HomeMy WebLinkAbout10-23-13 (3) t f
� 1505610143
REV-15Q0 �`�"'.��'
PA De artment of Revenue OFFICIAL USE ONLY
p pennsylvania co�,rny code Y� File Number
Bureau of individual Taxes 0°"R""A°''�OF1�1B"'�
Po Box.2soso� INHERITANCE TAX RETURN 21 13 0195
Harrisburg,PA ���2s-oso� RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Bi�th
182 46 4346 Ol 31 2013 07 17 1953
Decedent's Last Name Suffix Decedent's First Name MI
Fi sx�R cx T•F s M
(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
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1. Original Retum � 2. Supplemental Retum � 3. Remainder Retum(Date of Death
Prior to 12-13-82)
� 4. Limited Estate � 4a.Future interest Comaromise � 5. Federal Estate Tax Retum Required
. (date of death after 12-12-82)
� g Deoedent Died Testate � �. ��t Mair�'��a Living Trust � 8. Total Number of Safe Deposit Boxes
�nttecx,copy o�wiq �Pr
� 9. L'itiga6on Prooeeds Received � 10.�������'������' � 11.Eledion to tax under Sec.9113(A)
(Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORIIAATION SHOULD BE DIRECTED TO:
Name D�time Telephoa@ Numbsr
._.,
r�ARK A MA3'�YA �'�2 41 �5�$, �
��r � �' c�
- ....,
E�tS�R OF'V�ILL�l�ONLY
���::; � � �"'��
�.r:� ,°`:�:�� �'`�7 :::�r �
First Lfne of Address • ��w
�"` �-�.,` '°�; '"� '..f`i►
55 W CBURCH AVENUE � � ��� �.�
z, ... , �,;� -�-�
... ..�_
.�,� c�
Second Line of Address ` :� --� �°°� �..�
M. f� �
� � � �
�FILED�'
City or Post Office State ZIP Code
CARLISLE PA 17013 __ _.�___ ....
Correspondent's e-mail address: mam�mateyalaw.com
Under penalties of perjury,I dedare that I have examined this retum,induding acxompanying schedules arxi statemenffi,and to the best of my knowledge and belief,
it is true,cortect and complete.Declaration af prepar+er other than the personal representative is besed on all infi�rmation of which preparer has ar�y knowledge.
SI(3NATURE OF PERSON RESPONSIBLE FOR F I G RETURN DAT
Mar aret W Fisher 4 /7 Za�3
ADDRESS
3415 ona Road Mechanicsbu PA 17055
SIGNATU OF P ER O R TFU�1N ENTATNE DATE
�
Mark A.Mateya l O � $ �
ADDRESS -
55 W.Church Avenue,Carlisle, PA
Side 1
�„ 1505610143 15D561D143 J �
;
�
� ,
� 15�5610243
REV-1500 EX
Decedent's Social Security Number
o�a�c'$Ne�„�: Fisher, Charles M 182 46 4346
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&Notes Receivable(Schedule D)........................................................ 4.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 111,2 3 4. 5 7
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 122,336. 91
7. Inter-Vivos Transfers&Miscellaneou�t�no;Probate Property �
(Schedule G) U Separate Billing Requested............ 7. 8,38 9.2 6
8. Total Gross Assets(total Lines 1 through 7)........................................................ g. 2 41,9 6 0 . 7 4
9. Funeral Expenses and Administrative Costs(Schedule-H).................................... 9. 16,4 O 7 . 92
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 1,2 6� . 94
11. Total Deductions(total Lines 9 and 10)...............................................................• 11. 17, 6 6 8. 8 6
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 2 2 4,2 91.8 8
13. Charitable and Govemmental Bequests/Sec 9113 Trusts forwhich
an election to tax has not been made(ScheduleJ)............................................... 13.
