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HomeMy WebLinkAbout10-08-13 ( 1505610140 �1 REV-1500 Ex (01-10' OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of individual Taxes PO Box 260601 INHERITANCE TAX RETURN 2 1 1 3 0 7 8 3 Harrisbum, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security'Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 0 6 1 2 2 0 1 3 1 1 1 9 1 9 2 2 Decedent's Last Name Suffix Decedent's First Name MI L e w i s E v a I y n M (If Applicable)Enter Surviving Spouses 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 Q 1,Original Return 2.Supplemental Return 3.Remainder Return(date of death prior to 12.13.82) Ej 4.Limited Estate 4a.Future Interest Compromise(date of Ej S.Federal Estate Tax Return Required death after 12.12-82) © 6.Decedent Died Testate 7.Decedent Maintained a Living Trust 0 8.Total Number of Safe Deposit Boxes (Attach Copy of Witt) (Attach Copy of Trust) n 9. Litigation Proceeds Received 10.Spousal Poverty Credit(dale 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 SCOt t W . M o r r i son , E s q 717 582 2300 GIISSTER OF WILLS Lstio�Y CA 7J O First line of address M 71! ` i t o - Co rani rn 6 Wes It Mai n St r e e t YV Second line of address v C> -rt -n P 0 . Box 232 � _ -, . � C> DATErfILED — rrI City or Post Office State ZIP Code ,.o I� New BI Domf i e I d PA 17068 Correspondenrs e-mail address: smorrisonlaw(ftenturylink.net Under penatties of pedury,I declare that I have examined this return,including accompanying schedules and statements,and to the hest of my knowledge and t;_W, It is We,correct and complete.Declaration of preparer other than the personal representative Is based on all infom+aRon of which preparer has any knowledge, SIG"TURE OF PERSON RES /�PONSIBLE FDR' L RETURN DATE R ,� DATE U t.., �Q .d 10/4/2013 ADDRESS 34429 Owls Nest Rd.,Lewes,DE 55 Pine Ridge Circle Enota PA 1211 Highlander Way,Mechanisbum,PA SIGN F ARER OTHER THAN REPRESENTATIVE DATE 10/4/2013 st M in Street New Bloomfield PA 17068 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: Evalyn M. Lewis RECAPITULATION 1. Real Estate(Schedule A) . .. . ... .. ... .. .. .. .. . ..... . . . . . .. . ... .... . . 1. 2. Stocks and Bonds(Schedule B) ... .. . . . . .. ... ... ..... . . . . . . . . ... ..... 2. 4 7 9 . 1 6 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 ) 2 4 7 3 9 9 , 3 9 P p rty(Schedule E . . ..... 5. 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . ..... . 6. 7 3 2 2 , 5 8 7. Inter-Vivos Transfers&Miscellaneous N •Probate Property 1 5 0 5 9 4 , 4 9 (Schedule G) Separate Billing Requested . ... .. . 7. 8. Total Gross Assets(total Lines 1 through 7) 8. 4 0 5 7 9 5 , 6 2 9. Funeral Expenses and Administrative Costs Schedule H 7 9 0 2 • 5 4 10. Debts of Decedent,Mortgage Liabilities,and Liens Schedule I W. 2 4 9 . 4 6 11. Total Deductions(total Lines 9 and 10) .. .. .. . ... ..... . . . . . .. .. . ... . . . 11. 8 1 5 2 . 0 0 12. Net Value of Estate(Line 8 minus Line 11) . .. . .. . ..... . .. . . .. .. ....... 12. 3 9 7 6 4 3 . 6 2 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. 3 9 7 6 4 3 . 6 2 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 3 9 7 6 4 3 . 6 2 16. 1 7 8 9 3 . 9 6 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 7 8 9 3 . 9 6 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ Side 2 L 1505610240 1505610240 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 13 0783 DECEDENT'S NAME Eval n M. Lewis _ STREET ADDRESS 4905 E. Trindle Road CITY STATE 21P iMechanicsburg PA 17050 Tax Payments and Credits: 1, Tax Due(Page 2,Line 19) (1) 17,893.96 2. Credits/Payments 17 000.00 A.Prior Payments B.Discount 894.70 Total Credits(A+B) (2) 17,894.70 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) 0.74 5. If Line i +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00 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; ...................................................................... ❑ IZI b. retain the right to designate who shall use the property transferred or its income; 171 c. retain a reversionary interest;or ..........................................._.................................................. ❑ 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 receiving adequate consideration? ....................................................................................... 171 MX 3. Did decedent own an'in trust for'or payable-upon-death bank account or security at his or her death? ......... ❑ Q 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation?............