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REV-1500 EX (01-10) 1505610140
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 1 2 0 9 9 2
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
2 0 2 2 0 3 2 5 3 0 8 2 9 2 0 1 2 0 5 1 8 1 9 2 7
Decedent's Last Name Suffix Decedent's First Name MI
W h i t e R o m a i n e M
(If 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
❑X 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 Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
S t e p h e n i H o g g E s q 7 1 7 2 4 5 2 6 9 8
REGISTER Q5 WILLS USE (Y
p rri C?
y C__ G'.+
First line of address _
1 9 S H a n o v e r S t r e e t r r~~
Second line of address
S t e 1 0 1
City or Post Office State ZIP Code DATE FILED
C a r l i s l e P A 1 7 0 1 3 ;I
Correspondent's e-mail address:
i
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.
E FOR FILING RETURN DATE
SIGN URE OF PERSON RE PONS[ E FOR FILING RETURN DATE 1~kn. PA, In 19
L~CJ/
ADDRESS
410 Win 11 Road Shermansdale PA 17090
SIGNATUR HAN REPRESENTATIVE DATE
2z
ADDR S
19 S. Hanove treet, Ste. 101 Carlisle PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140
1505610240
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: Romaine M - W h i t e 2 0 2 2 0 3 2 5 3
RECAPITULATION
1. Real Estate (Schedule A) 1. 6 2 0 9 2. 6 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.
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 2 2 6 5 . 0 3
6. Jointly Owned Property (Schedule F) ❑ Separate Billing Requested 6. 0 . 0 0
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested 7.
8. Total Gross Assets (total Lines 1 through 7) . 8. 6 4 3 5 7 . 6 4
9. Funeral Expenses and Administrative Costs (Schedule H) . 9. 1 8 8 2 7 . 1 4
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule 1) 10. 4 6 4 3 0 . 5 0
11. Total Deductions (total Lines 9 and 10) . 11. 6 5 2 5 7 . 6 4
12. Net Value of Estate (Line 8 minus Line 11) . . 12. - 9 0 0 . 0 0
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) . . 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) 14. - 9 0 0 . 0 0
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 _ 0. 0 0 15. 0. 0 0
16. Amount of Line 14 taxable
at lineal rate X .0 _ 0. 0 0 16. 0. 0 0
17. Amount of Line 14 taxable
at sibling rate X .12 0. 0 0 17. 0. 0 0
18. Amount of Line 14 taxable
at collateral rate X .15 0 0 0 18. 0. 0 0
19. TAX DUE ......................................................19. 0. 0 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Side 2
1505610240 1505610240
REV-1500 EX Page 3 File Number
Decedent's Complete Address: 21 12 0992
DECEDENT'S NAME
Romaine M. White
STREET ADDRESS
CITY STATE ZIP
Tax Payments and Credits:
1- Tax Due (Page 2, Line 19) (1) 0.00
2. Credits/Payments
A. Prior Payments
B. Discount
Total Credits ( A + B) (2) 0.00
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3)
Fill in oval 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; ❑ ❑
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 December 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 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) [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.
REV-1502 EX+ (01-10)
pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Romaine M. White 21 12 0992
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of the settlement sheet if the property has been sold.
ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1. 736 E. Louther Street, Cumberland County, Carlisle, PA 17013 62,092.61
Cumberland County Courthouse - Deed Book
TOTAL (Also enter on Line 1, Recapitulation.) $ 62 092.61
If more space is needed, use additional sheets of paper of the same size.
REV-1 508 EX+ (11-10)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN CASH, BANK DEPOSITS, & MISC.
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
Romaine M. White 21 12 0992
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Members 1 st Savings Acct No. 55244-00 5.00
2. Members 1 st Checking Acct No. 55244-11 23.33
3. 1994 Ford Sedan VIN#1FALP52U8RA165166 1,294.00
4. State Farm Mutual Insurance Company 44.20
5. Jones & Martin Auctions, LLC - proceeds from auction 26.08
6. Erie Insurance Refund 501.00
7. Sale Items 371.42
TOTAL (Also enter on Line 5, Recapitulation) $ 2,265.03
If more space is needed, insert additional sheets of paper of the same size
REV-2511 EX+ (10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Romaine M. White 21 12 0992
Decedent's debts must be reported on Schedule 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Hoffman-Roth Funeral Home & Crematory, Inc. 11,280.80
2. Flowers 112.00
3. Church Lunch 100.00
4. Eby's Granite Works - engraving 119.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s) Donald L. Weibley 3,218.15
Street Address 410 Windy Hill Road
city Shermansdale State PA ZIP 17090
Year(s) Commission Paid:
2. Attorney Fees: Stephen J. Hogg, Esquire 3,218.15
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: 269.50
5 Accountant Fees:
6. Tax Return Preparer Fees:
7. Advertising: The Sentinel 189.54
Cumberland Law Journal 75.00
8. Inheritance Tax Return and Inventory 30.00
9. Accounting (Est) 215.00.
TOTAL (Also enter on Line 9, Recapitulation) $ 18 827.14
If more space is needed, use additional sheets of paper of the same size.
0
REV-1512 EX+ (12-08)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Romaine M. White 21 12 0992
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
1. Members 1st FCU Loan Acct No. 55244-26 201136132 12/8/11 $5,000.00 4,679.09
2. MERS, Inc. for Members 1st FCU 200838383 11/18/08 $35,400.00 37,443.89
3. Opening Checking Account for Estate 25.00
4. Transfer Car Title 87.33
5. U.S. Post Office 9.65
6. Lowe's 19.57
7. Lowe's 28.45
8. Kreider Fuel Oil 342.00
9. CenturyLink 219.79
10. PP&L Electric 201.29
11. Carlisle Regional Medical Center 350.00
12. Walnut Bottom Radiology 125.00
13. American Homepatient 11.25
14. Lung, Asthma & Sleep Associates 240.00
15. OSI 200.00
TOTAL (Also enter on Line 10, Recapitulation) $ 46 430.50
If more space is needed, insert additional sheets of the same size.
.
• 0 • Continuation of REV-1500 Inheritance Tax Return Resident Decedent
Romaine M. White 21 12 0992
Decedent's Name Page 1 File Number
Schedule I - Debts of Decedent, Mortgage Liabilities, & Liens
ITEM
NUMBER DESCRIPTION AMOUNT
16 2012-2013 School Taxes 1,021.30
17. County Taxes 2012 71.31
18. Final Water/Sewer 204.89
19. Realty Transfer Tax 610.00
20. Document Preparation/Attorney Fee 350.00
21. Borough of Carlisle Water/Sewer 181.24
22. American Homepatient 9.45
SUBTOTAL SCHEDULE 1 21448.19
GRAND TOTAL SCHEDULE I $ 46,430.50
REf1~13 E#: (01-10)
M
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Romaine M. White 21 12 0992
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. 9116 (a) (1.2).]
1. Donald L. Weibley Lineal 0.25
410 Windy Hill Road
Shermansdale, PA 17090
2. Sherry Short Lineal 0.25
929 Forbes Road
Carlisle, PA 17013
3. Carol Richardson Lineal 0.25
736 E. Louther Street
Carlisle, PA 17013
4. Robert D. White Lineal 0.25
121 Spruce Street
Carlisle, PA 17013
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 11 - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed, use additional sheets of paper of the same size.