14. Net Value Subject to Tax(Line 12 minus Line 13)............................................... 14. 2 2 4,2 91. 8 8
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 16 9,4 7 9. 9 6 15. O . 0 0
(a)(1.2)X.00
16. Amount of Line 14 taxable 5 4,811. 92 �s. 2,4 6 6. 5 4
at lineal rate X .045
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 . 4 4 18. 0. 0 0
19. TAXDUE................................................................................................................ 19. Z�466.54
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 21-13-0195
Decedent's Complete Address:
DECEDENTS NAME
Fisher,Charles M
STREET ADDRESS
2415 Arcona Road �
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 2,466.54
2. Credits/Payments
A. Prior Payments 1,500.00 •
B. Discount 78.95
Total Credits(A�+B) (2) 1,578.95
3. Interest (3)
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) $$7.59
Make Check Pa able to: REGISTER OF WILLS AGENT. -
PLEASE ANSWER THE FOLL�WING 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:............................................................................... ❑ �x
b. retain the right to designate who shall use the property transferred or its income:.................................. x
c. retain a reversionary interest;or............................................................................................................... x
d. receive the promise for life of either payments,benefits or care?............................................:............... x
2. If death occumed after Dec. 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?....... ❑ ❑x ,
4. Did decedent own an individual retirement account,annuity,or other non-probate property which
contains a beneficiary designation?.................................................................................................................. ❑ ❑x
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�surv'Ning
spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after January 1,1995,the ta�c rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(e)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosu�of
assets and filing a tax r+etum are still applicable even if the surviving spouse is the only beneficiary. •
For dates of death on or after July 1,2000:
• The tau 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)J.
•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(a)(1)l•
• 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)j, A
sibling is defined under Section 9102,as an individual who has at least one parent in common with the deoedent,whether by blood or adoption.
, .
Rev-1608 EX+(11-10)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
,NHERR,w,�E T,�RET„RN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Fisher,Charles M 21-13-0195
Indude the proceeds of li6gation and the dete the prooeeds were reoeived by tt�estete.
All property jointly-0wned with the right of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Susquehanna Valley Federal Credit Union-Member No. 14140-00 Regular Shares 31.149.37
2 Susquehanna Valley Federal Credit Union-Member No. 14140-Shar�e Draft-40 409.71
3 Thrift Savings Plan-Retirement Savings Plan with Federal Government-Account No. 63,293.49
1601716605940
4 Automobile-2001 Toyota Tundra-Kelly Blue Book value-See attached 10,352.00
5 Automobile-199T Toyota T100 truck-Kelly Blue Book Value-See attached 6.030.00
TOTAL(Also enter on Line 5,Recapitulation) 111,234.57
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Ladcner Group,inc. Form PA-1500 Schedule E(Rev.11-10)
Rw-1509 EX+(01-10)
pennsylvania SCHEDULE F
DEPARTMENTOFREVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT OECEDENT
ESTATE OF FILE NUMBER
Fisher Charles M 21-13-0195
M an asset was mad�joiM witl�ln one ysar of tlro dscsdsnt's dab of d�atl��it must bs roporEsd on scheduls G.
SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT
A. Margaret W Fisher 2415 Arcona Road Spouse
Mechanicsburg, PA 17055
B.
C.
JOINTLY OWNED PROPERTY:
DESCRIPTION OF PROPERTY o�pF DATE oF DEATM
ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTiTUTION AND BANK ACCOUNT DATE OF DEATH DECD'S VALUE OF
NUMBER FOR JOIN MADE NUMBER OR SIMILAR IDENTIFYING NUMBER.ATTACH DEED FOR ALUE OF ASSE INTEREST DECEDENTS INTEREST
TENANT .IOINT JOINTLY-HELD REAL ESTATE.
1 Real Estate-Arcona Road-Lot 4D-Parcel 15,000.00 50.000°� 7.500.00
� Identifier 42-11-0272-139-Assessed Value-
See attached
2 Susquehanna Valley Federai Credit Union- 51,949.32 50.000°� 25,974.66
Member No. 14140-53 3 Year CD-Jointly
with Margaret W.Fisher
3 Susquehanna Valley Federal Cr�edit Union- 96,349.51 50.000°� 48,174.76
Member No. 14140-5 Year CD-9117 Jointly
with Margaret W.Fisher .
