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HomeMy WebLinkAbout04-17-13 COMMONWEALTH OF PENNSYLVANIA REV-1162 EX01-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 017461 SHIELDS CHARLES EDWARD III SIX CLOUSER ROAD MECHANICSBURG, PA 17055 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- fold 101 $438.91 ESTATE INFORMATION: SSN: 192-12-7877 FILE NUMBER: 2112-0243 DECEDENT NAME: FORSBERG DONALD E DATE OF PAYMENT: 04/17/2013 POSTMARK DATE: 04/17/2013 COUNTY: CUMBERLAND DATE OF DEATH: 02/07/2012 TOTAL AMOUNT PAID: $438.91 REMARKS: CHECK# 1201 INITIALS: CJ SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS 1505610101 REV-1500 Ex(ei-10) nns lvania OFFICIAL USE ONLY PA Department of Revenue pe Y County Code Year File Number EinFTMs lNEVni Bureau oflndividualTaxes INHERITANCE TAX RETURN Wwwlrg PO BOX 28o6o2 j Harrisburg,PA 1J328-o6o1 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY W:µ k+ N . ., Decedent's Last Name Suffix Decedent's First Name MI ..=s .�'D 41, wsiwk (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI e:, J..ra 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 O 2.Supplemental Return Q 3. Remainder Return(date of death prior to 12-13-82) p 4. Limited Estate C=D 4a.Future Interest Compromise(date of C ) 5. Federal Estate Tax Return Required death after 12-12-82) !� 6.Decedent Died Testate O 7.Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) p 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(date of death O 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 Tele hon e _ tu�b5 e 1--+ 7r _ � 9 w- M RI&WR OPT-FILL NLY Zy r— i-a M M r— = tit ..,� First line of address �? , O Second line of address F--' tr— M ` CJ) co DATE FILED City or Post Office State ZIP Code ;T Correspondent's e-mail address: Ce.sh; come a S#•tie 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 E OF PERSO RESPONSIBLE FOR FILI G RETURN DATE )c L �,���a 9"IQ y �tj���3 ADDRESS"VpNNl4 L. C44PPE-? 10.3.2 14 171 ,r/ Pt Mech,micsddir . 14 /705'S• SIG ATU F PREPARER OTIPR THAN REPREaENTATIVE DATE / j ,, ADDRESS !?tt ` �G. -SHZEWS� ,�O, (o Chase/'�at, Ifte hAr l.;C.Sb14py / 00!4 170 ss- LIT PLEASE USE ORIGINAL FORM ONLY J Side 1 1505610101 1505610101 J -I 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: -Po nab d F. f;rS berg RECAPITULATION 1. Real Estate(Schedule A). ............................................ 1. O 2. Stocks and Bonds(Schedule B) ....................................... 2. b D 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0 0 4. Mortgages and Notes Receivable(Schedule D). . .. ... ..... ..... .. ..... ... 4. r; d 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 6. Jointly Owned Property(Schedule F) p Separate Billing Requested ......, 6. �J 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property i (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets(total Lines 1 through 7)... .. . .. .. . 0 ,3 7- 1 9. Funeral Expenses and Administrative Costs(Schedule H)... ... .. .. . ... .. . .. 9. 31 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1).............. 10. 3 L T 9 11. Total Deductions(total Lines 9 and 10).. 11. 12. Net Value of Estate(Line 8 minus Line 11) ................... .......... . 12. a. 77 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . . . . . . .. . .. . . . .. .. .. . .. . 13. E © d 14. Net Value Subject to Tax(Line 12 minus Line 13) ..... ... .. .............. 14. `J 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.OQ_ 15. #3b 16. Amount of Line 14 axable at lineal rate X.0 j 7 16. 17. Amount of Line 14 taxable at sibling rate X.12 17. 18. Amount of Line 14 taxable at collateral rate X.15 18. Q f 19. TAX DUE . .. . . . . . ... .. . .. . . . .. .. ... .. . . . :.. . . .. . . . .. . .. . . . .. . .. .. . 