HomeMy WebLinkAbout04-10-13 (2) 1505610143
REV-1500 EX(02-11) OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO BOK280601 INHERITANCE TAX RETURN 21 12 0858
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
07 10 2012 06 29 1915
Decedent's Last Name Suffix Decedent's First Name MI
SMITH THRESSA E
(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 1- l 3. Return(Date of Death
L Prior to 12-13-82)
4. Limited Estate 4a Fut re Interest Compromise F
(datue of death after 12-12-82) 5. Federal Estate Tax Return Required
6. Decedent Died Testate 7, Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust) —
L l 9. Litigation Proceeds Received t I 10_Spousal Pover%credit�Date of Death Election to tax under Sec,9113(A)
between 12-31, and -1-95) (Attach Schedule 0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX IN,FORMATION$HOULD:K ECTED TO:
Name Daytil Telephone kumbill n
LINDA J OLSEN ESQ 717' -540 4a-k2,
REGIS-TER.&WIl OIUSE,O_N&
First Line of Address
2000 LINGLESTOWN ROAD S
Second Line of Address
SUITE 202
City or Post Office State ZIP Code DATE FILED
HARRISBURG PA 17110
Correspondent's e-mail address: loisen@hazenelderlaw.com
Under penalties of perjury,f 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
SI NATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
James W Smith Lzz 1 2,1
RESS f 1
315 Robson Road, Dillsb rg, PA 17019
SIGNATU, OF PREPARE OTHER TAN REPRESENTATIVE DATE
Linda J. Olsen, Esq. Esq.
'
13 04ES'� SI
�13
'04ESS11
2000 Linglestown Rd. , Harrisburg, PA 17110
Side 1
1505610143 1505610143
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name Smith, Thressa E
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&Notes Receivable(Schedule D)....................................................... 4.
5. Cash, Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 1 , 585 . 99
6. Jointly Owned Property(Schedule F) ❑ Separate Billinq Requested............ 6. 13 , 915 . 91
7. Inter-Vivos Transfers&Miscellaneous coq Probate Property
(Schedule G) a Separate Billinq Requested............ 7. 91 , 729 . 97
8. Total Gross Assets (total Lines 1 through 7)........................................................ 8. 107 , 231 . 87
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 9, 576 . 70
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 31 , 391 . 23
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 40 , 967 . 93
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 66,263 . 94
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. 66, 263 . 94
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. 0 . 00
16. Amount of Line 14 taxable 661263 . 94 1s. 2 , 981 . 88
at lineal rate X .045
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 00 18. 0 . 00
19. TAX DUE................. . ........ 19. 2 , 981 . 88
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 51
Side 2
1505610243 1505610243 J
REV-1500 EX Page 3 File Number 21-12-0858
Decedent's Complete Address:
DECEDENT'S NAME
Smith, Thressa E
STREET ADDRESS
Green Ridge Village
210 Big Spring Rd
CITY STATE I ZIP
Newville PA 17241
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19) (1) 2,981.88
2. Credits/Payments
A. Prior Payments 3,500.00
B. Discount 149.09
Total Credits(A +B) (2) 3,649.09
3. Interest (3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) 667.21
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)
Make Check Pa able 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,.......................................................... ........... ..... ❑ u
b. retain the right to designate who shall use the property transferred or its income;........................ ......... �� 0
c. retain a reversionary interest;or............................................................................................................... 5.1
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?.................................................................................................................... 1
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... L] x1
4. Did decedent own an individual retirement account,annuity,or other non-probate property which
contains a beneficiary designation?.................................................................................................................. ❑x ❑
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 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(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-1508 EX+(11-10)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Smith, Thressa E 21-12-0858
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
NUMBER DESCRIPTION OF DEATH
1 PA Unclaimed property(Prudential &Highmark) 1,585.99
TOTAL(Also enter on Line 5, Recapitulation) 1,585.99
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev. 1 1-10)
Rev-1509 EX+(01-10)
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Smith,Thressa E 21-12-0858
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
A. James W Smith 315 Robson Rd Child
Dillsburg, PA 17019
B.
C.
