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HomeMy WebLinkAbout01-12-05 COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11 96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA ] 7128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 004838 DALLAM MARY LOUISE 117 TUSCARORA STREET HARRISBURG, PA 17104 ACN ASSESSMENT AMOUNT CONTROL NUMBER ........ fold .......... - ....... 101 $325.80 ESTATE INFORMATION: SSN: 165-16-2747 FILE NUMBER: 2105-0038 DECEDENT NAME: FORD AMY LOUISE DATE OF PAYMENT: 01 / 13/2005 POSTMARK DATE: 01/1 2~2005 COUNTY: CUMBERLAND DATE OF DEATH: 10/16/2004 TOTAL AMOUNT PAID: $325.80 REMARKS' M L DALLAM CHECK//663 INITIALS: VZ SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONW ^ HO REV'1500 PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE T/tX RETURN ,'E.U ,BER DEPT. 280601 .ARRISBURG, PA 17128-060I RESIDENT DECEDENT DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) COUNTY CODEYEAR NUMBER I'--' SOCIAL SECURITY NUMBER Z Louise UJ DATE OF DEATH(MM-DD-Year) 1 6 5 - I 6 - 2 7 4 7 ~ DATE OF BIRTH (MM-DD-Year) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 0 10/1 6/2004 03/30/1 91 7 REGISTER OF WILLS LU (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) /~ SOCIAL SECURITY NUMBER "' [] 1. Original Return ~- E~ 2. Supplemental Return ,,, ~_ ~ [] 3. Remainder Return (date of death prior to 12-13-82) OO.~ r'-'] 4. Limited Estate r--I 4a. FuturelnterestCompromise(dateofdeathafter12_12.~2) E~ 5. Federal Estate Tax Return Required "'0~ :: '"' "~E~ 6. Decedent Died Testate (Attach copy of Will) r--I 7. Decedent Maintained a Living Trust (Attach copy of Trust) 8. Total Number of Safe Deposit Boxes < ~ 9. Litigation Proceeds Received [] 10. SpousaIPovertyCredit(dateordeathbet,~eent2.31_91andl_1.g8) ~ 11. election to tax under Sec. B113(A)(AttachSchO) z NAME c~ COMPLETE MAILING ADDRESS z ueline A. Kelly o ~- FIRM NAME (If Applicable) u~ LU ,,, Jan L. Brown & Associates 845 Sir Thomas Court, Suite 12 tY o TELEPHONE NUMBER 717-541-5550 Harrisburg PA 17109 1. Real Estate (Schedule A) (1) OFF;[.C;~,~'AL USE ONLY 2. Stocks and Bonds (Schedule B) (2) T'~ - ~ - 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) - 4. Mortgages & Notes Receivable (Schedule D) (4) c..,.) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 681.13 - - ,.~- (Schedule E) - '- 0 6. Jointly Owned Property (Schedule F) (6) 5,751.96 , ~;? ~:-~ ~ [] Separate Billing Requested '-~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) 5,929.50 ~ (Schedule G or L) ,,~ 8. Total Gross Assets (total Lines 1-7) O (8) 12,362.59 LU 9. Funeral Expenses & Administrative Costs (Schedule H) tv' (9) 2,915.97 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 1,825.40 11. Total Deductions (total Lines 9 & 10) (11) 4, 741.37 12. Net Value of Estate (Line 8 minus Line 11) (12) 7,621.22 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 7,621.22 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES Z 15. Amount of Line 14 taxable at the spousal tax 0 ~ rate, or transfers under Sec. 9116 (a)(1.2) X (15) ~ 16. Amount of Line 14 taxable at lineal rate 7,621.22 x .045 (16) 342.95 O. 17. Amount of Line 14 taxable at sibling rate ~; X .12 (17) 0 18. Amount of Line 14 taxable at collateral rate 0 X .15 (18) <~ 19. Tax Due (19) 342.95 Decedent's Complete Address: STREET ADDRESS 325 Wesley Drive CITY Mechanicsburg 1 STATE ZIP PA -]' 17055 Tax Payments and Credits: 1, Tax Due (Page 1 Line 19) 2, Credits/Payments (1) 342.95 A. Spousal Poverty Credit B. Prior Payments C. Discount 1 7.1 5 3. Interest/Penalty if applicable Total Credits ( A + B + C ) (2) 1 7.1 5 D. Interest E. Penalty Total Interest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 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) 325.80 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 325.80 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 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 considerat on? ............... . ............................ [] [] 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, or other non-probate property which contains a beneficiary designation? IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEBULE G AND FILE IT AS PART OF THE RETURN, 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 pr,~arer other than the personal representative is based on all information of which preparer has any knowledge. SIGNA.