19. IG 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 1505610105 1505610105 REV-1500 EX Page 3 File Number .Z/ /.z z 7,7 Decedent's Complete Address: DECEDENT'S NAME �onceld �. �orsbtr� STREETADDRESS 1I00 Crandon Wow CITY TSTATE P� ' TD S I ZIP M ec han e,sbu, n Tax Payments and Credits: 7 1. Tax Due(Page 2,Line 19) (1) J 3. 16 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 0 3. Interest (3) r 75- 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. O Fill in oval on Page 2,Line 20 to request a refund. (4) 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred:.......................................................................................... El b. retain the right to designate who shall use the property transferred or its income;............................................ 1:1 c: retain a reversionary interest;or.......................................................................................................................... El 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?.............................................................................................................. El 3. Did decedent own an"in trust for'or payable-upon-death bank account or security at his or her death?.............. ❑ D9 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation? ........................................................................................................................ ❑ In IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S.§9116(1.2)[72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S. §9116(a)(1.3)].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. _ _ J . REV-,508 EX.(197) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INI ENT E �RE Dp C W PERSONAL PROPERTY ESTATE OF FILE NUMBER ZI_) 2^A If 3 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 MC-T20 RANK 4eeounis if s4v:n9s A*d Xv, 6a6 -7/f q34 /0, 069, oti 8- Cheek A#,d- No. 537 .2/(. y8,3 ( 5. ,757,00 C. Chec 4W No 78y k,M $33 /13 X/, 633.07 Cus-hd,an,' 7hbr, 0,00;14 L. dlrlpee, 71�r 6uteAf her Aa Mier, At decaexf) , -Pavia l it t /hl'I v&ffk os Oriyi,Yals awv7- /n error •7. c5fa✓te r•►'M Jj'15t y• fa.rHM1 ?MM;,-LM ?dl-n t dap71 ` 3. F II��l�lt5 (.�rp• r,- : C1 eGeY/Litt C/li�y -2S/ 7117 00 i rwizon, /aarhal Retina! /, 61 /j?isc. 1oPrsoa a I�/- �./ foZfr�, o 0 see. ifem;xeW iWk,11oh -. ►eBf akkcAM ) 6. C'asfi in ldallef ��?8; coo 7 Add;hona1 Oft/ 44,Jr�SIF rnon� �E�,"D iQa�nk ¢'11 71 TOTAL(Also enter on line 5,Recapitulation) $ aQ 637- 14 (If more space is needed,insert additional sheets of the same size) i I _ __ _ _ �,� _ _.�/_u�._al.lzsse••�_as�d_ P�,.'�l/,_G..��_ _,�'!/it__,rc�d�z`, ✓u��d _ _ _-�' ° _- __ Sa Zoo l0�l. _ _DIq�_//K/11���Cr_ _ _ _ __ �lD•oo I i REV-1511 EX+(10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER �ors�rlrq, 17ana.�c� C. �1-12- 2�{3 Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t. 1u1leral -H,rne, 111C_, eP Monessen, P.4 )f 7, 57.6 6, 9Z B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) -Donna j. . C_lQ'j3tr ¢1 J 031, 8 Street Address Y� 1039, -I�hla4ld �Ir . City t+IeG�1GLn sate zip 170 Ss Year(s)Commission Paid: 2. Attorney Fees C h A r-I c5 F. 3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation) Claimant lVi3 ONE /YaAIF Street Address City State Zip Relationship of Claimant to Decedent " 4. Probate Fees Arvtcj vri 4.�jn at t 5S ut 9t f t CEt�r#�C�'�t ,?3!SO 5. Accouhtant'sFees 'Ro6ert PArK S'na.ncW tt Mcehtin+csb�tr�r p lin�aY! e�, .00 lei re- Closeouf p1CX3ono xL"S I dz- 6. Tax Return Preparer's Fees T-ober+ Para, PAO-nod) 7. Adr iSinq :n C&mtuwlowJ 1.&,) :"otxrnJ 75-,oo �dd�rtis;/q� %n C4tr1,'J1e aSezltine! Jg 1 q7. v to f. fit- , ' lvi/Is 3o. oo ,� fry, of A*/ts f � Il. z ttY1�/j?CiW � {.f1�4Y•!!'S � c�?r.�lQl.t'� -�+-' �1/LOlr"L1�p�L"5� �c�.