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Home My WebLink About08-21-13 J REV-1500 E"c01-1°' 1505610143 � OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes DEPAR7MENTOF0.EVENUE Po BOX.28oso1 INHERITANCE TAX RETURN 21 13 Q�i 5 Harrisburg, PA 17128-0601 RESIDENT DECEDENT � ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 166 20 2447 05 15 2013 06 16 1925 DecedenYs Last Name Suffix DecedenYs First Name MI GRIMM MARY J (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 REGI�TER QF 4�1lI�.!� FILL IN APPROPRIATE OVALS BELOW � 1. Original Return ❑ 2. Supplemental Return � 3.Remainder Return(date of death prior to 12-13-82) � 4. Limited Estate � 4a.Future Interest Compromise � 5. Federal Estate Tax Return Required (date of death after 12-12-82) g Decedent Died 7estate �, Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes � (Attach Copy of Will) � (Attach Copy of Trust) � 9. Litigation Proceeds Received � �p,Spousal Poverty Credit(date of death � ��,Election to tax under Sec.9113(A) belween 12-31-91 and 1-i-ss) (Attach Sch.O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number �,.. ROBERT P KLINE 71� 770 �=�4Q,.., �� 0 R�IS'FfR OF V1�ILI�S USE�ryLY ..� n , , �3 ' -v :r (� " f\7 , First line of address � `= `�� '�'� ` �t, . . , �u> . „ , , y 714 BRIDGE STREET �� -, .� � , ___ ; �"., . —_� _ Second line of address ` -' ` � � ^ _ , . , PO BOX 4 61 � " � � ,; .., �;. : :< • DATE IL,ED '�t City or Post Office State ZIP Code NEW CUMBERLAND PA 17070 Correspondent's e-mail address: 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. SIGNATUR F PERSON RESPONSIBLE FOR FILING RETURN DATE JenniferA. Campbell 8'IQ-�3 ADDRESS Y 17 Marshall Drive, Camp Hill, PA 17011 SIGNATU OF PR ARER Q.�FI�R TH N REPRESENTATIVE DATE �/ Robert P Kline �O 2,0�j ADDRESS 714 Bridge Street, New Cumberland, PA 17070 Side 1 � 1505610143 1505610143 J � �505618243 REV-1500 EX Decedent's Social Security Number oe�aanes rvem�: G R I M M� M A R Y J U N E 16 6 2 0 2'4 4 7 - - --� ----- RECAPITU�ATION ��- � 1. Real Esta#e{Schedule A).......................................................................................... 1. 2. Stocks and Bonds(Schedule B)............................................................................... 2. 3. Closely Held Corparation,Partnership or 5ale-Praprietorship(Schedule C).......... 3. 4. Martgages&Nofes Receivable{Schedule D}.......................................................... 4. �• Cash,Bank De osits&Miscellaneaus Persanal Pra e } ?� - �� P p rtl'{Schedule E ................ 5. 6. Jointly Owned Properky{Schedule F) � Separate Billing Requested............. 6. � r $�5 . �0 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) � Separate Billing Requested............. 7. $. Totai Gross Assets(totaf Lines 1-7}....................................................................... 8. 3 , 9 0 6 . 0 3 - �_-- 9. Funera!Expenses&Administrative Costs(Schedule H}............. ............ 9. 1 Q , 9?1 . 3 6 ................ 10. Debts of Decedent,Martgage�iabilities,&�iens{Scheduie 1}................................ 14. $4 5 . �9 91. Total Deductions{total Lines 9&10)......................................................................11. 1 1 , 4 1 8 . 3 5 12. Net Value of Estate(Line 8 minus Line 11).............................................................12. -7 , 5 12 . 3 2 13. Charitabie and Governmen#ai BequestslSec 9113 Trusts for which an election to tax has not been made(Schedule Jj................................................. 13. 14. Net Value Subject to Tax{�ine 12 minus Line 13}.................................................14. -'? , 512 . 3 2 TAX CdMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES � 15. Amount of�ine 14 taxable at the spousal tax rate,or transfers under Sec.9116 t�)t�.z)x.aa �s. 16. Amaunt of Line 14 taxable at lineal rate X .045 '1s� 17. Amount of Line 14 taxabie at sibling rate X ,12 17. "!8. Amaunt of�ine 14 taxable at collateral rate X .15 1g� 19. Tax Due...................................................................................................................19. 0 . 