HomeMy WebLinkAbout11-15-13 REV-1500 EX(01-10) x. 1505610143
PA Department of Revenue OFFICIAL USE ONLY
P Pennsylvania County Code Year File Number
Bureau of Individual Taxes 0E9""TME1ROF RE"s"'s
PO BOX.280601 INHERITANCE TAX RETURN 21 X13 1024
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
12 05 20.12 12 12 1961
Decedent's Last Name Suffix Decedent's First Name MI
bR=ER THOMAS G
(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
❑
X 1. Original Return 2. Supplemental Retum 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)
a 8 Decadent Died Testate T Decadent Maintained Tin eed a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Wil) p
9. Litigation Proceeds Received 10.between Poveen)Strraoiitt(ditteof deem 1t.Election to tax under Sec.9113(A)and
(Attach Sch.O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
BRADLEY L GRIFFIE 717 243 5551
REGISTER OF WILLS USE ONLY
O o
C w Z7
First line of address W rrl rr
Irry
200 NORTH HANOVER STREE C °
x
Second Tine of address � � Cn M rTi
Z , ;;`1 ,L: C1
n -P O [7
City or Post Office ITAT��rILE,J
State ZIP Code
CARLISLE PA 17013 - i r n
W o
rV 'ri
Correspondent's e-mail address: bgriffie@griffielaw.com
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,_cqLrect and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNP,�U!JFPE.APON RESSPIONSI `JE FORR FILLING RETURN DATE
Qµf�. (,. Paul C. Mulder l�C -t7
ADDRESS P
55 reet Carlisle PA 17013
SIG&ATUREO PR215 1EPRESENTATIVE DATE
Bradley L Griffie
AD ESS
200 North Hanover Street, Carlisle, PA
Side 1
L, 1505610143 1505610143 J ^
1505610243
REV-1500 EX
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... i.
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. 7 ,581 . 62
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) U Separate Billing Requested............ 7,
8. Total Gross Assets(total Lines 1-7)..................................................................... 8. 7 , 581 . 62
9. Funeral Expenses&Administrative Costs(Schedule H)....................................... 9. 6,156. 8 0
10. Debts of Decedent,Mortgage Liabilities,&Liens(Schedule 1).............................. 10. 8 , 187 . 08
11. Total Deductions(total Lines 9&10)................................................................... 11. 14 ,343 . 88
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12, -6, 762 . 26
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, -6, 762 . 26
TAX COMPUTATION•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.00 15. 0 . 00
16. Amount of Line 14 taxable 0 . 00 'i6. 0 . 00
at lineal rate X .045
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 00 18. 0 . 00
19. Tax Due.................................................................................................................. 19. 0 . 00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. El
Side 2
L 1505610243 1505610243 J
REV-1500 EX Page 3 File Number 21-13-1024
Decedent's Complete Address:
DECEDENT'S NAME
Mulder, Thomas G.