�� AS S e �7r i TOTAL(Also enter on line 9,Recapitulation) $ to, 444#q3 (If more space is needed,insert additional sheets of the same size) Dalfonso-Billick Funeral Home Inc. and Cremation Services 77mothyJ.Billick,Supervisor 441 Reed Avenue " Monessen,PA 15062-1250 724-684-8750 1 I�. Donna L. Clapper February 21, 2012 1032 Highland Dr. Mechanicsburg, PA 17055-6005 Services for Donald E. Forsberg Services,Merchandise,and Cash Advanced on Your Behalf. $ 7,587.10 Discount $ 1.18 Payments Received February 17,2012 LCBA-Funeral Funding $ 7,585.92 Annuity Total Payments $ 7,585.92 4 Balance Due $ 0.00 Paid in Full. Thank you for letting us serve you_ i 3 i a . i REV-1512 EX+(12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS ' RESIDENT DECEDENT ESTATE OF FILE NUMBER rorsbGr�, Donald E. FILE XX3 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death,including unreimbursed medical expenses! ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 41 lQuanfuM 1Ntaf►n9 Mrar Tla�^apeul�;� S¢rr%ccs /o.✓o �, �2/n� </;I! �m er y r✓nc}, /��y�sic:ans 33.80 .51 -ootnn a &0t YTf/►lPi ue, TOTAL(Also enter online 10,Recapitulation) 5 3119'. (If more space is needed,insert additional sheets of the same size) REV,1513 EX+(11-08) pennsylvania SCHEDULE DEPARTMENT or REVENUE INHERITANCE TAX RETURN BENEFICIARIES - - RESIDENT DECEDENT ESTATE OF FILE NUMBER �DrS ,cg Donald E. al- /;Z -.2 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.2116(a)(1.2).) 1. 'Donna L. Capper c�a„►Lgh-f--'r Yz �o.�z H;�1,lamd Dr:, IYleeliar1►csbu�, a. -Donald iF. �rs6xj , J2- son Ya 1'-19(o CLNO Terrace, MDr�b Port 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 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN L B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON 13 OF REV-1500 COVER SHEET $ If more space is needed,insert additional sheets of the same size. LAST WILL AND TESTAMENT OF DONALD E. FORSBERG Date 1` 2 c)a5 Witness Witness LAST WILL AND TESTAMENT of DONALD E. FOR.SBERG I, DONALD E. FORSBERG, of Camp Hill, Cumberland County, Pennsylvania, being of sound mind,memory and understanding,do make,publish and declare this to be my Last Will and Testament,hereby revoking and making void all former wills, codicils and other testamentary dispositions by me at any time heretofore made. 1. I direct my Executor, hereinafter named, to pay as soon as practicable after my decease all my legally enforceable debts and the expenses of my last illness and burial. 2. I give, devise and bequeath all of my estate,whatsoever and wheresoever situate, unto my wife, Clara E.Forsberg,providing she survives me by sixty(60)days. 3. Should my wife predecease me, or die on or before the sixtieth (60`x) day following my death then and in that event, I give,devise and bequeath all of my estate to my children, Donna L. Clapper and Donald E. Forsberg, Jr., equally, share and share alike. 4. Should either of my children predecease me or die on or before the sixtieth(600') day following my death,then and in that event,I give,devise and bequeath the share of my estate,to which my deceased child would have been entitled had she or he survived me by more than sixty(60)days,to my surviving child. 2 5. I appoint my daughter,Donna L. Clapper,Executrix of this my Last Will and Testament. If Donna L. Clapper fails to qualify or ceases to act as Executrix,then and in her stead I appoint my son,Donald E.Forsberg,Jr.,as Executor. 