~U. RC_/OF PERSON~PONSIBLE FORy~/~G~ RETURN DATE /~ESS /~171-uscarora Street ~ Harrisburg SIGNA~J, JRE OF PREPARER OTHER ~i) ."~ ,, ?"~ PA 17104 THAN REPRESENTATIVE -, ~' ' DATE A ,E~R..~S7 ~,~5 Sir Thomas Court, Suit~'-2 · Harrisburq PA 17109 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [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% [72 P.S. §91 I6 (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 twenty-one 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% [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%, 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 decedenrs siblings is 12% [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. PEV-1508 EX + (6-98) ~ SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF FILE NUMBER Ford, Amy Louise Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. Check from Pennsylvania State Employees Retirement System 681.13 TOTAL (Also enter on line 5, Recapitulation) $ 681,13 (If more space is needed, insert additional sheets of the same size) REV-1509 EX + (6-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Ford, Amy Louise If an asset wes 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. Mary Louise Dallam 117 Tuscarora Street daughter Harrisburg, PA 17104 B Judith McCans 690 Boyds School Road daughter Gettysburg, PA 17325 C JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE, VALUE OF ASSET INTEREST DECEDENTS INTERES 1. A. 9/1994 PNC Bank 7,588.99 50. 3,794.5( Checking Account #8610332105 2. B. 2~2002 PNC Bank 80.39 50. 40.2( Savings Account #5003783082 3. B. 712003 PNC Bank 3,834.52 50. 1,917.2( Savings Account #5004329439 TOTAL (Also enter on line 6, Recapitulation) $ 5,751.96 (If more space is needed, insert additional sheets of the same size) RE,/-1510 EX + (6-98) SCHEDULE G INTER-VIVOS TRANSFERS & COMMONWEALTH OF PENNSYLVANIA INHERITANCE T,~ RETURNMISC. NON-PROBATEPROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Ford, Amy Louise This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM fNCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH ACOPYOFTHE DEED FORREAL ESTATE VALUE OF ASSET INTEREST (~FAP~-~CABLE) VALUE 1. iTransfer from joint checking account to daughter, 17,859.00 50. 3,000.00 5,929.5(: Mary Louise Dallam (Feb 2004) TOTAL (Also enter on line 7 Recapitulation) $ 5~929.50 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES& INHERITANCE TAX RETURN RESIDENT DECEDENT ADMINISTRATIVECOSTS ESTATE OF FILE NUMBER Ford, Amy Louise Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Varcoe Thomas Funeral Home 942.22 2. funeral luncheon and flowers 738.36 3. Memorial Services luncheon and flowers 220,39 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s)/BN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees Jan L. Brown & Associates 1,000.00 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 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Cumberland County Register of Wills, Inheritance Tax filing fee 15.00 TOTAL (Also enter on line 9, Recapitulation) $ 2,915.97 (If more space is needed, insert additional sheets of the same size) REV~1512 EX + (6-98) ~ SCHEDULE I COMMONWEALTH OF PENNSYLVANIA DEBTS OFDECEDENT, INHERITANCE TAX RETURN RESIDENT DECEDENT MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Ford, Amy Louise Include unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1, Bethany Village--outstanding nursing home bill 1,413,32 2. Alert Pharmacy--outstanding bill 20.50 3. Holy Spirit Hospital--outstanding medical bill 19.08 4. Metro Medical (ambulance services)--outstanding medical bill 132.50 5. Visiting Angels--outstanding debt 240.00 TOTAL (Also enter on line 10, Recapitulation) $ 1,825,40 (If more space is needed, insert additional sheets of the same size) R~-V-1513 EX '- (9-~c~ SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ford, An- / Louise FILE NUMBER ~ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE [. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a)(1.2)] 1. Mary Louise Dallam 117 Tuscarora Street daughter joint property; Harrisburg, PA 17104 1/4 of residue 2. Judith McCans daughter joint property; 690 Boyds School Road Gettysburg, PA 17325 1/4 of residue ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size)