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Home My WebLink About11-19-13 (2) � 15�561�143 REV-1�500 EX(01-10) �; OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes �PpRTMENTOFREVENUE Po Box.2soso� INHERITANCE TAX RETURN .21 13 102 6 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Sociai Security Number Date of Death Date of Birth .200 .22 6906 08 22 ,20:13 03 7.1. 1930 DecedenYs Last Name Suffix DecedenYs First Name MI HENRY FAIRI�YN C (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 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) O 6 Decedent Died Testate � � (pttacheCopy�of Trust)a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) � 9. Litigation Proceeds Received � 10.belween12 3rtY Crae dit�(dat�e5�f death � ��,Election to tax under Sec.9113(A) � (Attach Sch.O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime?elephone Number BRADLEY S� GRIFFIE 717 .243 =555'1 hi C"+ REGI�f�F WILL',�ISE�� m �' c� � �' � First line of address � � �-- �, � y-� 2 0 0 NORTH HANOVER S TREE � � rn � "� �� v? � � c:� 't7 'r! °`�� Second line of address � c'� r� � -�-a n �' �' �� Ca � '°.. - E FILED r°° � City or Post Office State ZIP Code b � � CARI�I SI�E PA 17 013 � Correspondent's e-mail address: bgriffie@grlffieiaw.COi11 Under penalties of perjury,I declare hat I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct an complete.Decl ation of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PER ON SPONSI FOR FILING RETURN DATE ` Gre ory W. Henry �I I 4 �3 ADDRESS � 7 Sprinq View Street Cariisle PA 17013 SIGNATURE OF OTHER THAN REPRESENTATIVE DATE Bradley L Griffie �, � S / 3 ADDR 200 N anover Street, Carlisle, PA Side 1 � 15D561D143 7,5�5610143 � � 15�561024.3 REV-1500 EX DecedenYs Social Security Number DecedenfsName: Heill,l, Fairfyn C. 200 22 6906 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. 6 ,103 . 02 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers&Miscellaneous I�aq Probate Property (Schedule G) U Separate Billing Requested............ 7. 8. Total Gross Assets (total Lines 1-7)..................................................................... 8. 6,:103 . �2 9. Funerai Expenses&Administrative Costs(Schedule H)....................................... 9. 2 ,17 6 . 8� 10. Debts of Decedent,Mortgage Liabilities,&Liens(Schedule I).............................. 10. 3�3 . s 3 11. 'Total Deductions(total Lines 9&10)................................................................... 11. •2 , 4 8� . 63 12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 3 , 622 . 3 9 13. Charitable and Governmental Bequests/Sec 9113?rusts for which an election to tax has not been made(Schedule J)............................................... 13. 14. Net Value Subject to?ax(Line 12 minus Line 13)............................................... 14. 3 , 62.2 .3.9 TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 0 . 0 0 (a)(1:2)X.00 15. 16. Amount of Line 14 taxable 3 , 622 .39 �s. 163 . �1 at lineal rate X .045 17. Amount of Line 14 taxable 0 . 0 0 17. 0 . 0 0 at sibiing rate X.12 18. Amount of Line 14 taxable 0 . 0 0 18. 0 . 0 0 at collateral rate X.15 19. Tax Due.................................................................................................................. 19. 163 . 01 20. FILL IN?HE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. � Side 2 � 1505610243 1505610243 � REV-150D EX Page 3 File Number 21-13-1026 Decedent's Complete Address: DECEDENT'S NAME Henry, Fairfyn C. STREET ADDRESS Claremont Nursing 8� Rehabifitation Center 1000 Claremont Road C�n STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 163.01 2. Credits/Payments A. Prior Payments B. Discount 0.00 Totai Credits(A +B) (2) 0.00 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 Page2 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) �63.0� Make Check Pa able�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............................................................................................................... 