6. My personal representatives shall have the following powers in addition to those invested in them by law and by other provisions of my Will, applicable to all property, including property held for minors,whether principal or income, exercisable without court approval and effective until actual disbursement of all property: A. To retain any or all of the assets of my estate,real or personal without regard to any principle of diversification,risk,or productivity. B. To invest and reinvest in all forms of property,including stocks,common trust funds and mortgage investment funds without restriction to investments authorized for Pennsylvania Fiduciaries,as they deem proper,without regard to any principle of diversification,risk,or productivity. C. To sell at public or private sale,to exchange or to lease,for any period of time,any real or personal property and to give options for sales,exchanges or leases,for such prices and upon such terms or conditions as they deem proper. D. To allocate receipts and expenses to principal or income or partly to each as my personal representative from time to time thinks proper in its sole discretion. E. To make distribution in cash or in kind or partly in cash and partly in kind. I direct that my Executrix,and her successor,shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I, Donald E. Forsberg, the Testator,have hereunto set my hand and seal to this my Last Will and Testament on this /9' - day of M3' a ,2005. (SEAL) Donald E.Forsberg 3 Signed, sealed, published and declared by the above named, Donald E. Forsberg as and for his Last Will and Testament in the presence of us, who, at his request and in his presence and in the presence of each other, have hereunto subscribed our names as witnesses. Witness Witness IZ COMMONWEALTH OF PENNSYLVANIA : ss. COUNTY OF CUMBERLAND I, Donald E. Forsberg, Testator, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will, that I signed it willingly, and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn to and acknowledged before me by Donald E.Forsberg,the Testator,this /9 day of r'Vt 92005. J.'a� t Y6A4� (SEAL) Notary Public COMMONWEALTH OF PENNSYLVANIA Notarial Seal Dawn S.Sunday,Notary Public Mechanicsburg Boro.Cumberland Cotmty My Commission Expires Oct 1,2008 Member.Pennsylvania Association Of Notaries 4 COMMONWEALTH OF PENNSYLVANIA ss. COUNTY OF CUMBERLAND we, z u.haK 6A1Vho• and G.-�I I t raeny L. 5�LC.I Qt2 ,the witnesses whose names are signed to the attached or foregoing instrument,"being duly qualified according to law, do depose and say that we were present and saw the Testator,Donald E. Forsberg,sign and execute the instrument as his Last Will,that he signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed, that each of us in the hearing and sight of the Testator, signed the Will as witnesses, and that to the best of our knowledge the Testator was at that time 18 or more years of age,of sound mind and under no constraint or undue influence. Sworn to and subscribed before me by r z aIepj2 C lv hA„_ and (u j► �,,,x L S v rn , witnesses, this / 9 --day of ,2005. 0 & Witness Witness Notary Public COMMONWEALTH OF PENNSYLVANIA Notarial Seat Dawn S.Sunday,Notary Public Medtartiosburg Boro,Cumberland County W Commission Expires Oct.S,2048 Member,Pennsylvania Association Of Notaries 5 Lo LU 0 iz a a Xs LL w o � Q o a w C4)z cn _ � CO) y E �.. � 0 N N��l�fGb , a V Cl) � Q � •r N ¢cor� cRdsSit m - O Z O d a = Lb cc W LL a w cc J – t�o o � w CC (1) -4, CL a W = 0 � (n ° ac oC U T U w � U) acv 'O cnw – a ° � s IUL _3 n w 2 V) CHARLES E. SHIELDS, III ATTORNEY-AT-LAW 6 CLOUSER ROAD Corner of Trindle and Clouser Roads MECHANICSBURG,PA 17055 GEORGE M.HOUCK TELEPHONE (717) 766-0209 (1912-1991) FAX (717) 795-7473 April 15, 2013 Register of Wills Cumberland County Court House 1 Courthouse Square Carlisle, PA 17013 Re: Estate of Donald E.Forsberg No.21-12-0243 Dear Register of Wills: Please find enclosed for filing 2 copies of the Inheritance Tax Return for the Donald E. Forsberg Estate as well as Check No. 1199 in the amount of$15.00 for the filing fee, Check No. 1200 in the amount of$30.00 for additional Probate and Check No. 1201 in the amount of $438.91 for the Inheritance Tax due. Thank you for your kind attention to this matter. Very truly yours, 4VZVZI eOpalp- Charles E. Shields, III Attorney-At-Law C") r", ''', M CES/mj j cri ; Enclosures rn —J t