STREET ADDRESS
55 East Penn Street
---- -- --- - ---- --
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0100
2. Credits/Payments
A. Prior Payments
B. Discount 0.00
Total Credits(A +13) (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 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) 0,00
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:...._............................ ❑ 0
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?_..........___.............. ..........__.... .......................__........... --------_ ❑
3. Did decadent own an"in trust for" or payable upon death bank account or security at his or her death?....... L1 rc r
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 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 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
172 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 decedent's lineal beneficiaries is 4.5 percent,except as noted in
72 P.S.§9116 11)[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 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
VIC CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCEWRETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mulder,Thomas G. 21-13-1024
Include the proceeds of litigation and the date the proceeds were revived 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 PNC Bank- 550.00
Checking Account No.XXXXXX7362
(See attached statement)
2 PNC Bank- 2,151.62
Checking Account No.XXXXXX3648
(See attached statement)
3 PNC Bank- 0.60
Checking Account No.XXXXXX3965
(See attached statement)
4 Metro Bank- 97.40
Checking Account No.XXXXX6867
(See attached statement)
5 2004 Toyota Camry- 4,188.00
(See attached Kelley Blue Book value)
6 2013 Personal Income Tax Refund(Estimated) 594.00
TOTAL(Also enter on Line 5, Recapitulation) 7,581.62
(If more space is needed,additional pages of the same size)
Copyright(c)2002 farm software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev.6-98)
REV-1151 EX+(10-05(
SCHEDULE H
COMM4NVJEALTH�F PENNGGUYLVANIA FUNERAL EXPENSES &
RESIDENTDECEDENURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Mulder, Thomas G. 21-13-1024
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBE
A. FUNERAL EXPENSES:
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(s)Commission Daid
2. Attomev's Fees Griffie&Associates, P.C. 2,000.00
3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation) 3,500.00
Claimant Thomas G. Mulder
Street Address 55 East Penn Street
city Carlisle state PA Zio 17013
Relationshio of Claimant to Decedent Brother
4. Probate Fees 163.50
5. Accountant's Fees 250.00
6. Tax Return Preparer's Fees
7. Other Administrative Costs 243.30
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) - - 6,156.80
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev. 10-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Mulder, Thomas G. 21-13-1024
ITEM
NUMBER DESCRIPTION AMOUNT
Accountant Fees
1 2013 Personal Tax Filings(estimate) 250.00
H-B5 250.00
Other Administrative Costs
2 The Sentinel(Advertising) 168.30
3 The Cumberland Law Journal(Advertising) 75.00
H-B7 243.30
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 Ex+(12 48)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONV E LTHOF PENNSYLVANIA
INHERITANCE TAX REIIRN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mulder,Thomas G. 21-13-1024
Report debts incumed by the decedent prior to death Mat remained unpaid at the date of death,including umaimbutsed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 US Airways Mastercard- 116.77
Account No.XXXX-XXXX-XXXX-4811
2 University of Rochester Medical Center- 837.68
(CBCS-Collection)
3 Critical Care Systems, Inc. 83,88
4 Tri-state Infectious Diseases 15.00
5 Carlisle Regional Medical Center- 2,002.00
(Paragon Revenue Group-Collection)
(Multiple bills)
6 Value Healthcare Management, LLC- 125.00
(Convergent Healthcare Recoveries, Inc.-Collection)
7 Walnut Bottom Radiology 20.00
8 Carlisle Medical Group, LLC 25.00
9 Carlisle Oncology- 25.00
(Apex Asset Management LLC-Collection)
10 Pinnacle Health Hospitals- 20.00
(Computer Credit, Inc.-Collection)
11 Boiling Springs Medicine- 20.05
(Apex Asset Management, Inc. -Collection
12 Carlisle HMA Physician Management 20.05
13 Carlisle Regional Medical Center- 530.21
(Allied Interstate-Collection)
Total of Continuation Schedule See attached page
TOTAL(Also enter on Line 10, Recapitulation) 8,187.08
(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 I(Rev. 12-08)
ReVAS12 EX.(6-98)
COLO SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TM RETURN continued
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mulder, Thomas G. 21-13-1024
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
14 Carlisle Regional Medical Center- 162.46
(Capio Partners-Collection)
15 Associated Otolaryngologists of PA, Inc. 13.54
16 Hospitalist of Central PA 13.60
17 Chase Credit Card - 164.34
Account No.XXXX-XXXX-XXXX-4635
18 Household Bank- 615.62
Account No.XXXX-XXXX-XXXX-6226
19 Mid America Bank-Trust Company VISA- 2,015.62
Account No.XXXX-XXXX-XXXX-4661
20 Wells Fargo(Auto loan)- 1,361.06
Loan No.XXXXXX1571
TOTAL(Also enter on Line 10, Recapitulation) 8,187.08
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev.6-98)
REV-1513 EX.(11-08)
q �p SCHEDULE J
COMMNHERITANCE TARET RNAN�A BENEFICIARIES
RESIDENT DE EDE
ESTATE OF FILE NUMBER
Mulder,Thomas G. 21-13-1024
NAME AND ADDRESS OF RELATIONSHIPTO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not List Trusteeisl I TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)1
Paul C. Mulder Brother Fifty percent of
55 East Penn Street net distributable
Carlisle, PA 17013 estate
Richard P. Mulder Brother Fifty percent of
4798 Birch Drive net distributable
Preston, MD 21655 estate
Total
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
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 forth software only The Lackner Group, Inc. Form PA-1500 Schedule J(Rev. 11-08)
LAST WILL AND TESTAMENT OF
THOMAS G. MULDER
I, THOMAS G. MULDER, of Cumberland County, Pennsylvania, declare this to
be my Last Will and Testament and hereby revoke all prior Wills and Codicils.