4 Susquehanna Valley Federal Credit Union- 9,388.61 50.000°� 4.694.31
Member No. 11339-00 Regular Shares-
Jointly owned with Margaret W.Fisher
5 Susquehanna Valiey Federal Credit Union- 75.00 50.000°� 37.50
� Mer�ber No. 11339-40 Share draft jointly
heid with Margaret W.Fisher
6 Susquehanna Valley Federal Credit Union- 13.478.84 50.000% 6.739.42
Member No. 3345-00 Share draft jointly held
with Margaret W. Fisher
Total of Continuation Schedule ee attached page
TOTAL(Also enter on Line 6,Recapitulation) 93,476.04
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form soflware ony The Lackner Group,inc. Form PA-1500 Schedule F(Rev.01-10)
rtw-�ao�ex+�o�-�o�
pennsylvania SCHEDULE F
DEPARTMENTOFREVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN .
RESIDENT DECEDENT cont�n ued
ESTATE OF FILE NUMBER
Fisher Charles M 21-13-0195
If an asset was made joint within one year of the decedent's date of death,it must be reported on schedule G.
JOINTLY OWNED PROPERTY
DESCRIPTION OF PROPERTY °�OF DATE OF DEATH
ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DECD'S VALUE OF
NUMBER FOR JOIN MADE NUMBER OR SIMILAR IDENTIFYING NUMBER.ATfACH DEED FOR ALUE OF ASSE INTEREST DECEDENTS INTEREST
TENANT JOINT JOINTLY-HELD REAL ESTATE.
7 Susquehanna Valley Federal Credit Union- 372.83 50.000°� 186.42
Member No. 3345-08 Share draft jointly heid
with Margaret W.Fisher
8 Susquehanna Valley Federal Credit Union- 157.50 50.000°�6 78.75
Member No. 3345-09 Share draft jointly held
with Margaret W.Fisher �
9 Susquehanna Valley Federal Credit Union- 180.44 50.000°�6 90.22
Member No. 3345�0 Share draft jointly held
with Margaret W.Fisher
TOTAL(Also en�er on Line 6,Recapitulation) 93,476.04
Copyright(c)2010 form software only The Ladcner Group,Inc. Form PA-1b00 Schedule F(Rev.01-10)
Rev-1b10 EX+(08-09)
SCHEDULE G
pennsylvania lNTER VIVOS TRANSFERS AND
DEPARTMENT OF REVENUE
INHERITANCETAXRETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Fisher,Charles M 21-13-0195
This schedule must be completed and filed ff the answer to any of questions 1 through 4 on p�e three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH 96 OF DECD�s �(CLUSION TAXABLE
NUMBER '�pq'��ETR WgFERSATTE�H A COPY�OUFTTHE DEED FORECREAL Es��. VALUE OF ASSET INTEREST (�F APPLICABLE) VALUE
1 Suquehanna Valley Federal Credit Union-IRA-11 8.389.26 8.389.26
TOTAL(Also enter on Line 7,Recapitulation) 8,389.26
(If more spac�e is needed.additional pages of the same size)
Copyright(c)2009 form soflware only The Ladcner Group,Inc. Form PA-1500 Schedule G(Rev.0&09)
, ,
REV-1b11 D(+(10-08)
pennsyivania SCHEDULE H
DEPARTMENT OF REVENUE F U N ERAL EXPENSES AN D
RESi e��c o�'R" ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Fisher,Charles M 21-13-0195
Decedent's debts must be reported on Schedule 1.