JOINTLY OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH VALUE OF
NUMBER FOR JOIN MADE NUMBER OR SIMILAR IDENTIFYING NUMBER ATTACH DEED FOR VALUE OF ASSE DECD$ DECEDENT'S INTEREST
TENANT JOINT JOINTLY-HELD REAL ESTATE INTEREST
1 A 07/10/2000 Members 1st checking acct.#195069-11 -jt. 15,008.64 50.000% 7,504.32
w/James
2 A 09/22/2011 Members 1st Investment savings acct. 6,804.38 50.000% 3,402.19
#195069-05-Jt.w/James
3 A 07/10/2000 Members 1st savings acct.#195069-00-jt.w/ 4,041.71 50.000% 2,020.86
James
4 A 07/10/2000 Members 1st suppl.Savings acct.#195069-01 1,977.07 50.000% 988.54
-jt.w/James
TOTAL(Also enter on Line 6, Recapitulation) 13,915.91
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule F(Rev.01-10)
Rev-1510 EX-a"9)
SCHEDULE G
pennsylvania INTER-VIVOS TRANSFERS AND
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Smith, Thressa E 21-12-0858
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION EL PROPERTY DATE OF DEATH %of DECD�S EXCLUSION TAXABLE
NUMBER THELDATE OF TRANSFER TRANSFEREE A COPYEOF THE DEED FOR ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1 Employees Life Co. annuity#L114604-benef.sons 40,415.00 100.000% 40,415.00
James&Eugene
2 Gifted to James Smith 43,500.00 3,000.00 40,500.00
3 Prudential Ins.#24 728 099-pre-paid funeral 10,814.97 100.000% 10,814.97
costs/death claim
TOTAL(Also enter on Line 7, Recapitulation) 91,729.97
(If more space is needed,additional pages of the same size)
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule G(Rev.08-09)
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
RESIDENT EDEN TURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Smith, Thressa E 21-12-0858
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 5,204.09
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State ZiD
Year(s)Commission Paid 2012
2. Attornev's Fees Hazen Elder Law 3,900.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Zio
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills 51.50
5. Accountant's Fees
6. Tax Return Preparer's Fees Paul Predmore, CPA 150.00
7. Other Administrative Costs 271.11
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 9,576.70
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Smith, Thressa E 21-12-0858
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Clarion Monuments -grave marker 1,479.00
2 Funeral -church service officiants-Father Dave Hillien and Dana Statler 150.00
3 General Sutter Inn/Lititz 7/14/12 222.09
4 Thompson Miller Funeral Home Inc. 3,353.00
H-A 5,204.09
Other Administrative Costs
5 Central Penn Business Journal -estate notice 150.00
6 Cumberland Law Journal-estate notice 75.00
7 Hazen Elder Law--disbursements 21.20
8 Sheetz Gas- -travel expense for executor 24.91
H-B7 271.11
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 EX+(12-08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Smith,Thressa E 21-12-0858
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 Alpha Diagnostics-medical bill 25.17
2 Darryl Guistwite DO-medical 141.81
3 Green Ridge Village-resident fees 21,730.76
4 Hazen Elder Law-EP fees 42.54
5 Millennium Pharmacy Systems -pharmacy bill 897.75
6 PA Department of Revenue-2012 personal state income taxes 163.00
7 Pinker&Associates-medical 8,20
8 U.S. Treasury-2012 personal Federal income tax 8,382.00
TOTAL(Also enter on Line 10, Recapitulation) 31,391.23
(If more space is needed,additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group,Inc. Form PA-1500 Schedule I(Rev. 12-08)
REV-1513 EX.(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Smith, Thressa E 21-12-0858
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT of i (Words) ($$$)
D. s
I• TAXABLE DISTRIBUTIONS (include outright spousal
distributions,and transfers
under Sec.9116(a)(1.
Eugene A. Smith Child Thirty-Five
17869 SE 87 Bourne Ave Percent of the
The Villages Residue of the
Lady Lake, FL 32162.4802 Estate.
James W Smith Child Sixty-Five
315 Robson Rd. Percent of the
Dillsburg, PA 17019 Residue of the
Estate
Total
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 7500 cover sheet,as a ro riate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10)
REGISTER OF WILLS CERTIFICATE OF
CUMBERLAND COUNTY GRANT OF LETTERS
PENNSYLVANIA
No. 2012- 00858 PA No. 21- 12- 0858
Estate Of: THRESSA E SMITH
(First,Middle,Last)
Late Of: NORTH NEWTON TOWNSHIP
CUMBERLAND COUNTY
0 Deceased
Social Security No: 376-05-3995
WHEREAS, on the 7th day of August 2012 an instrument dated
May 31st 2005 was admitted to probate as the last will of
THRESSA E SMITH
(First,Middle,Last)
late of NORTH NEWTON TOWNSHIP, CUMBERLAND County,
who died on the 10th day of July 2012 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, GLENDA FARNER STRASBAUGH , Register of Wills in and
for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby
certify that I have this day granted Letters TESTAMENTARY to:
JAMES W SMITH
who has duly qualified as EXECUTOR(RIX)
and has agreed to administer the estate according to law, all of which
fully appears of record in my office at CUMBERLAND COUNTY COURTHOUSE,
CARLISLE, PENNSYL VA NIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my office on the 7th day of August 2012.
egister 6f Wills
IN I
Deputy
v
**NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)
LAST WILL AND TESTAMENT
OF
THRESSA E. SMITH
I,THRESSA E.SMITH,now domiciled in Cumberland County,Pennsylvania,declare this
to be my Last Will. I revoke all other Wills and Codicils that I may have previously made.
Article I
My just debts and expenses of my last illness, funeral, and administration of my estate shall
be paid by my Executor from the principal of my residuary estate as soon as practicable after my
death.
Article II
All inheritance,estate,and succession taxes(including interest and penalties thereon,but not
including any generation skipping tax) payable by reason of my death shall be paid out of and be
charged generally against the principal of my residuary estate without reimbursement from any
person. This provision is not a waiver of any right which my Executor has to claim reimbursement
for any such taxes which become payable as the result of any property over which I have the power
of appointment.
