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HomeMy WebLinkAbout04-16-13 (2) 1505610140 REV-1500 EX (01-10' PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number PO BOX 260601 INHERITANCE TAX RETURN 2 0 1 3 0 2 1 1 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW 0 1 1 3 2 0 1 3 1 2 2 7 1 9 2 1 Decedent's Last Name Suffix Decedent's First Name MI B e I m o n t B e t t y J (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N / A Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW n 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) QX 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 0 B.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 - 1, Scot It W . M o r r i son , E s q 7 7 58i� 20 `00 � o rno QIEOI0-TER OF V%S U9�01 Ri y C) � nr F� rrrn First line of address ,a c^Ma 6 West Mai n St r e e t Second line of address P O . Box 232 C-11 W o City or Post Office State ZIP Code DATEEILED N e w B I o o m f i e I d PA 1 7 0 6 8 Correspondent's e-mail address: smorrisonlaw(cD enturylink.net Underpart", s of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, ct and complete.Dedarado f p parer other than the personal representative is based on all information of which preparer has any knowledge. ' SIG T E OF PERSON RES IB FILIN N 7 V RES 287 Upper Blailey Road Newport PA 17074 SIGNATURE P 0 HE THAN ATIVE OAT ADDRE 6 We ain reet New Bloomfield PA 17068 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 J 1505610240 REV-1500 EX 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. 2 5 7 4 8 , 3 9 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. 7. Inter-Vivos Transfers&Miscellaneous NI n--IProbate Property 2 6 0 8 0 3 . 6 2 (Schedule G) u Separate Billing Requested . . . .. . . 7. S. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . .. . . . . . . . . .. . . 8. 2 8 6 5 5 2 , 0 1 9. Funeral Expenses and Administrative Costs Schedule H 9. 1 4 4 1 1 9 9 10. Debts of Decedent, Mortgage Liabilities,and Liens Schedule I 10. 4 6 5 1 3 7 11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11. 1 9 0 6 3 . 3 6 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 2 6 7 4 8 8 . 6 5 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. 2 6 7 4 8 8 . 6 5 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable - at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.0 _ 0 . 0 0 15. 0 . 0 0 16. Amount of Line 14 taxable at lineal rate x.045 2 6 7 4 8 8 . 6 5 16. 1 2 0 3 6 . 9 9 17. Amount of Line 14 taxable at sibling rate X.12 0 . 0 0 17. 0 . 0 0 18. Amount of Line 14 taxable at collateral rate X.15 0 . 0 0 18. 0 . 0 0 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . .. .. . . .. . . . . . . . . . 19. 1 2 0 3 6 . 9 9 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ Side 2 1505610240 1505610240 J REV-1$00 EX Page File Number Decedent's Complete Address: 20 13 0211 DECEDENT'S NAME Be J. Belmont__-STREET ADDRESS 325 Wesiev Drive CITY --- ----- - - STATE 21P� Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) {1} 12 036.99 2, Credits/Payments A.Prior Payments B.Discount 601.85 Total Credits(A+B) (2) 601.85 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) �y11,435.14 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; ...................................................................... ❑ b. retain the right to designate who shall use the property transferred or its income; ............................ ❑ c. retain a reversionary interest;or ................................................................................................ ❑ 0 d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ nX 2. If death occurred after December 12,1982,did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ❑ 0 3. Did decedent own an'in trust for'or payable-upon-death bank account or security at his or her death? ......... ❑ 4, Did decedent own an individual retirement account,annuity of 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 it 3 percent 172 P.S.§9116(a)(1.1)(1)]. 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 H 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.