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Home My WebLink About11-21-13 � 1505610143 REV-1500 �``02-"'�`' PA De artment of Revenue y OFFICIAL USE ONLY p penns Ivania co�,r,cy code Year File Number Bureau of Individual Taxes °�"�T"�OF1� Po Box.2soso� INHERITANCE TAX RETURN 21 13 00504 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ° 04 12 2013 04 15 1948 � Decedent's Last Name Suffix DecedenYs First Name MI MOZINGO VICTORIA J (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Su�x Spouse's First Name MI MOZINGO SR GARY L Spouse's Social Securiry Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1. Original Retum � 2. Supplemental Return � 3. Remainder Retum(Date of Death Prior to 12-13-82) � 4. Limited Estate � 4a.Future Interest Compromise � 5. Federal Estate Tax Retum Required (date of death after 12-12-82) � g Decedent Died Testate � �• A�eCo a of Tru�st a Living Trust 8. Total Number of Safe Deposit Boxes (Att�h Copy of Will) PY ) r-�.,� � 9. Litigation Proceeds Received � 10.��P9��8 d�t�Da95�f Death � �� on to tax un`�k Sec.rn1� ��'°ch.Schedul� C? CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL T MA'['ION�OUL� ECTED TO: Name Day1�a'�_�"�'_on mber�i � FOREST N MYERS 71 � 9��6 � '� � � � Q a RE�rI�S�t�Wli�U��.Y � � i"' t"�1 � � First Line of Address -Q "'� � ,� C'3 137 PARK PLACE WEST � � � Second Line of Address DATE FILED City or Post Office State ZIP Code SBIPPENSBURG PA 17257 CoRespondent's e-mail address: fnmyers 'L'aalawofficeforestmyers.com Under penalties of perjury,I dedare that I have examined this retum,induding acxompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SI NAT OF PERSON R PONSIBLE FOR FILING RETUR DATE � � Ga L Mozin o Sr ��9-��3 ADDRESS 309 W Cceek Rd,Newburct, PA 17240 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE �� Forest N Myers �,�-��g-ZsJ\3 ADDRESS 137 Park Place West,Shippensburg,PA Side 1 � 1505610143 1505610143 � h � 1505610243 - REV-1500 EX DecedenYs Social Security Number o�,t'sName: MOZINGO,Victoria J 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 8 Notes Receivable(Schedule D)........................................................ 4. 10,0 0 0. 0 0 5. Cash,Bank Deposits 8�Miscellaneous Personal Property(Schedule E)............... 5. 6,3 S 3.3 8 6. Jointly Owned Properry(Schedule F) ❑ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers�Miscetlaneous f�an;Probate Property (Schedule G) U Separate Biiling Requested............ 7. g. Total Gross Assets(total Lines 1 through 7)........................................................ g. 16,3 5 3.3 8 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 16, 957 .24 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. �.�,4 97 .45 11. Total Deductions(total Lines 9 and 10)................................................................ 11. 2 7,4 5 4 . 6 9 12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. -11,1�1.31 13. Charitable and Govemmental 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. -11,101.31 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 15. 0 . 0 0 (a)(1.2)X.00 16. Amount of Line 14 taxable 0 . 0 0 16. 0 . 0 0 at lineal rate X .045 17. Amount of Line 14 taxable � . 0� at sibling rate X.12 � . �� 17. 18. Amount of Line 14 taxable 0 .0 0 at collateral rate X.15 0 . 0 0 18. 19. TAX DUE............................................. 0 . �0 ................................................................... 19. 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 21-13-00504 Decedent's Complete Address: DECEDENTS NAME MOZINGO,Victoria J STREET ADDRESS 309 West Creek Road CITY STATE ZIP Newburg PA 17240 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A. Prior Payments B. Discount 0.00 Total 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 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 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:............................................................................... x 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?............................................................ x 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without ❑ ❑ receivingadequate consideration?.................................................................................................................... x 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 ❑ ❑ containsa 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 afte�January 1,1995,the tax rate imposed on the net value of transfers to or for the use of the sunriving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse ftom tax,and the statutory requirements for disclosure of assets and filing a tax retum 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)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 decedenYs 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-1507 EX+(6.88) SCHEDULE D MORTGAGES & NOTES RECEIVABLE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MOZINGO Victoria J 21-13-00504 All property jointly-owned with right of survivorship must be dlsclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Note-Promissory Note,receivable; Prince Street Church 10.000.00 TOTAL(Also enter on Line 4,Recapitulationl 10,000.00 (If more space is needed,additional pages of the same size) Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule D(Rev.6-98) Rav-1608 EX+(11-10) SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OF REVENUE INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER MOZINGO,Victoria J 21-13-00504 Include U�e proceeds of litigation and the date the proceeds were received by the estate. All property joirrtly-owned with the rlgM of survivorship must be disclosed on schedule F. ��M VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Orrstown Bank*3081 -Interest Checking Account;principai 6.353.35 Accrued income on Item 1 through date of death 0.03 TOTAL(Also enter on Line 5,Recapitulation) 6,353.38 (If more space is needed,additional pages of the same size) Copyright(c)2010 form software only The Lackner Group,inc. Form PA-1500 Schedule E(Rev.11-10) R�-1811 EX�(10-09) , $CHEDULE H pennsylvania DEPARTMENTOFREVENUE FUNERAL EXPENSES AND RESI ENT DEC ENT URN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER MOZINGO,Victoria J 21-13-00504 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT q, FUNERAL EXPENSES: See continuation schedule(s)attached 14,922.74 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zio Year(s)Commission Paid 2. Attornev's Fees Law Office Forest N Myers 1,507.50 3. Family Exemption: (If decedenYs address is not the same as claimant's,attach explanation) Claimant Street Address City State Zi� Relationshi�of Claimant to Decedent 4. Probate Fees 138.50 See continuation schedule(s)attached 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 388.50 See continuation schedule(s)attached TOTAL(Also enter on line 9,Recapitulation) 16,957.24 Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.10-09) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER MOZINGO,Victoria J 21-13-00504_ ITEM NUMBER DESCRIPTION AMOUNT Funeral Exue,_nses 1 Fogelsonger-Bricker Funeral Home-funeral bill 12.122.74 2 Grave opening-for funeral 700.00 3 Headstone-for funeral 2,100.00 H-A 14,922.T4 Probate Fees 4 Register of Wills-initial Probate fees�costs 138.50 H-B4 138.50 Other Administrative Costs 5 Cumberland Law Journal-advertising estate 75.00 6 Deed preparation-prepare Deed to clear title 150.00 7 News-Chronicle-advertising estate 96.50 8 Recorder of Deeds-recording Deed 67.00 H-B7 388.50 Copyright(c)2002 form software only The Lackner Group,inc. Form PA-1500 Schedule H(Rev.6-98) Rev-1512 EX+(12-08) SCHEDULE i pennsylvania DEBTS OF DECEDENT, DEPARTMENT OF REVENUE INHERITANCETAXRETURN MORTGAGE LIABILITIES AND LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER MOZINGO Victoria J 21-13-00504 Rsport debts tncurred 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 Orrstown Bank*4581 -Installment Loan($20,994.91;joint with spouse) 10.497.45 TOTAL(Aiso enter on Line 10,Recapitulation) 10,497.45 (If more space is needed,additional pages of the same size) Copyright(c)2008 form software oniy The Lackner Group,Inc. Form PA-1500 Schedule I(Rev. 12-08) REV-1813 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BE N EFIC IARI ES RESIDENT DECEDENT ESTATE OF FILE NUMBER MOZINGO,Victoria J 21-13-00504 NAME AND ADDRESS OF RELATIONSHIP TO gHqRE OF ESTATE AMOUNT OF ESTATE NUMBER PERSONIS)RECEIVING PROPERTY DECEDENT (Words) ($$$) I TAXABLE DISTRIBUTIONS [include outright spousal • distributions,and transfers under Sec.9116 a 1.2 Gary L MOZINGO,Jr. Son One-fourth of net 50 Sergeantsville Rd distributable Fiemington,NJ 08822 estate Gary L MOZINGO Sr Husband One-half of net 309 W Creek Rd distributable Newburg,PA 17240 estate Shelly V PORTER Daughter One-fourth of net 95 Independence Dr distributable Shippensburg,PA 17257 estate Total 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 SHEE Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10) ^� �. -� �� , s� � '_„f�V` _� \ �/� � - ��, r� �- � �. �l Gr � �� T.�.w o�ct� ��O R��T �• l�.t YE R� 137 Park Placs Wast, Shippensburg, Pennsylvania 7 72b7 � 7 7 7.632.9Q46 Fax 717.632.88757 fnmyersC�lawofficeforestmyers..co m �_� November 19, 2013 � � rn � � �° ° � a�.n � � � � � d � y�,. r �a � rn Re ister of Wills � � � '� �' ° Cumberland County � � '�` � � � One Courthouse Sq �'�► ° � "� � � ' c� � � � Carlisle PA 17013 : � � � '�'' -a �, Q �-#°, � � RE: Estate of Victoria MOZINGO 21-13-00504 Dear Ms. Farner: Enclosed please find the original and finro copies of the PA-1500 (Inheritance Tax Return)for the above-captioned estate. There is no tax due and the filing fee was paid on 04/30/2013 upon opening the Estate. Please return a time-stamped copy to me in the enclosed envelope. Sincerely, ;.--�- Forest N. Myers ahh / enclosures �'�r�(;iaraft�.r�:'.C3�.1 �'�.�:�y^,•t:�--�:�r�.:i.�, P.1;=?,r,ur 4._t: ..I =�E.,. ro.V�._. i_ .-i.-� -, ..-�.�,� ... F�-. I��ii'f�.�. .�._ �, -VP, _ _ I�. i ( :,�e ic, �!'r',��t��1'i� .., .., ,.. . >� � r:i- ; �;�. , ; r��•- ,�� r,�y cr, ,- __ - ____ _ - :��- _ _ , s Woo�.pou.uiod.p�w.�uor.po�., ., }. ' . 1• � � •ti � � 1 r � W ? �y � � ti � �� aN ��o d��LL O�o =.a � � �� V � � � N � W r � � � Q � J � = r -a E... _ � O w ,_,� �"� c'� : _ � p = Q _` z a �- � ,� i'�- o c�.� _ � p~C W �- � C� � C.7 � ' W � � J � � � � � I— WDy ww CV, w � --� - (� � W � OC '_ Z c� vs Q �:� t,� = � UOc� W � c� � � C� � � � � G3 -��_ �.,.. � H D� � � � z � � � � a w � �0 a � � �.� � �