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Ci C - - -i-
D C✓'1 ��
Ca
Article III
I give, devise and bequeath my tangible personal property in accordance with any
memorandum I have handwritten or signed, located with my will or with my valuable papers and
found within 30 days of the probate of my will. Gifts may only be to persons who survive me or to
organizations which exist at my death, and if there is a conflict,the memorandum having the latest
date shall govern. To the extent no such memorandum is found, or all of my tangible personal
property is not disposed of pursuant thereto, my tangible personal property shall be added to my
residuary estate and pass under Article IV hereof.
Article IV
All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever
situate, I give, devise and bequeath according to the following:
A. SIXTY-FIVE PERCENT (65%) of my estate to my son, JAMES W. SMITH, of
Dillsburg, Pennsylvania, Per Stirpes. If JAMES W. SMITH predeceases me,
leaving no surviving issue, I give, devise and bequeath his share IN EQUAL
SHARES to the children of my son, EUGENE A. SMITH,Per Stirpes; and
B. THIRTY-FIVE PERCENT (35%) of my estate to my son, EUGENE A. SMITH,
JR., of Boiling Springs, Pennsylvania,Per Stirpes.
Article V
If a beneficiary under this Will has not attained the age of thirty-five(3 5)years,the share of
the beneficiary shall be placed in a separate trust, for the benefit of that beneficiary according to the
terms in Article VI.
-2-
Article VI
In the event that a Trust is created by or as a result of any part of this Will, the terms and
conditions of the Trust shall be as follows:
A. To expend and apply so much of the net income and so much of the principal of the
Trust as the Trustee shall consider advisable for the support, health, care and education of the child
until the child attains the age of thirty-five (35) years.
B. Upon attaining the age of thirty-five(35), the remaining principal and accumulated
income of the child's share shall be distributed outright to the child.
C. No beneficiary or remainderman of this Trust shall have any right to alienate,
encumber, or hypothecate his or her interest in the principal or income of the Trust in any manner,
nor shall any interest be subject to claims of his or her creditors or liable to attachment,execution,or
other processes of law.
Article VII
In order to carry out the purposes of the Trust established by this Will, the Trustee, in
addition to all other powers granted by this Will or by law,shall have the following powers over the
Trust estate, subject to any limitations specified elsewhere in this Will:
(a) to retain in the form received and/or to sell either at public or private sale, any real
estate or personal property except that which I specifically bequeath herein,
(b) to manage real estate,
-3-
(c) to invest and reinvest in all forms of property without being confined to legal
investments, and without regard to the principal of diversification,
(d) to exercise any option or right arising from the ownership of investments,
(e) to compromise claims without court approval and without consent of any beneficiary,
(fl to file fiduciary/income tax returns and pay the tax due for any year for which such a
return is required,
(g) to make distributions in cash or in kind,or in both,and to determine the value of any
such property,
(h) to employ any attorney,investment advisor,or other agent deemed necessary by my
Executor; to pay from my estate reasonable compensation for all their services,
(i) to conduct along with or with others,any business in which I am engaged in or have
an interest in at the time of my death, and
6) to receive reasonable compensation in accordance with their standard schedule of fees
in effect while their services are performed.
Article VIII
I hereby appoint my sons, EUGENE A. SMITH, JR. and/or JAMES W. SMITH, to act
jointly and/or individually, as Co-Trustees of any Trust(s) created in this Will.
Article IX
I nominate, constitute,and appoint my son,JAMES W.SMITH,Executor of my Last Will
and Testament. In the event of the renunciation,death,or inability to act,for any reason whatsoever
4
of my Executor, I nominate, constitute and appoint my grandson, MARK T. SMITH, of Lititz,
Pennsylvania, successor Executor of my Last Will and Testament. I direct that my Executor or
successor Executor be permitted to serve without bond. In addition to those powers granted by law, I
grant them power to distribute in cash or in kind,in like or in unlike shares,and to file any qualified
disclaimer I could have filed if living. My Executor or successor Executor shall receive reasonable
compensation for services rendered to my estate.
Article X
In addition to the powers conferred by law,I authorize my Executor or successor Executor in
his/her absolute discretion:
(a) to retain in the form received and to sell either at public or private sale,any real estate
or personal property except that which I specifically bequeath herein,
(b) to manage real estate,
(c) to invest and reinvest in all forms of property without being confined to legal
investments, and without regard to the principal of diversification,
(d) to exercise any option or right arising from the ownership of investments,
(e) to compromise claims without court approval and without consent of any beneficiary,
(fl to file any federal income tax return for any year for which I have not filed such return
prior to my death,
(g) to make distributions in cash or in kind,or in both, and to determine the value of any
such property,
_5_
(h) to employ any attorney, investment advisor,or other agent deemed necessary by my
Executor; and to pay from my estate reasonable compensation for all their services,
(i) to conduct alone or with others, any business in which I am engaged in, or have an
interest in at time of my death, and
6) to receive reasonable compensation in accordance with their standard schedule of fees
in effect while their services are performed.
IN WITNESS WHEREOF, I, THRESSA E. SMITH, hereby set my hand to this my Last
Will and Testament, on ! , 2005, at Harrisburg, Pennsylvania.