___............................................................................... ® n 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 5 3 percent[72 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)(11)(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,undet Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-1589 EX+(698) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER EValyn M. Lewis 21 13 0783 All property jointlyrovmed with right of survivorship must he disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 10 shares of Metro Life stock 479.16 TOTAL(Also enter on line 2,Recapitulation) $ 479.16 (if more space is needed,insert additional sheets of the same size) REV-15DB EX-(6-96) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Evalyn M Lewis 21 13 0783 Include the proceeds of Iititi and the date the proceeds were received by the estate. All property jointly-owned with night of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Belco Community Credit Union Account#891234 97,738.55 2. Elderton State Bank CD#130019615 40,017.53 3. Elderton State Bank CD#130008584 33,615.41 4. Ally CD#3019903198 26,023.66 5. Saving &Trust Bank Account#5001286250 50,004.24 TOTAL(Also enter on line 5,Recapitulation) $ 247 399.39 (If more space Is needed,insert additional sheets of the same size) REV-1509 EX+(01-10) pennsylvania SCHEDULE F DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Evalyn M. Lewis 21 13 0783 If an asset was made jointly owned within one year of the decedent's date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A.Carol A. Lewis 55 Pine Ridge Circle Daughter Enola, PA 17025 B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE, VALUE OF ASSET INTEREST DECEDENT'SINTEREST 1. A. 717111 Metro Bank checking account#2833815970 14,645.16 50. 7,322.58 TOTAL(Also enter on Line 6,Recapitulation) E 7,322.58 If more space is needed,use additional sheets of paperof the same size. REV-1510 EX-(08-09) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC, NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Evalyn M. Lewis 21 13 0783 This schedule must be completed and filed if the answer to any otquestions 1 through 4 on page three of the REV-1500 is yes. ITEM DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % DECUS EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IFAPKIIOAM VALUE 1. First Commonwealth IRA#01001910003376 8,570.28 100.00 8,570.28 Three children, David B. Lewis, Carol A. Lewis and Patti L. Baer are beneficiaries 2. First Commonwealth IRA#13250006694509 1,694.23 100.00 1,694.23 Three children, David B. Lewis, Carol A. Lewis and Patti L. Baer are beneficiaries 3. Ameriprise Investments Account#104383013001 140,329.98 100.00 140,329.98 payable on death to children, David B. Lewis, Carol A. Lewis and Patti L. Baer i TOTAL (Also enter on Line 7,Recapitulation) $ 150 594.49 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 Evelyn M Lewis 21 13 0783 Decedent's debts must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Roseann's Rest-funeral meal 374.58 2. Shoemaker Monuments-gravestone lettering 100.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 2, Attorney Fees: Scott W. Morrison 6,500.00 3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: Glenda Farrier Strasbaugh 493.50 6 Accountant Fees: 6. Tax Return Preparer Fees: 7. The Sentinel -estate advertising 359.46 8. Cumberland Law Journal-estate advertising 75.00 TOTAL(Also enter on Line 9,Recapitulation) $ 7,902.54 If 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 Evalyn M. Lewis 21 13 0783 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. Checks 8.25 2, OIP -medical account 10.00 3. Parry- medical account 10.00 4. Patient First- medical account 14.26 5. PSERS - return of pension 206.95 f i I TOTAL(Also enter on Line 10,Recapitulation) $ 249.46 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: Eval n M. Lewis 21 13 0783 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 pnclude outdght spousal distributions and transfers under Sec.9116(a)(1.2).] 1. David B. Lewis Lineal 34429 Owls Nest Road one-third Lewes. DE 19958 2. Carol A. Lewis Lineal 55 Pine Ridge Circle one-third Enola, PA 17025 3. Patti L. Baer Lineal 1211 Highlander Way one-third Mechanicsburg, PA 17050 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: i. TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size. LAST WILL AND TESTAMENT OF EVALYN M. LEWIS of 4905 E.Trindle Road,Apt. 1033,Mechanicsburg, mid raemor�and mailing do hereby . .. make publish and declare this my Last Will and Testament,hereby expressly revoking all other writings in nature testamentary by me at any time heretofore made. FIRST: I direct that all my debts and funeral expenses be paid as soon after my decease as may be practicable. SECOND: I direct that inheritance tax on property disposed of herein shall be paid from my residuary estate. THIRD: I hereby give, bequeath and devise all the rest and residue of my estate and property,real,personal and mixed,of whatsoever nature and wheresoever situated of which I may own at the time of my death, or to which I maybe