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑ Side 2 � 1505610243 1505610243 � REV-1500 EX Page 3 File Number 21 - 1 3 Decedent's Complete Address: D T' NA Grimm, Mary June STREET ADDRESS 17 Marshall Drive CITY STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due(Page 2, Line 19) (1) 0.0 0 2. Credits/Payments A. Prior Payments B. Discount Total Credits(A +B) (2) 0.00 3. Interest (3) 0.0 0 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2 Line 20 to request a refund 5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) �.�� 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:.................................................................................0 ❑x b. retain the right to designate who shall use the property transferred or its income:....................................� � c. retain a reversionary interest;or................................................................................................................0 ❑x d. receive the promise for life of either payments,benefits or care?..............................................................❑ � 2. If death occurred after December 12, 1982,did decedent transfer property within one year of death without receivingadequate consideration?.....................................................................................................................0 � 3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?......... � x� 4. Did decedent own an Individual Retirement Account,annuity,or other non-probate property which contains a beneficiary designation?...................................................................................................................� 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETUR � � � �.:,�.� �..�,,,,�a = , �� ._ . � _ 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 re�urn 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 decedenYs lineal beneficiaries is 4.5 percent,except as noted in 72 P.S.§9116 1.2)[72 P.S.§9116(a)(1)l• •The tax rate imposed on the net value of transfers to or for the use of the decedenYs siblings is 12 percent[72 P.S.§9116(a)(1.3). A sibling is defined under Section 9102,as an individual who has at least one parent in common with the decedent,whether by bloo or adoption. SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMONWEALTHOFPENNSYLVANIA PERSONAL PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF Grimm, Mary June . 2� - �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 DESCRIPTION VALUE AT DATE OF NUMBER DEATH 1 Discover Card Refund 46.03 2 Giesinger Health Refund 24.00 TOTAL(Also enter on Line 5, Recapitulation) 70.03 SCHE�U�E F COMMONWEALTH OF PENNSYLVANIA INHERITpNCETAXRETURN Jt)INTLY-OWNED PRQPERTY RESIDENT DECEDENT - --_ __. ESTATE OF FILE NUMBER Grimm, Mary June 21 - 13 If an asset was made joint within one year of the decedenYs date of death, it must be reported on schedule G. SURVIVING JOfNT TENANT(S)NAME ADDRESS REIATiONSHIP TfJ DECEDENT George Mayes � � 119 Nittany Street - -Son � q Beilefonte, PA 16823 � Jennifer A. Campbel{ 17 Marshali Drive Granddaughter g Camp Hill, PA 17011 JOINTLY OWNED PRt?PERTY: -- �CRIPTa�PRO�E 2�TY � - - o - ITEM �.ETTER DATE Include name o inancial ms itu ion an bank account numb rDATE OF DEATH �0�F DA7E OF DEATH NUMBER FOR JOINT MADE or similar identi in number.Attach deed for'aintl -hsid reai VA�UE OF ASSET D�CD'S VALUE OF TENANT JOINT � � j Y INTERES °EC�°ENrs�NT�RESr estate. - -- - - - -- --- - 1 A,6 PNC BankAcct#1p-2235-0137 ��,5os.�2 33.3% 3,836.00 � i ! i I � I i � � � I � I � TOTAL(Atsa enter on line 6, Recapitulation) � 3,83g.pp SCFiEDULE H CqMMONWEALTH OF PENNSYLVANIA E�J'1J��7t INHERITANCE TAX RETURN n��Q��/�(�T'C RESIDENT DECEDENT rzn�r��v��r��vvv�v -_ _ ___ ._ .___ ___ _.__ . _,�._ F1LE NUMBER ESTATE OF Grimm, Mary June 21 - 13 - -- --- Debts af decedent must be reparted on Schedule i. - - ITEM -- _ — NUMBER �UNERAL EXPENSES: DESCRIPTION AMOUNT A. 1 Mark D. Heintzelman Funeral & Cremation Services, LLC 8,356.36 � 2 Mayes Memorials, I nc. 1,1 p0.00 � B. ADMINISTRATIVE COSTS: 1. Personai Representative's Commissions Name of Personal Representative(s) Street Address � City State Zip Ysar{s}Gommissfon paid � 2. Attorney's Fees Kline Law Office 1,5Q0.00 g. Family Exempiian: {If deceden#'s address is nat the same as ciaimanYs,attach explanationj Claimant I Street Address � City State Zip Relatianship of Claimant to Decedent I 4. Probate Fees Register of Wills 15.00 � 5. Accauntant's Fees B. Tax Retarn Preparer's Fees 7. �ther Administrative Costs � 1 � � � TOTAL(Also enter on line 9, Recapitutatianj �[p,g7�,3g � SCHEDULEI ' DEBT� OF DECEDENT, MORTGAGE C4MMONWEALTHOFPENNSYLVANIA LlABILITIES & LIENS � INHERiTANCE TAX RETURN } RESIDENT DECEdENT � ......... ...... _ --,_, �L._ _.