THRESSA E. SMITU
In our presence,the above-named THRESSA E.SMITH signed this and declared this to be
her Last Will and now at her request,in her presence, and in the presence of each other, we sign as
witnesses.
ame Address
2000 Linglestown Rd., Suite 202 Harrisburg PA 17110
J f d
x` fr i 2000 Linglestown Rd., Suite 202 Harrisburg PA 17110
F,. l
-6-
I,THRESSA E.SMITH,Testatrix,who signed the foregoing instrument,having been duly
qualified according to law, acknowledge that I signed and executed this instrument as my Will,and
that I signed it willingly as my free and voluntary act for the purposes therein expressed.
Sworn to or affirmed and
acknowledged before me by
THRESSA E. SMITH, the Testatrix,
on 3 i , 2005.
No ary P lice T RESSA E. SMI
COMMONWEALTH OF PENNSYLVANIA
Notarial seal
Marielle F. Hazen, Notary Public
Susquehanna Twp., Dauphin County
My Commission Expires Sept. 23, 2006
We, the undersigned witnesses who signed the foregoing instrument, being duly qualified
according to law, depose and say that we were present and saw the Testatrix sign and execute this
instrument as her Will;that she signed and executed it willingly as her free and voluntary act for the
purposes therein expressed;that each of us in her sight and hearing signed the Will as witnesses,and
that to the best of our knowledge, that she was at that time eighteen (18) years or more of age, of
sound mind, and under no constraint or undue influence.
Sworn to or affirmed and
subscribed to before me
and tness
witnesses, on _ / , 2005.
t' Wiiness
`f Notary Pdblic
�._
COMMONWEALTH OF PENNSYLVANIA
=S.squehanna tarial Seal
azen, Notary Public
wp., Dauphin County
Expires Sept. 23, 2006
St
MEMBERS 1st
FEDERALCREDIr UNION
SAVINGS ACCOUNT:
Account Number/Suffix 195069-00
Date Account Established 07/10/2000
Principal Balance at Date of Death $4,041.47
Accrued Interest to Date of Death $.24
Total Principal and Accrued Interest $4,041.71
Name of Joint Owner James W. Smith
Date Joint Ownership Established 07/10/2000
CHECKING ACCOUNT:
Account Number/Suffix 195069-11
Date Account Established 07/10/2000
Principal Balance at Date of Death $15,008.29
Accrued Interest to Date of Death $.35
Total Principal and Accrued Interest $15,008.64
Name of Joint Owner James W. Smith
Date Joint Ownership Established 07/10/2000
INVESTMENT SAVINGS ACCOUNT:
Account Number/Suffix 195069-05
Date Account Established 07/10/2000
Principal Balance at Date of Death $6,803.88
Accrued Interest to Date of Death $.50
Total Principal and Accrued Interest $6,804.38
Name of Joint Owner James W. Smith
Date Joint Ownership Established 07/10/2000
SUPPLEMENTAL SAVINGS ACCOUNT:
Account Number/Suffix 195069-01
Date Account Established 09/22/2011
Principal Balance at Date of Death $1,976.95
Accrued Interest to Date of Death $.12
Total Principal and Accrued Interest $1,977.07
Name of Joint Owner James W. Smith
Date Joint Ownership Established 09/22/2011
hE BE R S 1 ST FEDER CR ION
Danielle A. Kline
Lending Insurance Support Specialist
August 17, 2012
Estate of: THRESSA E. SMITH
Date of Death: 07/10/2012
Social Security Number: 376-05-3995
5000 Louise Drive • P.O. Box 40 • Mechanicsburg, Pennsylvania 17055 • (800) 283-2328 www.memberslst.org
n�A
EMPLOYEES Al � `� Isl
LIFE COMPANY(MUTUAL) L is
916 Sherwood Drive ____________________�
Lake Bluff, IL 60044-2285
August 21, 2012
Hazen Eldler Law
ATTN: Corinne Eggers Woodhouse
2000 Linglestown Road, Suite 202
Harrisburg PA 17110
Re: Poll icy No. L 1 14604
Owner/Deceased: Thressa E. Smith
Primary Beneficiary: State of Pennsylvania-Medicaid
Contingent Beneficiary(s): James W. Smith & Eugene A. Smith, Jr.
Dear Ms. Woodhouse:
We are very sorry to learn of the loss of our annuitant and extend our sincere sympathy to the
surviving family members.
The information directly below is in regard to the original contact on the deceased. This
information will be helpful to you in electing a settlement option.
Premium Paid - $68,000.00
Period Certain- 10 Months
Payments $6,831.06
Payments remaining- 6 Months
if the PA Dept of Public Welfare has any interest in the claim, we will require in writing from
the state, attesting to any benefits paid on behalf of our annuitant. In the event Medicaid was
not applied for and/or no benefits were paid, we will accept a statement from an attorney
attesting that no Medicaid benefits were paid on behalf of our annuitant, We have included a
Hold Harmless Affidavit, the beneficiary(s) signature on this document will allow our company
to pay the beneficiary(s), and make the beneficiary(s) responsible for any payment due the state.
If applicable, for the contingent beneficiary(s), two settlement options are available,
Continuation of Benefit or the Commuted Value. Once elected, an option cannot be changed.
Be sure to complete the proper forms and return them along with one original death certificate
that shows the cause of death.
Under the Continuation of Benefit option the benefit continues as the original contract was
issued. The beneficiary(s)must complete a Continuation of Benefit Form and a IRS W-9 form.
