HomeMy WebLinkAbout01-23-13~ 1505610105
REV-1500 EX (o2-ii) (FI) ~~
enns lvania OFFICIAL USE ONLY
PA Department of Revenue P Y County Code Year Fite Number
~EPAFTMENT OF PEVENUE
Bureau of Individual Taxes INHERITANCE TAX RETURN /~,
PO BOX 280601 ~ ~ (~
Harrisburg, PA 1'71.28-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
5/08/2012 07/21 /1918
Decedent's Last Name Suffix Decedent's First Name MI
Holicek Margaret A
(tf Applicable) Enter Surviving Spouse's information Below
Spouse's Last Name Suffix Spouse's First Name
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
Ct~ 1. Original Return O 2. Supp{emental 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)
O 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 Schedule O)
---
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
Christopher Lilienthal (717) 8297 823 : _ : _ i
First Line of Address
327 Charles Road
Second Line of Address
City or Post Office
Mechanicsburg
State ZIP Code
PA 17050
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REGIEF~„~F WILLS t~;;E ONLY"~'tl •y
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Correspondent's a-mail address: mlSterthal COmCaSt.net
Under penalties of perjury, !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 R OF P RSO RESPO~S LE FOR F1 ING RETURN DATE
~~ ,~__ ~ "7; ~ '. _ , .D~ ~l 01/21/2013
327 Charles'Road, Mechanicsburg, PA 17050
SIGNATURE OF PREPARER OTHER TNAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
L 1505610105
Side 1
1505610105
~~
J
1505610205
REV-1500 EX (FI)
Decedent's Social Security Number
Decedents Name: Margaret Holicek
RECAPITULATION
1. Real Estate (Schedule A} .......................................... ... 1. 0.00
2.
....................................
Stocks and Bonds (Schedule B) 2,
... 0.00
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 0.00
4. Mortgages and Notes Receivable (Schedule D) ........................ ... 4. 0.00
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).... ... 5. 4,575.35
6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. 765.34
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
00
0
(Schedule G) O Separate Billing Requested..... ... 7. .
8.
( 9 ) .............................
Total Gross Assets total Lines 1 throu h 7 8. 5,340.69
9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. 3,074.91
10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............ ... 10. 619.87
11. Total Deductions (total Lines 9 and 10) .............................. ... 11. 3,694.78
12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. 1,645.91
13. Charitable and Governmental BequestslSec 9113 Trusts for which
an election to tax has not been made (Schedule J) ..................... ... 13. 0.00
14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. 1,645.91
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 taxable
at -ineal rate X .0 45
16.
74.07
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19. TAX DUE ...................................................... ...19. 74.07
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
1505610205 1505610205
REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address:
Margaret A. Holicek
STREET ADDRESS
20 North 12th Street, Apt. 119
CITY _ _ STATE ZIP
Lemoyne PA 17043
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) 74.07
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 oval on Page 2, Line 20 to request a refund. (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 74.07
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 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? .............. ^
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 Juiy 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)J.
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)J. 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)J.
• 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)J.
• 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.
REV-1508 EX-+- (is-io}
~ Pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE C/iSI7, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Margaret A. Holicek
Include the proceeds of litigation and the date the proceeds were received by the estate.
AIt property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Funeral Trust Amount 3,503.95
2, Rent Refund for balance of May 529.04
3. Verizon Phone Bill Refund 1.02
4, Provider Services Refund Account 41.34
5, Personal Property: Bed 50.00
g. Personal Properly: Couch 200.00
7, Personal Property: Walker 50.00
g. Personal Property: Wheelchair 50.00
g. Personal Property: Shelves 25.00
10. Personal Property: Lamp 40.00
11. Personal Property: Wig 10.00
12. Personal Property: Jewelry 25.00
13. Personal Property: Miscellaneous Household Items 50.00
TOTAL (Also enter on Line 5, Recapitulation) $ , 4,575.35
If more space is needed, use additional sheets of paper of the same size.
REV-15o9 EX+ {oi-io)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCNEDt~LE F
JOINTLY-OWNED PROPERTY
ESTATE OF: FILE NUMBER:
Margaret A. Holicek
if an asset became jointly owned within one year of the decedent`s date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A• Christopher M. Lilienthal
327 Charles Road
Mechanicsburg, PA 17050
Grandson-in-Law
B.
C.
JOINTLY OWNED PROPERTY:
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTrrUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET °1o OF
DECEDENT'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
1. A• 07127110 M&I Bank Statement Savings ~ Account # 100915478 1,074.71 50 537.36
2. A. 07127110 M&I Bank Interest Gold Checking ~ Account # 13006408 440.48 50 220.24
3. A. 11/01/11 Belco Community Credit Union Savings ~ Account # 896026 5.40 50 2.70
4. A. 11101111 Belco Community Credit Union Checking ~ Account #8960262 5.07 50 2.54
5. A. 11/01111 Belco Community Credit Union Savings ~ Acct. # 895390 (VA Benefit) 5.00 50 2.50
6. A. 11101/11 Belco Community Credit Union Checking ~ Acct. # 8953903 (VA Benefit) 0.00 50 0.00
TOTAL (Also enter on Line 6, Recapitulation) I $ 765.34
If more space is needed, use additional sheets of paper of the same size.
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
_-- - --
ESTATE OF FILE NUMBER
Margaret A. Holicek __
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER
DESCRIPTION
AMOUNT
A. FUNERAL EXPENSES:
1' Use of Staff and Equipment: Graveside Service 275.00
2. Miscellaneous Merchandise: Prayer Cards 30.00
3. Direct Cremation {As Selected) 995.00
a. Cemetery Charges 825.00
5. Clergy/Church Honorarium 200.00
s. Death Notice 297.91
~. Marker Inscription 244.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 0.00
Name(s) of Personal Representative(s) _ _ _
Street Address
City State ZIP
Years} Commission Paid:
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.}
Claimant
Street Address
City State
Relationship of Claimant to Decedent
4. Probate Fees;
5. Accountant Fees:
6. Tax Return Preparer Fees:
~~ Certified Copies
s. Cremation Permit
9. Cremains and Certified Copies Mailing
~o Honorarium for Memorial Service in Lemoyne Pa. -Trinity Lutheran Church
ZIP
TOTAL (Also enter on Line 9, Recapitulation) I $
If more space is needed, use additional sheets of paper of the same size,
0.00
0.00
0.00
0.00
0.00
18.00
25.00
65.00
100.00
3,074.91
i pennsylvania SCHEDULE I
DEPARTMENTdFREVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Margaret A. Holicek
Report 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
i • Quantum Imaging and Therapeutic Associates 3.81
2. West Shore Emergency Medical Service 181.99
3. Carlisle Medical Group 23.30
4. Adult Medicine 8 Aesthetics LLC 25.68
5. Holy Spirit Hospital 6.68
6. Capital Cardiovascular Associates 109.57
7. Spirit Physican Services Inc. 161.42
8. Quantum Imaging and Therapeutic Associates 2.07
9. Adult Medicine & Aesthetics LLC 12.84
10. Camp Hill Fire Co. No. 1 16.07
11. Camp Hill Emergency Physicians 7.96
12. Quantum Imaging and Therapeutic Associates 13.57
13. Quantum Imaging and Therapeutic Associates 13.57
14. Camp Hill Emergency Physicians 41.34
TOTAL (Also enter on Line 10, Recapitulation) I $ 619.87
If more space is needed, insert additional sheets of the same size.