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 ❑ � receiving adequate consideration?.................................................................................................................... z 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?.................................................................................................................. ❑ � IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF?HE 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 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 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 decedenYs lineai 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)j. 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. Rev-1508 EX+(6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMON WEALTH OF PENNSYLVANIA ' INHERITANCE TAX RETURN RESIDENTDECEDENT ESTATE OF FILE NUMBER Henry, Fairlyn C. 21-13-1026 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 1 2013 Personal income Tax Refund(Estimate) 1,600.00 2 Claremont Nursing&Rehab Facility Refund 2,430.00 3 F&M Trust- 2,073.02 Checking Account No.XXXXXX5840 (See attached statement) TOTAL(Also enter on Line 5, Recapitulation) 6,103.02 (If more space is needed,additionai pages of the same size) Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev.6-98) REV-1151 EX+(10-06) SCHEDULE H COMMONWE7AL��iE �E NgUYLVANIA FUNERAL EXPENSES 8� �NRESIDENTDECEDENTRN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Henry, Fairiyn C. 21=13-1026 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT q, FUNERAL EXPENSES: B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zio Yearlsl Commission oaid 2, Attornev's Fees Griffie 8�Associates, P.C. �1;500.00 3, Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation) Claimant Street Address City State Zip Relationshio of Claimant to Decedent 4. Probate Fees 133.50 5. AccountanYs Fees 300.00 6. Tax Return Preparer's Fees 7. OtherAdministrative Costs 243.30 See continuation schedule(s) attached TOTAL(Also enter on line 9, Recapitulation) 2,176.80 Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev. 10-06) S�HEDUl.E H FUNERAL EXPENSES AND ADMINISTRATNE COSTS continued ESTATE OF FILE NUMBER Henry, Fairlyn C. 21-13-1026 ITEM NUMBER DESCRIPTION AMOUNT Accountant Fees 1 Cohick&Associates- 300.00 (2013 Personal Income Tax Return-Estimated) H-B5 300.00 Other Administrative Costs ;2 The Cumberland Law Journal (Advertising) 75.00 3 ?he Sentinel(Advertising) 168.30 H=B7 243.30 Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98) Rev-7512 EX+��2-08) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMON WEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENTDECEDENT ESTATE OF FILE NUMBER Henry, Fairlyn C. 21-13-1026 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 Alert Pharmacy Services, Inc. - 104.26 (Paid pre-death/processed post-death) 2 Alert Pharmacy Services, Inc. - 19.79 3 Commercial Acceptance Company- 89.98 (Paid pre-death/processed post-death) 4 Commercial Acceptance Company- 89•$0 (Paid pre-death/processed post-death) TOTAL(Also enter on Line 10, Recapitulation) 303.83 (If more space is needed,additional pages of the same size) Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule 1(Rev. 12-08) REV-1513 EX+(71-OB) SCliEDULE J COM IN�HERITANCE T�RETURN A"'A BE N EF IC IARI ES RESIDENT DECEDENT ESTATE OF FILE NUMBER Henry, Fairiyn C. 21-13-1026 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSONISI RECEIVING PROPERTY DECEDENT (Words) ($$$) I� TAXABLE DISTRIBUTIONS [include outright spousal distributions,and transfers under Sec. 9116 a 1.2 Carol L. Henry Daughter One-third of net 1,207.46 130.Dorwood Drive distributable Cariisfe, PA 17013 estate Gregory W. Henry Son One-third of net 1,207.46 7 Spring View Street distributable Carlisle, PA 17013 estate Jeffrey E. Henry Son One-third of net 9,207.46 281 Small Valley Road distributable Halifax, PA 17032 estate Total 3,622.38 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: II. 