&§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedents siblings is 12 percent 172 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-150 EX+(6-96) CASH, E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. IN RES DENT D C DENT RN PERSONAL PROPERTY ESTATE OF FILE NUMBER Betty J. Belmont 20 13 0211 Include the roceads of litigation and the date the proceeds were received by the estate. All propertyjpolnt -0wned with right of survivorship moat be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. First National Bank of Mifflintown checking account#1195023 12,189.32 2, First National Bank of Mifflintown savings account#61051162 3,213.85 3. Onstown Bank savings account#4412539920 10,345.22 TOTAL(Also enter online 5,ReWitulatlon) $ 25 748.39 (It more space is needed,insert additional sheets of the same size) REV-1610 EX+(08-00) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER•VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Betty J. Belmont 20 13 0211 This schedule must W completed and filed If the answer to any of questions 1 through A on page three of She REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % DECO'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST OF APrucneEE) VALUE 1. Jackson National Life Insurance Company Policy#1010537203 260,803.62 100,00 260,$03.62 children, Cecilia A. Hogg, Richard C. Belmont, Barbara E. Henry, Frances Douglas, Kathleen Purvis and Thomas W. Belmont are beneficiaries TOTAL Also enter on Line 7,Recapituladion)l $ 26O$03.62 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(10.09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Betty J. Belmont 20 13 0211 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. David M. Myers Funeral Home, Inc. 10,611.47 2, Rice Memorial Works -gravestone 2,350.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Names)of Personal ReprasentaNve(s) Street Address City State ZIP Years)Commission Paid: 2, Attorney Fees: Scott W. Morrison 1,000.00 3, Family Exemption;(if decedent's address is not the same as claimants,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: Glenda Farner Strasbaugh 143.50 51 Accountant Fees: B, Tax Return Preparer Fees: T The Sentinel-estate advertising 232.02 & Cumberland Law Journal -estate advertising 75.00 TOTAL(Also enter on Line 9,Recapitulation) $ 14 411.99 9 more space is needed,use additional sheets of paper of the same size, REV-1512 EX-(12-08) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, &LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Betty J. Belmont 20 13 0211 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. Bethany Village-account 4,651.37 TOTAL(Also enter on Line 10,Recapitulation) $ 4,651.37 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: Bettv J. Belmont 20 13 0211 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not Ust Trustee(s) OF ESTATE j TAXABLE DISTRIBUTIONS pndude outI hts set distributions and transfers under Sec.91 1 (a)(t2).) 1. Cecilia A. Hogg Lineal P. 0. Box 354 one-sixth Seneca, PA 16346 2. Richard C. Belmont Lineal 2436 Nassau Lane one-sixth Fort Lauderdale, FL 33312 3. Barbara E. Henry Lineal 327 E. 25th Street one-sixth Baltimore, MD 21218 4. Frances Douglas Lineal 6404 Oasis Drive one-sixth Austin, TX 78749 5. Kathleen Belmont Purvis Lineal 8781 Oleander Avenue one-sixth Vienna, VA 22181 6. Thomas W. Belmont Lineal 287 Upper Bailey Road one-sixth Newport, PA 17074 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1504 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size. LAST WILL AND TESTAMENT OF BETTY J. BELMONT I, betty J. gelmont, of Sloomfield Borough, Percy Cotnrty,. Pennsy%Ivnnta, b xog of sotm4 and dispgsing mina rnem _ and understantlutg, too 7ietebv hake, publish and declare this as y Last Will and T4starrze'ri ieucilcirtg all prior Wills,as follows lu i. tlireot in y berenafter named Execrttcrs to pay y.just" debts, ftxneraf e p tts s nn costs' bf administration oft it estate as soon as possible sand 6onvetIuenVida my death, 2. I _direct any here3�r, named Ex(sutors trs pay.zthr- d f the 0-,io of my estate, all state inheritance taxes and federal estate,iar s; if AtLy' be due, which may be wsessed by reason of my death go property PA rirt under this my Last'Gill srrtt Testarx ent,xrr n property pawing tar, y; csov Or 'Persons, by reason o joint owngship thereof, stick as �eertifiastes of dTogit, savings bgrtds,. etc. to th°e 'idient and ef%e t that no person be required to : pay any l ettnsylvaina iti eritanee tare br' 'wera tax.; thereon, 3 l give; devise and bequeath all the rest, residue remainder of my property, both;personal and real, and wheresoever s%t %'te, to my .hus,band, Frank A; Belmont, provided lie atu`viv die ley tliiztY 4�mss: 4. In the event. Inv hytsband, . A_ Belmont, ,should predecease me or die on, or before,the thirtieth (30th)Aay following.my, death, .l give, devise bequeath all the Wit, reslAuo amyl rexnaitxder ofpt estate, both real and personal, and of whatever nature and wheresoever situate, to my children, in equal shares. '. 