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Home My WebLink About02-07-13 1505610140 REV-1500 EX (°'-'°' PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes Po Box zsosol INHERITANCE TAX RETURN County Code Year File Number Harrisburg PA 17128-0601 RESIDENT DECEDENT 2 1 1 2 0 8 2 6 ENTER DECEDENT INFOR MATION BELOW Social Security Number Date of Death MMDDYYW Date of Birth MMDDYYYY 1 1 2 1 2 0 1 1 0 9 1 6 1 9 2 9 Decedent's Last Name Suffix Decedent's First Name MI R O B E R T S O N T H E O D O R A F (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 ^ 1. Original Return a 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 D A V I D W R E A L E R 7 1 7 7 6 3 1 3 8 3 First line of address 2 3 3 1 M A R K E T S T R E E T Second line of address City or Post Office State C A M P H I L L p p ZIP Code REGISTER O~LLS USE AbILY rn msc~ ~" ~~ b~~ N -.a ~~ ~ x ca Q O c~ ~ ~ ~ ~~ ~ C DATE FILED -° ~ ~~-- ~ ~t---~ ~ t_ 1 7 0 1 1 ~ F--~ ~" r-+ ~^ Correspondent's a-mail address: DWREAGERaREAGERADLEP.PC • 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 T RE OF Pjr_RSO)jl RE~LE FO ING RETUR ADDRESS 1031 CH ST SIGNATURE .~12RE1 P HUMMELSTOWN rctrrttJtN IATIVE PA 17036 / ~ 2331 MARKET STREET CAMP HILL PA 17011 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 J J 1505610240 REV-1500 EX Decedent's Social Security Numb Decedent's Name: THEODORA F• ROBERTSON 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. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 1 2 5 $ . 5 9 7. Inter-Vivos Transfers i3< Miscellaneous N -Probate Property (Schedule G) ~ S eparate Billing Requested ....... 7. • 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 1 2 5 5 , 5 9 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 1 0 5 9 0 . 7 9 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. 11. Total Deductions (total Lines 9 and 10) ............................... 11. 1 0 5 9 0 • 7 9 12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. - 9 3 3 5 . 2 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 3 3 5 . 2 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 _ 15. 16. Amount of Line 14 taxable at lineal rate X .0 • 16. 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. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610240 1505610240 J REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 12 0826 DECEDENT'S NAME THEODORA F• ROBERTSON_ STREET ADDRESS - - 100 MT• ALLEN DRIVE - -- - _ CITY STATE MECHANICSBURG ZIP PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 2. Credits/Payments A. Prior Payments B. Discount Total Credits (A + B) (2) 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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 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: a. retain the use or income of the property transferred : ...................................................................... Yes No ^ b. retain the right to designate who shall use the property transferred or its income; ............................ .. ^ a c. retain a reversionary interest; or ................... ........................................................................... : ^ ^X d. receive the promise for life of either payments, benefits or care? .................... . ................. ^ XD 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? .................... . .. ........................................ ^ a ........................ 3. Did decedent own an "intrust for" or payable-upon~ieath bank account or security at his or her death? ......... ^ X^ 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)]. Asibling 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-1509 EX+ (01-10) pennsylvania DEPARTMENT OFREVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: THEODORA F• ROBERTSON 21 12 0826 H an asset was made jointly owned within one year of the decedents date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A_ NANfY R. 41ARCTMAhI B.JOHNA R. MALAMUD C. 1031 CHESTNUT PLACE HUMMELSTOWN, PA 17036 351 MARTINGALE DRIVE CAMP HILL, PA 17011 JOINTLY•OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. A.B. 4/2005 AMERIPRISE FINANCIAL BROKERAGE ACCOUNT ACCOUNT *OOD52589967 021 DAUGHTER DAUGHTER DATE OF DEATH DECEDENT'S D VALUE OEFATH VALUE OFASSET INTEREST DECEDENTS INTEREST 3,766.77 33.3333 1,255.59 TOTAL (Also enter on Line 6, Recapitulation) I 3 If more space Is needed, use additional sheets of paper of the same size. 1, 2 5 5 5 REV-1511 EX+ (10-09) Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT rn~~~r w ~~ ~.+~ ~ yr FILE NUMBER THEODORA F. ROBERTSON 21 12 0826 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A• FUNERAL EXPENSES: 1• NEILL FUNERAL HOME 10,066.79 B 2. 3. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: AttomeyFees: REAGER 8 ADLER, PC Family Exemption: (If decedent's address is not the same as claimants, attach explanation.) Claimant 4. 5. 6. 7. Street Address City State ZIP Relationship of Claimant to Decedent Probate Fees: Acx:ountant Fees: Tax Retum Preparer Fees: REGISTER OF WILLS - FILING FEE SUPPLEMENTAL RETURN 500.00 24.00 TOTAL (Also enter on Line 9, Recapitulation) 13 If more space is needed, use additional sheets of 10 , 5 9 0 7 9 paper of the same s¢e.