entitled or of which I may Carol A. Lewis and Patti L. Baer, each person to share equally. EVALYN M. LE S Page one of two f I. i IT I , FOURTH: I hereby appoint my three children, David B. Lewis, Carol A. Lewis and Patti L. Baer, as Executors of this,my Last Will and Testament. I direct that they shall e bond or other security in any jurisdiction wherein proceedings hate heremto set me hand and gad its 2nd day of February, 2011. WI SS: p (SEAL) EVALYV M. LEWI / 4 i Page two of two i ,• pennsylvania DEPARTMENT OF PUBLIC WELFARE July 29, 2013 SCOTT W MORRISON ESQUIRE 6 W MAIN ST PO BOX 232 NEW BLOOMFIELD PA 17068 Re: Evalyn Lewis SSN: ###-##-6735 Dear Attorney Morrison: Pursuant to your letter dated July 24, 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 t . 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 BLLCO COMMUNITY CREDIT UNION Decedent Account Information (On Date of Death) Belco Community Credit Union 1. Name(s) in which the account was held: Evalyn M. Lewis 2. Account Number: 891234 3. Total Account Balance as of Date of Death: $97,738.55 Balance Accrued Dividends Date Opened Regular Savings $5.00 $0.00(1/I/13-06/12/13) 03/29/2011 Holiday Club $ Whatever Club $ Money Market $97,733.55 $255.84(1/1/13-06/12/13) 05/16/2011 Checking $ IRA $ Certificates: Certificate Number Balance Accrued Dividends Date Opened $ $ 4. Name(s)in which Safe Deposit Box was held: 5. Date the box was initially rented: 6. Branch address at which the box is located: ELD E RTO N The Right Direction State Bank July 29, 2013 Scott W. Morrison Center Square P O Box 232 New Bloomfield, PA 17068 Re: Evalyn M. Lewis Dear Mr. Morrison, Below please find the information you requested on the accounts of Evalyn M. Lewis. All balances are as of June 12, 2013. NAME ACCOUNT PRINCIPAL ACCR INT DATE OPENED -Evalyn M. Lewis CD 130019615 40,000.00 17.53 10-23-2006 -Evalyn M. Lewis CD 130008584 33,599.06 16.35 4-6-2004 Stephen B. Lewis is still listed on CD's and his social security number is being used to report the interest. If any additional information is needed,please feel free to call. Sincerely, &[ 7 I . / 1 Cheryl A. Hankey Branch Manager ELDERTON STATE BANK 143 North Main Street • Elderton, Pennsylvania 15736 • 724.354.2111 • Fax:724.354,2060 eldertonbank.tom ally P.O. Box 951 Horsham, PA 19044 08/12/2013 Scott W Morrison P.O. Box 232 New Bloomfield, PA 17068 RE: Estate of Evalyn M Lewis Dear: Scott Morrison In response to your inquiry, the above-named decedent had the following account(s)with Ally Bank: Type of Account Aaount Title____ AttouM Number Balance on 24M Raise Your Rate Evelyn M Lewis 3019903198 Principal: $26,000 CID $23.66 The principal balance(s) listed above represents the account balance, including any interest earned on the account(s) up to the last statement cycle date. The interest amount(s) represent the accrued interest from the last interest posting up to but not including the date of death of the account holder. Questions? We're here to help, anytime. Just call 877-247-ALLY(2559) 24 hours a day, 7 days a week. You can press"0"to reach a Customer Care Associate immediately. Or go to allybank.com. Sincerely, &444M-Q. Susan W. Green Ally Bank Deposit Executive Member FDIC OPS-I l V i n METRO BANK Harrisburg, Street, PA17111 my 0 metr bank.com 7/26/13 Scott W. Morrison, Esquire Law Offices of Scott W. Morrison 6 West Main St. P.O. Box 232 New Bloomfield, PA 17068 RE: Estate of: Evalyn M. Lewis Tax Identification Number: 185-14-6735 Date of Death: June 12, 2013 To Whom It May Concern: This letter is in reference to decedent account information you requested for the individual listed above. We are able to provide the following: Account Type: CK Account Number: 2833815970 Date Opened: 07/07/2011 Date Closed: 07/22/2013 Primary Owner: Evalyn M. Lewis Secondary Owner: Carol A. Lewis Accrued Interest: `"$0.00 Date of Death Balance: $14,645.16 *` Please note: The accrued interest will not be paid if the account is closed prior to the date the interest is scheduled to post. Please feel free to contact us at 1-888-937-0004 if we may be of further assistance. Sincerely, Jennifer Jacobs Research Associate Metro Bank COO'a IV101 Page 1 FIRST Cammonwvealth EXHIBIT"A„ RE: DECEDENT: Evalyn Lewis SOCIAL SECURITY NUMBER: XXX-XX-6735 DATE OF DEATH: June 12, 2013 CERTIFICATE OF DEPOSIT- IRA Account Number. 01001910003376 Title: Evalyn M. Lewis Open Date: July 19,2011 Date of Death Balance: $ 8,568.82 Accrued Interest: $ 1.46 CERTIFICATE OF DEPOSIT-IRA Account Number: 13250006694509 Titic: Evalyn M.Lewis Open Date: March 27, 1996 Daze of Death Balance: $ 1,694.19 Accrued Interest: $ 0.04 SAFE DEPOSIT BOX Box No: None Title: Location: C00'a H11VaMH0WW00 ISiIId 9v:Lt CTOZ-SE-Inr �n .fir PpSiPpE U•SPPIpE�D pO' l3 cp OG PpppNT '� �� JN�iEO J�CE 1000 I i � P G? „0 n l CJ �? C()U(� 1013