916 SHGRW(.)UD DRIVI;• LAKF, BIJIT, IL,1,1N01S 60044-2285 •(847)295-6000•(800)962-8(110• [.,,\X (847)295-1145
EMPLOYEES
LIFE COMPANY(MUTUAL)
916 Sherwood Drive
Lake Bluff, IL 60044-2285
August 21, 2012
Page Two
The Commuted Value is the second option. This is a lump sum settlement. The commuted
value is the present value of future benefits at the discounted rate listed below. If this is
desired, the beneficiary(s) is to complete the Commuted Value Claim Form, IRS W-9 form for
social security verification, and the original policy
Discounted rate- 6%
Commuted Value - $40,415.00
The continuation of benefit settlement is considered income. Therefore, you will receive a
1099-R from us each year. We are not tax consultants and do not give tax advice.
The commuted value is normally not taxable since no gain will be realized. However, if the
premium paid came to us directly from another company, some part of the value may be
taxable.
Please advise us where the deceased's 1099 is to be mailed. You may provide this
information below and return it with the proof of loss documents. If you do not notify us, we
will assume that the address of record is correct.
If you have any questions, please contact us in the claim department @ 800-962-8610 Monday
through Thursday 8:00 a.m. to 4:30 p.m. or before 1:00 p.m. on Fridays (Central Time).
Sincerely,
EMPLOYEES LIFE COMPANY(MUTUAL)
Mary Navulis, ACS
Claims Supervisor
Policyholders Benefits Department
Enc.
916 SHERD 001)DRIvF;•LAKE BLU1=F, ILLINOIS 60044-2285-(84 7)295-6000•(800)962-8610• FAX(847)295-1145
PENNSYLVANIA INHERITANCE TAXI
BUREAU OF INDIVIDUAL TAXES INFORMATION NOTICE FILE NO. 67
PO BOX 280601 pennsylvania AND ACN 12143288
HARRISBURG PA 17128-0601 DEPARTMENT OF REVENUE TAXPAYER RESPONSE FILE
08-01-2012
REV-1543 EX AFP (05-11)
TYPE OF ACCOUNT
EST. OF THRESSA E SMITH R SAVINGS
SSN 376-05-3995 ❑ CHECKING
DATE OF DEATH 07-10-2012 ❑ TRUST
COUNTY YORK ❑ CERTIF.
REMIT PAYMENT AND FORMS TO:
JAMES W SMITH REGISTER OF WILLS
315 ROBSON RD 45 NORTH GEORGE STREET
DILLSBURG PA 17019-8920 YORK PA 17401-1240
MEMBERS 1ST FCU provided the department with the information below, which was used in calculating the inheritance tax due.
Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you are the spouse of the
deceased and any amount other than zero is reflected below on the Potential Tax Due line. note no tax may be due, but you must
notify the dep artment of your relationship to the deceased by checking Box C in PART 1 below and writing;,spouse" in PART 2.
If you believe the information is incorrect, please obtain written correction from the financial institution, attach a cop to this form and return
it to the above address. Please call 717-787-8327 with questions.
COMPLETE PART I BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 195069-05 Date 07-10-2000 To ensure Proper credit to the account, two
Established copies of this notice must accompany
payment to the Register of Wills. Make check
Account Balance 6,804.38 Payable to "Register of Wills, Agent".
Percent Taxable X 50.000
NOTE: If tax Payments are made within three
Amount Subject to Tax 3,402.19 months of the decedent's s date of death,
Tax Rate X .045 deduct a 5 percent discount on the tax due.
Any inheritance tax due will become delinquent
Potential Tax Due 153.10 nine months after the date of death
PART TAXPAYER RESPONSE
A. ❑ The above information and tax due is correct.
Remit Payment to the Register of Wills with two copies of this notice to obtain
CHECK a discount or this notice to the Register of Wills and
C ONE an officia l a s sessm e nt will i s sued by the PA Department of Revenue.
BL OCK B. Th above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return
ONLY A e
filed by the estate representative.
C. ❑ The above informs ion is incorrect and/or debts and deductions were paid.
Complete PART M and/or PART Ffl below.
PART If indicating a different tax rate, please state
M-1 relationship to decedent:
TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS
LINE 1. Date Established 1 '010
IM,
2. Account Balance 2 01 MINE,
3. Percent Taxable 3 X
4. Amount Subject to Tax 4
5. Debts and Deductions 5
6. Amount Taxable 6
7. Tax Rate 7 X
8. Tax Due 8
PART DEBTS AND DEDUCTIONS CLAIMED
Pyl
1171
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation)
Under penalties of perjury, I declare that the facts I reported above are true, correct and
complete to the best of my knowledge and belief.
HOME C
WORK (--)/-7 -77,-� -7l 7 2
TAXPAYER SIGNATURE TELEPHONE NUMBER DATE
GENERAL INFORMATION
1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information
submitted by the financial institution.
2. Inheritance tax becomes delinquent nine months after the decedent's date of death.
3. A joint account is taxable even when the decedent's name was added as a matter of convenience.
4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to
death are fully taxable.