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 SHEET Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J(Rev. 11-08) . . .ti�r . ., . . . -- ti LAST WILL AN,D TESTAMENT OF FAIRLYN C. �TENR,Y I, F'AIPuLYN C. 13ENR,Y, of Sou�h Middleton Township (624 For-ge Road Carlisle) Curnbesiand County, Pennsylv,ania, being of sound and disposi:ng xni+nd, memory and under.standing, do h�reby ma�ke, publish and declare this ,as•and�r my Last Wi11 and Testament�ereby revoking and making voi�l any �and a11 Wills by me at any time heretofpre made, 1. I direct my her-einafter nam�d Executor to pay all of my just debts ;and funeral egpeases as soon after my �ieath as may be found convenient to = dn^so. 2. All the rest, residue and reuzainder of my estate, real, per�onal asnd mixed, and wh�er.esoever the same �nay be si:tuate, I give, devise and b;equeath to my Ymz:sband, William D. Henry, his heirs and assigns, to the ex- e clusian of my chiidren b-orn and unborn; providsd my said husband sha11 survu e � me by a period of Ninety (9A) days. 3. ShouLd my said husband, W�.liam D. Henry, pre-decease xne or fai � t.o survive me }ry the aEoresaid period.c��' N'snety (90') days, then in such event a].1 tY�e re>st, residue and remainder of my estate, real, personal and mi�ed, a;nd whereso.evsr the sam,e may be situ�te, I giv.e, devise and bequeath in (� �qual shar..es to my childmen, their heix�s and assigns, the ahare any deceased v�� chil:d would have received to pass.to hi� or her issue per stirpes and i:Y there tre no i•ss�ue such.share 5hall lapse an��e added to the r•emaining shares per � �tirpes. At the present time I am the�'fl�er of the following th�ee chil•dren: Carol L. S,hoads, Gregory �V. Henry, :and Jeffrey E. Henry. 4. Should arry�person.le.s-s than'21 �ears of age be entitled to distribu- tion from my,estate, in such event I noasii�ate, sonstitute and appoi�nt j < , . . , t, . . , .. . . . :I�?,au,phin Deposit Ba�nk & Trust Gom�pany„ and its successors, 2 West High S?tre:et, CaxTisle, Pe:rrnsyYvania., as Guamd'ian of the estate of each such person and author.ize and direct it to receiv-e and to invest the same, and to pay the income arising therefrom, together wi�h so much of the principal thereof as in its opi<nion is necessary or desirable`to be e�pended for the proper mainte- =nance, support and education of such p�rson, to or for the benefit of such person, and upon snch person attaining:21 years of age to pay to him or her �he then remai.ning..principal tog.ether w�i.th any und'istributed income. 5. I herz�by nominate, constitutJe and app;oiut my said husband, Willi - I�. Henry, as Executor of this my Last�Will attd Testament but should he pre- dECease m.e or fxil to qualify, then in s�ch event I nominate, constitute:and �ppoint my son, Gregory W. Henry, as�`Executor, but should he fail to qualify, then in such event I nominate, :constitute and appoint Dauphin I}eposit Bagk & Trusi Company and its success:ors, 2 West High Street, Cariisle, ,Pen,�nsylrvania, as Egecut.or,, and i furtrh!�r direct that none of them shall be - `requir.ed,to post an,y bond #.o secur-e t�h:e°�ffaitlafz�l per,formance of his, her or its duties in the Commonwealth of Pennsyi�vania or in any other juri•sdiction. IN`t?CFI7'NE:SS WF�EREOF I have tiereunto set my hand and seal to this >my I..ast Wi11 and-:Testament written on�two pages this lOth day of January, 1.9 8`0.. �� 1... � (SEAL) Fj'/airiyn C. Henry v Sig�ed, sealed, publish.ed and el�eclared by FAIR,LYN C. HENRY, the Testatrix above named, as and for her�last Wili and Testament, in our px�esence, who, in her p�:esenc.e, at her request, and in the presence of each dther have hereunto subscribed our names as attesting witnesses. �� . � -� � Page 2 of 2 Pages Attachment to Schedule "E" � d � N � W C �O 7 O) a. t � d C 3 N 0= c U � c O Q lL � C O �0 N m Q � L M pO � O ~ N 0� C � GI 7 � c� u Q � N U � = M � O � N m y� M w O 0'N d M N � O � U� � Z M W � 2 0 {-- N N U �y d co � zN bo � � � � � 2 , LL laL Q O O � � a m � Eo ZQ z' � °� `o � O � � M U U � v Q c 0 .� � m > s m � � c O F' �[ � f�.1 N (d U L � Q U