� FILE NUMBEFt ESTATE OF Grimm, Mary June 21 - 13 Report debts incurred by the decedent prior ta deafh that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM DESCRIPTION AMOUNT NUMBER 1 PNC 8ank VISA#4489-1530-4024-7149 � Y W 212.99 2 Haliday Hair �g.pp 3 East Pennsbaro Ambualr�ce Service ��p.pp 4 Haly Spirit Nospital g�,�p TOTAL(Also enter on Line 10, Recapitulation) 44$.99 � � REV-1573 EX+(11-08) SCHEDULEJ COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT � ESTATE OF FILE NUMBER Grimm, Mary June 21 - 13 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY Do Not List Trustee(s) I� TAXABLE DISTRIBUTIONS[include outright spousal distributions,and transfers under Sec.9116(a)(1.2)] 1 George Mayes Brother Joint Account 119 Nittany Street Bellefonte, PA 16823 2 Jennifer A. Campbell Granddaughter Joint Account 17 Marshall Drive Camp Hill, PA 17011 Enter dollar amounts for distributions shown above on lines 15 through 18 on 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 B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHE T 0.00 �, ,.,.m�.�.�, �,�Y��-�.,�,...�.... ,.>_.. .,.�.�,�.,;.,..�.��.�. �n�¢ .�,� ��.�.,�,H�.�.,,��,;. . H105.112 REV.1/OS � WARNING: IT IS ILLEGAL TO ALTER THIS COPY OR (FEEFORTHIS TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH. CERTtFICn�r�56.00) :COMMONVIIEALTH OF PENNSYLV}fN1A DEPAR'FMEi�1T:.QF H�ALTH VITAL.REGOR4S LOCAC REGISTRAR'S CERTIFICATION QF QEATH ` �i��".C�'i''.�� ` �'�� THOFp\\ ��'� �N'y� ��:- �P .m , , _,.� �...t' � `�,� `�/��/ p� �G 'T /� �"�, C� 1i1 � a CERT. NO. I � `t'�'��'�C� �{��, - ,�� l�a� 28, 2flf3 _ �. Oate of Issue of This Cerf�tication� �ay _��Q'� ��` ;e' '<<�h�� K�� GUMBE�`LAPyD CO., ;P� Name ofi [�e�sdent ` Mary Jun� < Fye 'Ma�es Grimm . Fi�st Middle Last �� . � Sex �'�T�1� ' Social Seeurity No. �66-20-24�7 .` Date csf C7eath Ma� <15, 2t12�--::- _ D�te of Birth �une 16, 1925 $irthplace Hcawarc�; PA Cenere Caunt�r ------_ Place of Death Holy Spirit Hospital '' Cum'�erland Camp Hi11 Borouqh Penns�GrEi�._ Faciliry Name . County ::. . City.Bprpu�h or Township Race : white Occ�!pation ' 1��zsician Ar�n�i Fbrces? (Yes or No) N� Decedent's Marital Status widowed � Mailing Address I7 Marshall Drive Camp Hill PA 17011 - �>.Number �$lieet.. < :�.Cityor7awn:.. � State -- Infortnant Ge�rge Eu�ene Mayes Funer�l Dirsctor Mark D. xei.nta:elmari -------------- 1Vame and Address'of ;Funera4 EstablishrnentMark D. Heintzelman> Funeral and Creroation Serv�:G.es P.C. 226 S. P�nnsyl;vania Avenue ; Centre Hall PA 16828 ' interva) Between ' � Part L > Immediate Cause ; Onset and Deati� __ (a}Rup�izred Tharacic Aortic Rneurysm � ; , .--- -- _ ___. , . �b� , ' --------- � � �� ' -- , - - � �d) — _ � ;---- P�rt,ll: Other Sign�ficant Conditions ; ; , ; Manner of Death Descri�e how injury occurred: Natural' �] Homicide ❑ 'Acciden# ❑ ' Perding Inves#igation ❑ --- _ _------ Suieide ❑ Could not be Deterr�ined ❑ : __,, ; Name and Title of Certifier�rnest M. Josef, M.D.'` (M.D., D:;O., �oron�r, �'t�;,E.; �cldress 1830 Good Hope Road Enola PA 17�25 This is to certify that fhe information here given: is correctly copied fram an orfginal ce;:tifEcate :of death duly filed with me as 'Local Registrar. The arigina( certificate will f�e forwarded ta the State Vital Recor�ls O�#ice fior permanent #iling.` • �s^Y1a-►�-v��y.�;. .s. . 3.4-15 0 __ ' � �� .Local RegislF� .Fecords , Disti r.f No . May 28, 2013 123 Grandview' Ftaad Ce,ntre Hall PA 16826 � � -- Date fieceived by Locaf Registrar �� - StreeC�ltldress - � City,eorough.Township � � � � � � � � � �J'� t'�.i n � p""""'. .cC y� r'"" .:.� � � ;ex _ 1 � a �i��{� # �� +3a o d �� °� � �� _ � � � �� . i R_. ;y �r- ,.._ � ..., E ,s� R„ - , ^.: �' _ � U Gy ._.-1 � C', � �_,_, . , y a .: � 1.._ .. �� ..� �� :, � � CJ1 � �. . , e� �-' � ' � � � O N G � , c_! ,'� + , U � � � ,fi y �\f � °� tS.,! .S:i �. � � �'✓ ,.� o k' : ., '-- c� � o � � s, �='_ °�_ t.Z, }., '� �} ��; F ; `_ ` �, `�- � c� v c� __ t.�a P.:. �`"., ��,,� -o � ..fl U �n v,, , , .�� e� � •�j �,� , .. .. .. .—�.r �ti.�Jt � �".. e3 - . . � 4.:� U Q � �+ i il'-I: - S , i��' � i �4 ; ;�, ¢ i �