1 'hereby nominate and appoirtt my sons, Thomas W. Belmont and Richard C. Delmont, or the survivor thereof, as Co-ExeeUtors of this my Last Will and Testament: fr. I direct that my Executors or their successors shall lint be required to. give 'bond or other security in any juris'diptian. �vliU6 proceedings may be held 1n Copttection with my estata, Near shall any gua:r4ian of pr6perty or persons be required to give bond for.the faithful: gerforman of their dt€ties,itt any j urisdiction. IN WZT ESS f?F,T Hereunto set my hand and:sea!this >u day of` , 2001. '. (SEAT.) itttesr� a . witrtess i „Iq6 COMMONWEALTH OF PENNSYLVANIA * ss' COL NTY OF PERRY We, Betty`.l. Belmont, the testatrix in, and k`4jWy +q. 179"ftl and 4fJfs IR. MW01 l,, the witnesses to the Last Will and.Testament, the attached or foregoing instrument, who have signed the instrument, having been. duly qualified according to law do, depose and say; t ) that ,t, tho testatrix, do hereby acknowledge that 1 .sib and e cnt rho irtstritmont-as my last Will, that I signed it willingty acid as_' mq free and voluntary act for the purposes therein expressed,and b tlsat t A the vv trtessa's, were-present and saw the testae alga anrl'. execute the Xitstruxneztt as he last wits, that she »illingly signed and oxecttted it'as:hex free And voluntary act for the purposes therein.expressed that each-of us-in the hearing and sight;of the t'atfix signed t'he wif as a witness and tha(to the best of our lctiowledge the testate x bas t that tiiiie I:B or more years of age, of sound mind and cinder no constraiant or undue influence, of _tn t Witness My.Comunissi expires, 1+urscn LY' < j'Rf'.F+' cuvc, pennsylvania DEPARTMENT OF PUBLIC WELFARE March 5, 2013 SCOTT W MORRISON ESQUIRE 6W MAIN ST PO BOX 232 NEW BLOOMFIELD PA 17068 Re: Betty Belmont SSN: ###-##-1292 Dear Attorney Morrison: Pursuant to your letter dated February 23, 2013, the Department's, Estate Recovery Program, has reviewed the information you provided regarding the above-referenced individual. It has been determined that this individual did not receive any type of assistance during the questioned period. Therefore, according to the information you provided, the Department's Estate Recovery Program will not seek any recovery from this estate. If your client applied for Medical Assistance and had an application and/or hearing pending at the time of death, please advise us and provide any additional information that may affect a recovery by our Department. Thank you for your cooperation in this matter. If you have any questions, please contact me. Sincerely ' W� OL K4,& Vince A. Porter Recovery Section Manager (717)772-6604 Bureau of Program Integrity I Division of Third Party Liability I Recovery Section PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 Of ffi lmorow PO BOX 96 MIFFLINTOWN PA 17059 RESPONSE TO ACCOUNT INQUIRY TO: SCOTT W MORRISON DECEDENT: BETTY J BELMONT DATE OF DEATH: 01/13/2013 SOCIAL SECURITY#: 165-38-1292 We held accounts in which this decedent had an interest at the time of his/her death as follows: ACCOUNT OWNER(S): BETTY J BELMONT Type of Account : INDIVIDUAL CHECKING Account #: 1195023 Principal Balance at D.O.D: $ 12,189.32 Interest Rate: 0.000% Original Opening Date: 01/26/2007 Interest to DOD: $ 0.00 NON-INTEREST BEARING ACCOUNT ACCOUNT OWNER(S): BETTY J BELMONT Type of Account: INDIVIDUAL SAVINGS Account#: 61081162 Principal Balance at D.O.D: $ 3,213.61 Interest Rate: 0.2000% Original Opening Date: 01/7/2007 Interest to D.O.D: $ 0.24 ACCOUNT OWNER(S): Type of Account: Account#: Principal Balance at D.O.D: $ Interest Rate: % Original Opening Date: Interest to D.O.D: $ Penalty is waived on withdrawal of decedent's fund before maturity: Yes No Safe Deposit Box: Yes No First Community Financial Corp. s ock or other securities: Yes No Trust Dept. Accounts: Yes Authorized ignature/Title Date ORRSTOWN BANK A Tradition of Excellence February 27, 2013 Law Offices of Scott W. Morrison Scott W. Morrison, Esquire Center Square PO Box 232 New Bloomfield,PA 17068 Fax: 582-4220 Re: Estate of Betty J. Belmont Social Security Number 165-38-1292 Date of Death 1/13/2013 IT IS HEREBY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD THE FOLLOWING ACCOUNT WITH ORRSTOWN BANK: SAVINGSACCOUNT Account No.- 4412539920 Account Type- Statement Savings Date Opened- 1/11/2007 Joint Account(name/date)- Frank A. Belmont, Beneficiary Balance- $10,344.66 Accrued Interest- $0.56 Best Regards, I Ji I R.Worthington Deposit Processing Clerk 2695 Philadelphia Avenue • Chambersburg,PA 17201 BEi' MCIARY ACCESS ACCOUNT I Confirmation Certificate i 1 Insurer. netty Belmont OpeningiDate: $?I912013 Mail pate:: 2J2onoll Opening Interest Rate., 1a046/0 Account Number: 9311149471 Name: Thomas W Beimont P'L1 A5ECONi'ACT YOUR BENEFITS: SENEIPTOAPY ACCEU ACCOUNT tERvICEREPRESENTATIVEAT Policy Number:. Not$enentAmountl 1-308343.25Sl10YOUNAVEANY I010M2 4 ,46?.27 QUESTIONS. i 'TOTAL BENEFITS p�+.,> r. wt�tslt� rr��nl��lr�ro �vl� s FOR IMIOKE IWOROAMN' IV Ito YYE reCOlsxriendyou raview tfuptndosed booklet for deviled intonoation on your account, AC KK�. The toirM and cbndiUOtrs of yaur'a¢cvurrt die q ,*vd on the other side of t5Es,certibcate.- xA'i ,At UWWWAARCE ctSW*W