S. Accounts established jointly between husband and wife more than one year prior to death are not taxable.
6. Accounts held by a decedent "in trust for" another or others are fully taxable.
REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE
1. BLOCK A - If the information and calculation in the notice are correct and deductions are not being claimed, place an "X"
in Block A of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with a check for the amount of
tax to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment
(Form REV-1548 E)O upon receipt of the return from the register of wills.
2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania inheritance
tax return filed by the estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign two
copies and return to the register of wills of the county indicated.
3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check Block C and complete Parts 2 and 3
according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the register
of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt
of the return from the register of wills.
TAX RETURN - PART 2 - TAX CALCULATION
LINE
1. Enter the date the account originally was established or titled in the manner existing at date of death.
NOTE: For a decedent who died after 12/12/82, accounts the decedent put in joint names within one year of death are
fully taxable. However, there is an exclusion not to exceed 03,000 per transferee, regardless of the value of
the account or the number of accounts held.
If a double asterisk (») appears before your first name in the address portion of this notice, the 03,000 exclusion
was deducted from the account balance as reported by the financial institution.
2. Enter the total balance of the account including interest accrued to the date of death.
3. The percentage of the account that is taxable to each survivor is determined as follows:
A. The percentage taxable of joint assets established more than one year prior to the decedent's death:
1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE
JOINT OWNERS SURVIVING JOINT OWNERS
Example: A joint asset registered in the name of the decedent and two other persons:
1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7 percent (TAXABLE TO EACH SURVIVOR)
B. The percentage taxable for assets created within one Year of the decedent's death or accounts owned by the decedent but held
in trust for another individual(s) (trust beneficiaries):
I DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED BY 100 = PERCENT TAXABLE
OWNERS OR TRUST BENEFICIARIES
Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by
the decedent.
1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50 percent (TAXABLE FOR EACH SURVIVOR)
4. The amount subject to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable (Line 3).
5. Enter the total of the debts and deductions listed in Part 3.
6. The amount taxable (Line 6) is determined by subtracting the debts and deductions (Line 5) from the amount subject to tax (Line 4).
7. Enter the appropriate tax rate (Line 7) as determined below.
Date of Death Spouse Lineal Sibling Collateral
07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent
01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent
07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent
.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.
The lineal class of heirs includes grandparents, parents, children and other lineal descendents. "Children" includes natural children
whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the
natural parents and their descendents, whether or not they have been adopted by others; adopted descendents and their descendants;
and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood
or adoption. The Collateral class of heirs includes all other beneficiaries.
CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED
Allowable debts and deductions are determined as follows:
A. You are legally responsible for payment, or the estate subject to administration by a personal representative is insufficient
to pay the deductible items.
B. You actually paid the debts after the death of the decedent and can furnish proof of payment.
C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use 8 112" x 11" sheet of paper. Proof of
payment may be requested by the PA Department of Revenue.
PENNSYLVANIA INHERITANCE TAXI
INFORMATION NOTICE
BUREAU OF INDIVIDUAL TAXES Z FILE NO. 67
PO BOX 280601 pennsytvania AND ACN 12143287
HARRISBURG PA 17128-0601 DEPARTMENT OF REVENUE TAXPAYER RESPONSE DATE 08-01-2012
REW-1543 EX AFP (05-11)
TYPE OF ACCOUNT
EST. OF THRESSA E SMITH 1-1 SAVINGS
SSN 376-05-3995 I-XI CHECKING
DATE OF DEATH 07-10-2012 ❑ TRUST
COUNTY YORK ❑ CERTIF.
REMIT PAYMENT AND FORMS TO:
JAMES W SMITH REGISTER OF WILLS
315 ROBSON RD 45 NORTH GEORGE STREET
DILLSBURG PA 17019-8920 YORK PA 17401-1240
MEMBERS 1ST FCU provided the department with the information below, which was used in calculating the inheritance tax due.
Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you are the spouse of the
deceased and any amount other than zero Is reflected below on the Potential Tax Due line, note no tax may be due, but you must
notify the defartment of your relationship to the deceased by checking Box C in PART 1 below and writing "spouse" In PART 2.
If you believe h e information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return
it to the above address. Please call 71.7-787-8327 with questions.
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 195069-11 Date 07-10-2000 To ensure Proper credit to the account, two
Established copies of this notice must accompany
payment to the Register of Wills. Make check
Account Balance
15,008.64 payable to "Register of Wills, Agent".
Percent Taxable X 50.000 NOTE: If tax Payments are made within three
Amount Subject to Tax 7,504.32 months of the decedent's date of death,
Tax Rate X .045 deduct a 5 Percent discount on the tax due.
Any inheritance tax due will become delinquent
Potential Tax Due yr 337.69 nine months after the date of death.
PART TAXPAYER RESPONSE
The above information and tax due is correct.
Remit payment to the Register of Wills with two copies of this notice to obtain
ONE
a discount or avoid interest or turn this notice to the Register of Wills and
C CHECK an official assessment sessment will � return
issued sued by the PA Department of Revenue.
B LOCK B. The above asset has been or will be reported and tax Paid with the Pennsylvania inheritance tax return
ONLY filed by the estate representative.
C. ❑ The above informs ion is incorrect and/or debts and deductions were paid.
Complete PART M and/or PART M below.
