another to s
for her, and executed it in the presence of said witne
free and voluntary act f
s th
sa
m
s
as he
or the
~Pr
said witnesses stated before ma~thats
erf
~ ,
~' the
the
or
executed and acknowledged by the Testatrix as her oLa
Testament and i t~ Wi11
n the presence or said witnesses,
presence and at her request, and in the presen
s
b am
, in he:
u
ce of eac
scribe their nacres thereto as attesting witnesse
the dat Cher, di.
s o
e of said Will, and that the Testatrix at the
execution of sa"id Will
wns he day o:
of the
,
over the age of eighteen 1
of sound and disposing mind and
~ ); years an
memory.
ELOISE L. 'I',7ERx _rrr_
,ate a
8ubacribad, sworn and. ac
TJBItNPiGBL the Testatrix, sub
cl os~Prt~ b~~~~/
1991.
. _ ~ ~~~
~S 3
~~