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Home My WebLink About02-21-13 1505610140 REV-1500 ~`~°'-'°' PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po Box 28oso1 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 1 2 0 5 2 1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYW Date of Birth MMDDYYW Decedent's Last Name Suffix Decedent's First Name MI H U R S E N T R U D Y A (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 ~ 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) ^X 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~lOULD BE DIRECTED T0: Name Dayt Telephone~mbe~ ~ t~ M U R R E L W A L T E R S I I I E S Q 7~`t~ 6 `~7 ~c~' S 0 First line of address 5 4 E A S T M A I N S T R E E T Second line of address City or Post Office State M E C H A N I C S B U R G P A Correspondent's a-mail address: ZIP Code E7~4S~It OFNIaLLS t f rr SLY ~* ~ O ,C~ ~~~ _~ ~~ ~ ~ ~~ ~C`7 c.~ e- Im ~ W ~ -J DATE FILED 1 7 0 5 5 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. ~S~-+~I~4TURE OF PERSON~PONSIBLE FOR FILING RETURN DATE ~ t ~ ADDRESS ;~` PATRICIA PELK Y, 29 SOUTH ST• COVENTRY CT 06238 SIGNATURE OF~R R OT T REPRESENTATIVE :2 T , 5~, ~ / A ADDRESS ~ ~// '/'" - ~- MURREL R• W LTERS, III, 54 E• MAIN ST MECHANICSBURG PA 17055 PLEASE USE ORIGINAL FORM ONLY L 1505610140 Side 1 1505610140 J ~~ J 150561,0240 REV-1500 EX Decedent's Social Security Number Decedent's Name: T R U D Y A- H U R S E N 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. 3 5 6 5 6 4 . 6 3 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. • 7. Inter-Vivos Transfers 8~ Miscellaneous No -Probate Property (Schedule G) a Se arate Billin Re uested 7 p g ....... q . 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 3 5 6 5 6 4 . 6 3 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9• 2 4 6 6 2 . 7 3 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ... ......... . 10. 3 ~ 3 9 6 . 9 8 11. Total Deductions (total Lines 9 and 10) ..................... ......... . 11. 2 8 0 5 9 . 7 1 12. Net Value of Estate (Line 8 minus Line 11) .................. ......... . 12. 3 2 8 5 0 4 . 9 2 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............ ......... . 13. 1 9 8 5 0 4 . 9 2 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... 14. 1 3 0 0 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.o 0. 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .045 1 0 5 0 0 0. 0 0 16. 4 7 2 5. 0 0 17. Amount of Line 14 taxable 0 0 0 17 0 0 0 at sibling rate X .12 . . 18. Amount of Line 14 taxable at collateral rate X .15 2 5 0 0 0. 0 0 1 g. 3 7 5 0. 0 0 19. TAX DUE ............................................ ......... .19. 8 4 7 5. 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^ Side 2 1505610240 1505610240 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 12 0521 DECEDENT'S NAME TRUDY A. HURSEN STREET ADDRESS 417 N. WALTNUT STREET CITY MECHANICSBURG STATE PA ZIP 17055 Tax Payments and Credits: ~• Tax Due (Page 2, Line 19) (1) 8,475.00 2. Credits/Payments A. Prior Payments 8,051.25 B. Discount 402.56 Total Credits (A + B) (2) 8,453.81 3. Interest (3) 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) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 21.19 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 : ...................................................................... ^ Q b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q c. retain a reversionary interest; or ................................................................................................ ^ d. receive.the promise for life of either payments, benefits or care? ....................................................... ^ ^X 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 "intrust for" orpayable-upon-death 