1. I direct that all my just debts, funeral expenses and administrative
expenses shall be paid from my estate as soon as practicable after my death. It is my wish
that upon my death my body shall be cremated and my ashes shall be given to my
brother, Paul C. Mulder.
2. 1 direct that all real property and all personal property that I own at the
time of my death shall be given to my brother, Paul C. Mulder and my brother, Richard
P. Mulder, in equal shares,per capita.
3. I appoint my brother, Paul C. Mulder, as Executor of this my Last Will
and Testament. In the event that Paul is deceased, unable or unwilling to serve or shall
cease to serve for any reason whatsoever, then I nominate, constitute and appoint my
brother, Richard P. Mulder, as alternate Executor of this my Last Will and Testament.
4. The Executor of this Will shall have the power to distribute my estate in
cash or in kind, or partly in either.
5. I direct that the Executor acting under this Will shall not be required to
enter bond in any jurisdiction.
6. I recommend that my Personal Representative retain the law firm of Allied
Attorneys of Central Pennsylvania, L.L.C., to probate my estate.
IN WITNESS WHEREOF, I h ve hereunto set my hand this day
of (7c"��gy�, 2012. g�
THOMAS G. MULDER
Page 1 of 4
The preceding instrument consisting of this and three other pages was on the day and date
hereof signed, published and declared by THOMAS G. MULDER, as and for his Last
Will and Testament in the presence of us, who at his request, in his presence and in the
presence of each other have subscribed our names as witnesses hereto.
tness Witness
V
Page 2 of 4
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
: SS
COUNTY OF CUMBERLAND
I,THOMAS G. MULDER,the TESTATOR,whose name is signed to the attached
or foregoing instrument,having been duly qualified according to law, do hereby
acknowledge that I signed and executed the instrument as my Last Will and Testament;that
I signed it willingly, and that I signed it as my free and voluntary act for the purposes therein
expressed.
THOMAS G. MULDER
Sworn or affirmed and acknowledged before me by THOMAS G. MULDER,the
TESTATOR,this 01A day of 0 C 06g_r: 2012.
Notary Public/Attorney
COMMONWEALTH OF PENNSYLVANIA
L 1 Deluca,Adam Deluca,Notary Public
Cadlsle Boro,Cumberland county
My Commission Fxplres)an.26,2016
Page 3 of 4
}
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF CUMBERLAND
WE, JOCL L ynoCd and_1_ Lam✓`/ yl Jd L[ ��
the witnesses whose names are attached to the foregoing document, being duly qualified
according to law, do depose and say that we were present and saw testator sign and
execute the instrument as his Last Will;that he signed willingly and that he executed it as
his free and voluntary act for the purposes therein expressed; that each subscribing
witness in the hearing and sight of the testator signed the Last Will and Testament as
witnesses and that to the best of our knowledge the testator was at the time 18 or more
years of age, of sound mind and under no constraint or undue influen
V --\�
Sworn or affirmed land subscribed before me' by
JO�� 44rkL A and M-6'S /� wilco t) this
JJ day of ((JJnC� , 2012.