PART If indicating a different tax rate, please state
Pil relationship to decedent:
TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS 00
LINE 1. Date Established I
2. Account Balance 2
3. Percent Taxable 3 X
4. Amount Subject to Tax C.
5. Debts and Deductions 5
6. Amount Taxable 6
7. Tax Rate 7 X
R1
S. Tax Due 8
,
PART DEBTS AND DEDUCTIONS CLAIMED
M
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation)
Under penalties of perjury, I declare that the facts I reported above are true, correct and
�Plete to the best of my knowledge and belief. HOME C
6o ( � WORK (7/? ) 7
Ttk,XPAYER SIGNATUR-E TELEPHONE NUMBER DATE
GENERAL INFORMATION
1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information
submitted by the financial institution.
2. Inheritance tax becomes delinquent nine months after the decedent's date of death.
3. A joint account is taxable even when the decedent's name was added as a matter of convenience.
4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to
death are fully taxable.
S. Accounts established jointly between husband and wife more than one year prior to death are not taxable.
6. Accounts held by a decedent "in trust for" another or others are fully taxable.
REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE
1. BLOCK A - If the information and calculation in the notice are correct and deductions are not being claimed, place an "X"
in Block A of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with a check for the amount of
tax to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment
(Form REV-1549 EX) upon receipt of the return from the register of wills.
2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania inheritance
tax return filed by the estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign two
copies and return to the register of wills of the county indicated.
3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check Block C and complete Parts 2 and 3
according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the register
of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt
of the return from the register of wills.
TAX RETURN - PART 2 - TAX CALCULATION
LINE
1. Enter the date the account originally was established or titled in the manner existing at date of death.
NOTE: For a decedent who died after 12/12/82, accounts the decedent put in joint names within one Year of death are
fully taxable. However, there is an exclusion not to exceed 83,000 per transferee, regardless of the value of
the account or the number of accounts held.
If a double asterisk 00 appears before your first name in the address portion of this notice, the 83,000 exclusion
was deducted from the account balance as reported by the financial institution.
2. Enter the total balance of the account including interest accrued to the date of death.
3. The percentage of the account that is taxable to each survivor is determined as follows:
A. The percentage taxable of joint assets established more than one year prior to the decedent's death;
1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE
JOINT OWNERS SURVIVING JOINT OWNERS
Example: A joint asset registered in the name of the decedent and two other persons:
1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) = .167 X 100 = 16.7 percent (TAXABLE TO EACH SURVIVOR)
B. The percentage taxable for assets created within one Year of the decedent's death or accounts owned by the decedent but held
in trust for another individual(s) (trust beneficiaries):
1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED BY 100 = PERCENT TAXABLE
OWNERS OR TRUST BENEFICIARIES
Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by
the decedent.
1 DIVIDED BY 2 (SURVIVORS) = .50 X 100 = 50 percent (TAXABLE FOR EACH SURVIVOR)
4. The amount subject to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable (Line 3).
5. Enter the total of the debts and deductions listed in Part 3.
6. The amount taxable (Line 6) is determined by subtracting the debts and deductions (Line 5) from the amount subject to tax (Line 4).
7. Enter the appropriate tax rate (Line 7) as determined below.
Date of Death Spouse Lineal Sibling Collateral
07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent
01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent
07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent
*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.
The lineal class of heirs includes grandparents, parents, children and other lineal descendents. "Children" includes natural children
whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the
natural parents and their descendents, whether or not they have been adopted by others; adopted descendents and their descendants;
and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood
or adoption. The Collateral class of heirs includes all other beneficiaries.
CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED
Allowable debts and deductions are determined as follows:
A. You are legally responsible for payment, or the estate subject to administration by a personal representative is insufficient
to pay the deductible items.
B. You actually paid the debts after the death of the decedent and can furnish proof of payment.
C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use 8 112" x 11" sheet of paper. Proof of
payment may be requested by the PA Department of Revenue.
PENNSYLVANIA INHERITANCE TAXI
BUREAU OF INDIVIDUAL TAXES INFORMATION NOTICE FILE NO. 67
PO BOX 280601 pennsytvania AND ACIN 12143286
HARRISBURG PA 17128-0601 DEPARTMENT OF REVENUE TAXPAYER RESPONSE DATE 08-01-2012
REV-1543 EX AFP(05-11)
TYPE OF ACCOUNT
EST. OF THRESSA E SMITH Fil SAVINGS
SSN 376-05-3995 ❑ CHECKING
DATE OF DEATH 07-10-2012 FITRUST
COUNTY YORK ❑ CERTIF.
REMIT PAYMENT AND FORMS TO:
JAMES W SMITH REGISTER OF WILLS
315 ROBSON RD 45 NORTH GEORGE STREET
DILLSBURG PA 17019-8920 YORK PA 17401-1240
MEMBERS 1ST FCU provided the department with the information below, which was used in calculating the inheritance tax due.
Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you are the spouse of the
deceased and any amount other than zero is reflected below on the Potential Tax Due line, note no tax may be due, but you must
notify the department of your relationship to the deceased by checking Box C in PART 1 below and writing "spouse" in PART 2.
If you believe the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return
it to the above address. Please call 717-787-8327 with questions.