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? .................................................................................................. ^ 0 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 i~ 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-1508 EX+ (11-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: TRUDY A. HURSEN 21 12 0521 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. CHARLES SCHWAS ~ 73,599.75 3247-2946 2. CHARLES SCHWAS 10,154.54 5411-3097 10,137.51 & 17.03 , 3. CHARLES SCHWAB 22,302.02 300015218054 4. ING DIRECT 246,685.95 5. PRUDENTIAL-COMPUSHARE 1,052.12 SHARES 6. CASH 263.00 7. PNC 1,650.00 CHECKING 8. LEGAL SHIELD 317.20 COMMISSION 9. UNITED HEALTHCARE INSURANCE COMPANY 310.50 AARP SUPPLEMENTAL & PERSONAL HEALTH REFUND 10. HARTFORD INSURANCE COMPANY 24.00 REFUND -RENTER'S INSURANCE 11. HARTFORD INSURANCE 31.00 AUTO INSURANCE REFUND 12. COMCAST 121.62 REFUND 13. CARD SERVICES REFUND 26.00 REFUND 14. VERIZON 26.93 REFUND 15. U.S. TREASURY 820.00 2011 REFUND TOTAL (Also enter on Line 5, Recapitulation) I ~ If more space is needed, insert additional sheets of paper of the same size REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER TRUDY A. HURSEN 21 12 0521 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. MYERS BUHRIG FUNERAL HOME AND CREMATORY, MECHANICSBURG, PA 8,527.24 B. 2 3 4. 5. 6. 7. City COVENTRY State CT ZIP 06238 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) PATRICIA PELKEY Street Address 2931 SOUTH STREET Year(s) Commission Paid: 2013 Attorney Fees: MURREL R. WALTERS, III Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address 5,000.00 10,600.00 City State ZIP Relationship of Claimant to Decedent Probate Fees: CUMBERLAND COUNTY REGISTER OF WILLS 517.50 Accountant Fees: Tax Return Preparer Fees: ESTATE ACCOUNT CHECKS I 17.99 TOTAL (Also enter on Line 9, Recapitulation) I $ 24,662.73 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER TRUDY A. HURSEN 21 12 0521 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. LL BEAN 65.95 CREDIT CARD 2. KOHLS 93.05 CREDIT CARD 3. CARD MEMBER SERVICE 2,675.89 AARP CREDIT CARD 4. UNITED WATER 11.09 WATER 5. ROBERT JONES 540.00 RENT 6. BARRY HECKARD, TAX COLLECTOR 11.00 2012 PER CAPITA TAX TOTAL (Also enter on Line 10, Recapitulation) S 3.396.98 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsylvania ~ SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: TRUDY A. HURSEN 21 12 0521 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).J 1. PAMELA ANN HALL Lineal 35,000.00 3158 PINE NEEDLE COURT LILBURN, GA 30047 2. AUSTIN WAYNE HALL Lineal 35,000.00 3158 PINE NEEDLE COURT LILBURN, GA 30037 3. MAKENNA HURSEN HALL Lineal 35,000.00 3158 PINE NEEDLE COURT LILBURN, GA 30047 4. DR. MELINEA HOLMAN Collateral 10,000.00 14682 TRIPLE EAGLE COURT FT. MYERS, FL 33912 5. PATRICIA PELKEY Collateral 10,000.00 2931 SOUTH STREET COVENTRY, CT 06238 6. RAE McDONALD Collateral 5,000.00 25 OXFORD ROAD SW MARIETTA, GA 30008-5044 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. THE PENN STATE UNIVERSITY-PATERNO LIBRARY 49,626.23 UNIVERSITY PARK, PA 16802 2. PEOPLE FOR THE ETHICAL TREATMENT OF ANIMALS, INC. 49,626.23 P.O. BOX 42516 WASHINGTON, DC 20015 3. FRIENDS OF ANIMALS 49,626.23 777 POST ROAD DARIEN, CT 06820 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 198 504.92 If more space is needed, use additional sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent TRUDY A. HURSEN 21 12 0521 Decedent's Name Page 1 File Number Schedule J -Beneficiaries - 2B II. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 4. UNITY SCHOOL OF CHRISTIANITY, FEDERAL TAX IDENTIFICATION NUMBER 44-0546000 49,626.23 1901 NW BLUE PARKWAY UNITY VILLAGE, MO 64065-0001 SUBTOTAL SCHEDULE J-26 ~ 49,626.23