tTEM DESCRIPTION AMOUNT
p, FUNERAL EXPENSES:
See continuation schedule(s)attached 3,993.55
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
C�y State Zio
Year(s)Commission Paid
2. Attomev's Fees Mark A.Mateya 11,000.00
3. Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation)
Claimant
Street Address
� City State Zia
Relationshi�of Claimant to Decedent
4. Probate Fees 348.50
5. Acxountant's Fees
6. Tax Retum Preparers Fees
7. Other Administrative Costs 1,065.87
See continuation schedule(s)attached
TOTAL(Also enter on line 9,Recapitulation) 16,407.92
Copyright(c)2009 form software only The Lackner Group,Inc. FoRn PA-1500 Schedule H(Rev.10-09)
. �
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued �
ESTATE OF FILE NUMBER
Fisher,Charles M 21-13-0195
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Exoenses
�
1 Malpezzi Funeral Home-Funeral Expense 3.993.55
H-A 3,993.55
Other Administrative Costs
2 Cumberland County Register of Wills-Fee for filing of Surety Bond 15.00
3 Cumberland Law Joumal-Legal Advertisement 75.00
4 State Farm Insurance-Surety Bond-Policy No. 98-LX4255-2 688.00
5 Susquehanna Federal Credit Union-Check order fee 16.47
6 The Guide-Legal Advertisement 50.00
7 The Sentinel-Legal Advertisement of Estate 221.40
H-B7 1,065.87
Copyright(c)2002 form software only The Ladcner Group,Inc. FoRn PA-1500 Schedule H(Rev.6-98)
. *
Rav-1 s12 EX+(12-08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCETAXRETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Fisher Charles M 21-13-0195
Report d�bb incum�d by ths d�cedent prior to death that rsmainsd ur�paid�t ths date of dealh�inclu�rp un�Mmbursed msdical sxp�raes.
�M t/ALUE AT DATE
NUMBER DESCRIPTION OF DEATH '
1 Camp Hill Emergency Physicians-Medicai services on 1/18/13 30.07
2 Heritage Medicai Group Lab-Medical bill-Account No. PLAB035634 4•4�
3 Holy Spirit Hospital-Medical Expenses-Account No. 44326114 350.33
4 Holy Spirit Hospital-Medical Services Account 44386159 30.95
5 Holy Spirit Hospital•Medical Expenses-Account No. 44342038 152,10
6 Quantum Imaging 8�Therapeutic Associates-Medical Bill 15.31
7 Quantum Imaging�Therapeutic Associats-Medical Services 12.91
8 Urology of Central PA-Medical bill-Account No. 73748 521.32
9 West Shore Anesthesia Associates-Medical Services 52.20
10 West Shore Anesthesia Associates-Medical bill Account 32546-G 91.35
TOTAL(Also enter on Line 10,Recapitulation) 1,260.94
(If more space is needed,additionai pages of the same size)
Copyright(c)2008 form software oniy The Ladcner Group,Inc. Fortn PA-1500 Schedule I(Rev.12-08)
, . s
REV-1513 D(+(01-10)
pennsylvania SCHEDULE J
DEPAR7'l1�NT OF REVENUE
INHERITANCE TAX 12ETURN BENEFICIARIES -
RESIOENT�ECEDENT
ESTATE OF FILE NUMBER
Fisher,Charles M 21-13-0195
RELATIONSHIP TO
NAME AND ADDRESS OF SHARE OF ESTATE MOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) ($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
• distributions,and transfe�s
under Sec.9116 a 1.2
Daniel Fisher Child One-half of 54,811.92
1400 Princeton Road residual estate
Mechanicsburg,PA 17055
Margar+et W Fisher Spouse One-half of 169,479.96
2415 Arcona Road residual estate
Mechanicsbucg,PA 17055
Total 224,291.88
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet as a ro riate.
NON-TAXABLE DISTRIBUTIONS: �
�• A.SPOUSAL DfSTRIBUTIONS 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
Copyright(c)2010 form soflware only The Ladcner Group,Inc. Form PA-1500 Schedule J(Rev.01-10)
RS Picku Trade In Values-Kelle Blue Book P e 1 of 4 �
1997 Toyota.T 100 Xtra.cab S p y �
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