COMPLETE PART I BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 195069-00 Date 07-10-2000 To ensure Proper credit to the account, two
Established copies of this notice must accompany
payment to the Register of Wills. Make check
Account Balance 4,041.71 Payable to "Register of Wills, Agent".
Percent Taxable X 50.000 NOTE: If tax Payments are made within three
Amount Subject to Tax $ 2,020.86 months of the decedent's date of death,
Tax Rate X .045 deduct a 5 percent discount on the tax due.
Any inheritance tax due will become delinquent
Potential Tax Due 90.94 nine months after the date of death.
PART TAXPAYER RESPONSE
®R
III�ffi i�0
PON'Wk
A. ❑ The above information and tax due is correct.
Remit payment to the Register of Wills with two copies of this notice to obtain
C discount or this notice to the Register of Wills and
C HECK -an officia l a.sessm.nt will i s sued by the PA Department of Revenue.
ONE
B LOCK B. The above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return
ONLY YYNN filed by the estate representative.
C. ❑ The above information is incorrect and/or debts and deductions were paid.
Complete PART M and/or PART M below.
PART If indicating a different tax rate, please state
relationship to decedent:
TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS
LINE 1. Date Established 1
2. Account Balance 2
3. Percent Taxable 3 X
4. Amount Subject to Tax 4
5, Debts and Deductions 5
10
6. Amount Taxable 6 M
7. Tax Rate 7 X
A
8, Tax Due 8
n 1'1� V
PART DEBTS AND DEDUCTIONS CLAIMED
P]
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
TOTAL-(-En-ter on Line 5 of Tax Computation) 4
Under penalties of perjury, I declare that the facts I reported above are true, correct and
colete to the best of knowledge and belief. HOME
WORK ( 7/7 77c.2- -71 '7'
_?
TAXF#i9YER SIGNATURE TELEPHONE NUMBER DATE
GENERAL INFORMATION
1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information
submitted by the financial institution.
2. Inheritance tax becomes delinquent nine months after the decedent's date of death.
3. A joint account is taxable even when the decedent's name was added as a matter of convenience.
4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to
death are fully taxable.
S. Accounts established jointly between husband and wife more than one year prior to death are not taxable.
6. Accounts held by a decedent "in trust for" another or others are fully taxable.
REPORTING INSTRUCTIONS - PART I - TAXPAYER RESPONSE
1. BLOCK A - If the information and calculation in the notice are correct and deductions are not being claimed, place an "X"
in Block A of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with a check for the amount of
tax to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment
(Form REV-1548 EX) upon receipt of the return from the register of wills.
2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania inheritance
tax return filed by the estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign two
copies and return to the register of wills of the county indicated.
3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check Block C and complete Parts 2 and 3
according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the register
of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Farm REV-1548 EX) upon receipt
of the return from the register of wills.
TAX RETURN - PART 2 - TAX CALCULATION
LINE
1. Enter the date the account originally was established or titled in the manner existing at date of death.
NOTE: For a decedent who died afterl2/12/82, accounts the decedent put in joint names within one year of death are
fully taxable. However, there is an exclusion not to exceed 53,000 per transferee, regardless of the value of
the account or the number of accounts held.
If a double asterisk (xx) appears before your first name in the address portion of this notice, the 53,000 exclusion
was deducted from the account balance as reported by the financial institution.
2. Enter the total balance of the account including interest accrued to the date of death.
3. The percentage of the account that is taxable to each survivor is determined as follows:
A. The percentage taxable of joint assets established more than one year prior to the decedent's death:
1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE
JOINT OWNERS SURVIVING JOINT OWNERS
Example: A joint asset registered in the name of the decedent and two other persons:
1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7 percent (TAXABLE TO EACH SURVIVOR)
B. The percentage taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held
in trust for another individual(s) (trust beneficiaries):
1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED BY 100 = PERCENT TAXABLE
OWNERS OR TRUST BENEFICIARIES
Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by
the decedent.
1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50 percent (TAXABLE FOR EACH SURVIVOR)
4. The amount subject to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable (Line 3).
5. Enter the total of the debts and deductions listed in Part 3.
6. The amount taxable (Line 6) is determined by subtracting the debts and deductions (Line 5) from the amount subject to tax (Line 4).
7. Enter the appropriate tax rate (Line 7) as determined below.
Date of Death Spouse Lineal Sibling Collateral
07101/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent
01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent
07/01/00 to present 0 percent 4.5 percent 12 percent 15 percent
xThe 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.
The lineal class of heirs includes grandparents, parents, children and other lineal descendents. "Children" includes natural children
whether or not they have been adopted by others, adopted children and step children, "Lineal descendents" includes all children of the
natural parents and their descendents, whether or not they have been adopted by others; adopted descendents and their descendants;
and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood
or adoption. The Collateral class of heirs includes all other beneficiaries.
CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED
Allowable debts and deductions are determined as follows:
A. You are legally responsible for payment, or the estate subject to administration by a personal representative is insufficient
to pay the deductible items.
B. You actually paid the debts after the death of the decedent and can furnish proof of payment.
C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use 8 112" x 11" sheet of paper. Proof of
Payment may be requested by the PA Department of Revenue.
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