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Home My WebLink About04-01-13 Ex(01.10) 1505610143 -J REV-1500 i ., PA Department of Revenue yl OFFICIAL USE ONLY p Pennsylvania County Code Year File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE PO BOx.280601 INHERITANCE TAX RETURN 21 12 00746 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 198 64 4067 06 29 2012 07 02 1974 Decedent's Last Name Suffix Decedent's First Name MI DELL BRIAN W (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 ❑ 5. Federal Estate Tax Return Required (date of death after 12-12-82) ❑ g. Decedent Died Testate ❑ Decedent Maintained a Living Trust 0 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 RICHARD E CONNELL ESQ 717 232 8731 o _ RE99ISTER&f'WIL1'M L%ONLY n 6D First line of address C-7 2303 MARKET STREET M N tr? C> , Second line of address , rf c `u c City or Post Office State ZIP Code DIKFB FILA t CAMP HILL PA 17011 CID Correspondent's e-mail address: connell @bmc-law.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. SIGNA URE OF PERSON RESPONSI FOR FILING RETURN DATE Lv- Judith W. Dell 2$ 01 RESS 2104 Beacon C' , echanicsburg, PA 17055 IGNATURE OF PRE R THA EPRPiPENTATIVE DATE Richard E Connell Esq ZD f DD . 2303 Market Street, Camp Hill, PA 17011 Side 1 1505610143 1505610143 j \ _! 1505610243 REV-1500 EX Decedent's Social Security Number Decedents Name: DELL, BRIAN W. 198 64 4067 RECAPITULATION 1. Real Estate(Schedule A).......................................................................................... 1. 2. Stocks and Bonds(Schedule B)............................................................................... 2. 5 , 567 . 47 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C).......... 3. 4. Mortgages&Notes Receivable(Schedule D).......................................................... 4. 5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)................ 5. 9 , 155 . 60 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested....:........ 6. 40 . 9 4 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested............. 7. 3 , 000 . 00 8. Total Gross Assets(total Lines 1-7)....................................................................... 8. 17 , 764 . 01 9. Funeral Expenses&Administrative Costs(Schedule H)......................................... 9. 11 , 536 . 5 0 10. Debts of Decedent,Mortgage Liabilities,&Liens(Schedule 1)................................ 10. 1 , 303 . 77 11. Total Deductions(total Lines 9&10)...................................................................... 11. 12 , 840 . 27 12. Net Value of Estate(Line 8 minus Line 11)............................................................. 12. 4 , 923 . 74 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. 4 , 923 . 74 TAX COMPUTATION-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.00 15. 16. Amount of Line 14 taxable at lineal rate x .045 4 , 882 . 80 16. 219 . 73 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 40 . 9 4 18. 6 . 14 19. Tax Due..................................................................................................................... 19. 225 . 87 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 L 1505610243 1505610243 REV-1500 EX Page 3 File Number 21 - 12 - 00746 Decedent's Complete Address: DECEDENT'S NAME Dell, Brian W. STREET ADDRESS 2104 Beacon Circle CITY STATE ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 225.87 2. Credits/Payments A. Prior Payments B. Discount 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. (4) Check box on Page 2 Line 20 to request a refund - 5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 225.87 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;.................................... ❑ ❑x 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 receivingadequate consideration?....................................................................................................................... ❑x ❑ 3. Did decedent own an"in trust for" or payable 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?...................................................................................................................... Fx� ❑ 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 January 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 rebri 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 bloo�or adoption. SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dell, Brian W. FILE NUMBER 21 - 12 -00746 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM DESCRIPTION UNIT VALUE VALUE AT DATE OF NUMBER DEATH 1 Wasatch Funds 5,567.47 Account No. 4003455800 TOTAL(Also enter on line 2, Recapitulation) 5,567.47 SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF Dell, Brian W. 21 - 12 -00746 Include the proceeds of litigation and the date the proceeds were received by the estate.All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE OF NUMBER DESCRIPTION DEATH 1 2004 Honda Civic 5,319.00 VIN 2HGES26754H565816 Mileage 80,000 Good Condition 2 Susquehanna Valley Federal Credit Union Savings Account 89.64 3 Susquehanna Valley Federal Credit Union Checking Account 2,047.96 4 Federal Tax Refund for 2012 1,699.00 TOTAL(Also enter on Line 5, Recapitulation) 9,155.60 SCHEDULE F COMMONWEALTH T PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Dell, Brian W. 21 - 12-00746 If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G. SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT Katie Maren 310 Valley Street Friend A Marysville, PA 17053 JOINTLY OWNED PROPERTY: DESCRIPTION OF PROPERTY ITEM LETTER DATE DATE OF DEATH %OF DATE OF DEATH FOR JOINT MADE Include name of financial institution and bank account number DECD'S VALUE OF NUMBER TENANT JOINT similar identifying number.Attach deed for jointly-held real estat VALUE OF ASSET INTEREST DECEDENTS INTEREST 1 A 09/17/2008 PSECU Account#4315205545170 81.88 50% 40.94 TOTAL(Also enter on line 6, Recapitulation) 40.94 COMMONWEALTH OF PENNSYLVANIA SCHEDULE G INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS & RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY ESTATE OF Dell, Brian W. FILE NUMBER 21 - 12-00746 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF EXCLUSION NUMBER Include the name of the transferee,their relationship to decedent VALUE OF ASSET DECD'S CIF APPLICABLE) TAXABLE VALUE and the date of transfer. Attach a copy of the deed for real estate. INTEREST 1 T. Rowe Price Coventry Health Care, Inc. Retirement Savings Plan Transferee:Judith W. Dell, mother Decedent was 37 years old at the date of death. He had no present right to the money held in the retirement program and had not been determined to be disabled. As such,the entire interest of$8589.00 is excludible. 2 Cash-Transfer of cash from decedent's checking 3,000.00 100% 3,000.00 account to parents immediately preceding death. TOTAL(Also enter on line 7, Recapitulation) 3,000.00 SCF E DULE H FINERAL DXPENSES& COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ADMNSTRATW COM RESIDENT DECEDENT FILE NUMBER ESTATE OF Dell, Brian W. 21 - 12-00746 Debts of decedent must be reported on Schedule I. ITEM NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT A. 1 Funeral gathering, post-funeral 520.00 2 Malpezzi Funeral Home 5,628.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zip Year(s)Commission paid 2. Attorney's Fees Ball, Murren &Connell 1,500.00 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation) . Claimant Judith W. Dell 3,500.00 Street Address 2104 Beacon Circle city Mechanicsburg State PA Zip 17055 Relationship of Claimant to Decedent Mother-(resided 5/2009 to date of death) 4. Probate Fees Cumberland County Register of Wills 115.00 5. Accountant's Fees Matthew Babb- Boreman & Babb 100.00 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1 Cost of Estate Checks 16.50 TOTAL(Also enter on line 9, Recapitulation) 11,536.50 Schedde H Funeral EVmM& COMMONWEALTH INHERITANCE T PENNSYLVANIA J 1■n�v*A__,�_ __r�v d INHERITANCE TAX RETURN (�(�[� RESIDENT DECEDENT FILE NUMBER ESTATE OF Deli, Brian W. 21 - 12 -00746 2 The Sentinel- Legal Advertising 82.00 3 Cumberland Law Journal-Legal Advertising 75.00 Page 2 of Schedule H SCHEDULEI DEBTS OF DECEDENT, MORTGAGE COMMONWEALTH OF PENNSYLVANIA LIABILITIES & LIENS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dell, Brian W. FILE NUMBER 21 - 12 -00746 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM DESCRIPTION AMOUNT NUMBER 1 Cumberland County Tax 15.90 2 Hershey Medical Center 281.37 3 Plnnacle Health Hospital 250.00 4 Holy Spirit Hospital 125.00 5 Telephone, Internet, Club Membership-automatic bank withdrawals 340.00 6 PennDOT 36.00 7 Upper Allen Township Tax 5.50 8 Consolidated Ambulance Network 125.00 9 Hershey Medical Center 125.00 TOTAL(Also enter on Line 10, Recapitulation) 1,303.77 REV-1 513 EX+(11-08) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Dell, Brian W. 21 -12-00746 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY Do Not List Trustee(s) TAXABLE DISTRIBUTIONS[include outright spousai distributions,and transfers under Sec.9116(a)(1.2)] 1 Stephen M. Dell Father One-Half 12 Gadwall Cr.Heritage Shores Bridgeville, DE 19933 2 Judith W.Dell Mother One-Half 2104 Beacon Circle Mechanicsburg, PA 17055 Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate. III NON-TAXABLE DISTRIBUTIONS: A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REVA500 COVER SHEET 0.00