_ ^ Notary Public/Attorney
COMMONWEALTH OF PENNSYLVANIA
Notadal Seal
Adam Deluca,Notary Public
Carlisle Boro,Cumberland County
My Commisslon Expires Jan..26,2016
Page 4 of 4
UL L. I. GUU 1l 1)1 R1 Iire uattn
u PNC
October 1,2013
Bradley L Griffie
Attorney At Law
200 N Hanover St
Carlisle PA 17013
RE: Thomas G Mulder
SSN: 267-83-2040
DOD: 12105/2012
Dear Sir/Madam:
In response to your request for Date of Death(DOD)balances for the customer noted above,our
records show the following:
Checking Account
Account#5005817362 Established: 10/14/2008
THOMAS G MULDER
DOD balance: S 550.00 non-interest bearing
Account#5112023648 Established: 03/08/2002
THOMAS G MULDER
DOD balance: $2,151.60+0.02 accrued interest
Account#5112063965 Established: 05/0812006
THOMAS G MULDER
DOD balance: $ 0.60 non-interest bearing
Please note that this office provides date of death balances for deposit accounts(IRAs,CDs,Checking and
Savings). We do not process any financial transactions or provide statements. If you need assistance with
any of these items,please call 1-888-PNC-BANK(1-888-762-2265)or stop by your local PNC Bank branch
office.
Sincerely,
National Financial Services Center
PNC Bank,N.A.
Member FDIC
Page 1 of 2
METRO
BANK Harrisburg,burg, Street
mymetr ba k.com
10/16/13
Bradley L. Griffie
Griffie &Associates
200 North Hanover St.
Carlisle, PA 17013
RE: Estate of: Thomas G. Mulder
Tax Identification Number: 267-83-2040
Date of Death: December 5, 201.2
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: 538346867
Date Opened: 12/01/2008
Primary Owner: Thomas G. Mulder
Accrued Interest: ** $0.00
Date of Death Balance: $97.40
** Please note: The accrued interest will not be paid if the account is closed prior to the
date the interest is scheduled to post. Also please note that the other account
833454689 that you listed in your letter had closed on 5/7/2012, which is prior to the
decedent passing away, and the decedent did not have any withdrawals in excess of
$3,000.00 that occurred within twelve months prior to the date of death.
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
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Kelley Blue Book®Trade-in Value-This is the amount you on expect to receive when you trade in Tip:
your or to a dealer.This value is determined based on the style,condition,mileage and options It's crucial to know your car's
indicated' true condition when you sell it,
Trade-in Range-The Trade-In Range is Kelley Blue Bodes estimate of what you on reasonably expect so that you can price it
to receive this week based on the style,condition,mileage and options of your vehicle when you trade it appropriately.Consider having
in to a dealer.However,every dealer is different and values are not guaranteed. your mechanic give you an
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Kelley Blue Book®Private Party Value-This is the starting point for negotiation of a used-car sale f
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I
Private Party Range-The Private Party Range is Kelley Blue Book's estimate of what you can
reasonably expect to receive this week for a vehicle with stated mileage In Me selected condition and
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I
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title history,with some service records available,and will pass safety and smog inspection.
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may need professional servicing.The tires may need replacing and there may be some reparable rust
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®2013 Kelley Blue Book Co.,Inc.All tlgh[s reserved.11/1/2013.111712013fdbon for Cennsylvnnia 17241.The specific Inhrmatlon mg.eed to determine Me valve{or Mls danxular veMde was sup Plied
Cy Me de o generating Mrs rear[Vehicle valuaulons are opinions and may vary from veMtle M vehicle.RcNal valuanons will vary based upon market .uuiuraer s,kaficacians,vehicle condldon or other
particular n¢ora lanes pertinent co Ill.particllar vehidd or Me hansadioo or the parted M Me transaction.This report is lnuended for Me Individual use of the person generating Mis report only and shall
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