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Home My WebLink About12-11-13 pennsylvania 15051313110 EPA-1.11 REVENUE EX(06-13) RE V-1"1 500 OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN �� a) Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 01222013 08301931 Decedent's Last Name Suffix Decedent's First Name MI DJUVIK ROY H (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI DJUVIK MARY ANNE B Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH 052-26-2558 THE FILL IN APPROPRIATE BOXES BELOW REGISTER OF WILLS 1. Original Return Q 2. Supplemental Return Q 3. Remainder Return(date of death Prior to 12-13-82) Q 4. Agriculture Exemption Q 5. Future Interest Compromise(date of 6. Federal Estate Tax Return Required date of death on or after 7-1-2012) death after 12-12-82) FX 7. Decedent Died Testate Q 8. Decedent Maintained a Living Trust 9. Total Number of Safe Deposit Boxes (Attach copy of will.) (Attach copy of trust.) 0 10. Litigation Proceeds Received 11. No Taxable Asset Return 12. Election to Tax under Sec.9113(A) (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number CHARLES G . CHELEDEN, ESQ . 215-230-4300 `Irst Lin:',o`A.ddress . 21 A EAST ASHLAND ST . Second Line of Address City or Post Office State ZIP Code C= ; Ci DOYLESTOWN PA 18901 1 ACOO _ G'krC5U _ REGIS P1;V9_::2 IIn U LYM REGISTER OF WILLS USE ONLY l }"'� DATE FILE�D 'rte- Correspondent's email address: C G T R U S T a9 A 0 L . C O M DKM FILED STAMPS Under penalties of perjury,I declare 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 preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE,FOR FILING RETURN /DATE ADDRESS r �/ 223 TOUCHSTONE DRIVE, CARLISLE , PA 17015 SIGNATURE OF PREP ER THER THA REPRESENTATIVE DATE ��- 21—/3 ADDRESS 21 A EAST ASHLAND ST . DOYLESTOWN PA 18901 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505613110 1505613110 � 1 1505613210 REV-1500 EX Decedent's Social Security Number Decedents Name: ROY H DJUVIK 198-24-3689 RECAPITULATION 1. Real Estate(Schedule A). .. .. .. . . . . . .. . . .. ... . . ... . . . . . . . . . . .... ... 1. 0 . 00 2. Stocks and Bonds(Schedule B). .. .. . .. . . . . .. . . . . .. . . . . . . . . . . . . . ... . 2. 0 . 00 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C). . . 3. 0 . 00 4. Mortgages and Notes Receivable(Schedule D). . . . . . . . . .. .. . . . . . .. . . . . . 4. 0 .00 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). . . . . 5. 0 . 00 6. Jointly Owned Property(Schedule F) =Separate Billing Requested. . . . .. . 6. 0 . 00 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) =Separate Billing Requested. .. . . . . 7. 3140432 . 00 8. Total Gross Assets(total Lines 1 through 7). . .. . . . . . . . .. . . .. . . .. . . .. . . 8. 3140432 . 00 9. Funeral Expenses and Administrative Costs(Schedule H). . . .. . . ... . . . .. . . . 9. 0 • 011 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1). . . . .. . . . . .. .10. 0 - 00 11. Total Deductions(total Lines 9 and 10).. . .. .. . .. . .. .. . . . . . . . . . . . . . .. 11. 0 • 00 12. Net Value of Estate(Line 8 minus Line 11). . . . . . . . ... .. .. . . . . . .. . . ... . 12. 3140432 . 00 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J). .. . . .. . .. . . . . . .. . . . . . 13. 0 . 00 14. Net Value Subject to Tax(Line 12 minus Line 13). . . . . . . . .. . . . . . . .. . .. . 14. 3140432 . 00 TAX CALCULATION-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.0 0 3140432 . 00 15. 0 . 00 16. Amount of Line 14 taxable at lineal rate X .0 45 16. 0 . 00 17. Amount of Line 14 taxable at sibling rate X . 12 17. 0 . 00 18. Amount of Line 14 taxable at collateral rate X . 15 18. 0 . 00 19. TAX DUE. . . . .. . . . . . . . . . . . .. . . . . . . . ... .. ... . . . .. .. . . ... .. . .. .. ... 19. 0 . 00 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT = Side 2 1505613210 1505613210 REV-1500 EX Page 3 File Number 198-24-3689 Decedent's Complete Address: DECEDENT'S NAME ROY H DJUVIK STREET ADDRESS 223 TOUCHSTONE DRIVE CITY STATE ZIP CARLISLE PA 17015 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A.Prior Payments B. Discount 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. Fill in box on Page 2,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) 0.00 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................................................:........................................ 0 ❑ b. retain the right to designate who shall use the property transferred or its income............................................ 0 ❑ c. retain a reversionary interest............................................................................................................................. ❑ 0 d. receive the promise for life of either payments,benefits or care?..................................................................... ❑ Q 2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death without receiving adequate consideration?...........................................................................................:................. ❑ X❑ 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?........................................................................................................................ FX] ❑ 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 Jan. 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: 9 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(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-1510 EX+(08-09) SCHEDULE G Pennsylvania DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND RESIDENT DECEDENT"R" MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Roy H Djuvik This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE.THEIR RELATIONSHIP TODECEDENTAND DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER.ATTACH A COPY OFTHE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (WAPPLIGABLE) VALUE 1. Vanguard Rollover IRA 885,453 100.00% 885,453 Beneficiary: Mary Djuvik 0 0 2. Vanguard Roth IRA 1,862,775 100.00% 1,862,775 Beneficiary: Mary Djuvik 0 0 3. Vanguard Roth IRA Brokerage Account#31756328 361,812 100.00% 361,812 Beneficiary: Mary Djuvik 0 0 4. Assets held in Roy H. Djuvik&Mary A. Djuvik Tr UA 03-17-93 0 a.Vanguard Brokerage Account#32699370 52,425 50.00% 26,213 0 b.Vanguard Account 8,357 50.00% 4,179 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TOTAL Also enter on Line 7, Reca itulation $ 3,140,432 If more space is needed, use additional sheets of paper of the same size. REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Roy H D'uvik 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 Ann Djuvik, 233 Touchstone Drive, Carlisle, PA 17015 Spouse 100%of residue ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. 0.00 If more space is needed,use additional sheets of paper of the same size. CL -n M CD CD a ca CD �. (D m W o mm -n <C' -i_ m m CD �m (D z O C G m -. m (. cD CD 0 c� X, m w CD N - N O W CD Ut Ul � O O N (D .— ye � 0o2 ® CD C) % - � Cn @m + � \ Charles G. Cheleden Attorney and Counselor-at-Law Doylestown•Montgomeryville December 2, 2013 4 !�.qq� M O M C) Register of Wills M =r C-> c cn Courthouse M u i 1 Courthouse Sq. X-- cn Carlisle, PA 17013-3387 r c:. c� p- RE: Estate of Roy H.Djuvik Date of Death: January 22, 2013 Dear Register: Enclosed please find the following paperwork for filing: • Copy of first page of the REV-1500 - please time stamp and return in the envelope provided; • Original REV-1500 PA Inheritance Tax Return for the Register of Wills; • Original Rev-1500 PA Inheritance Tax Return for the Department of Revenue. Thank you. Sincerely, CG Cheleden Charles G. Cheleden CGC:jsl Enclosures � o� � a� N_ CD CaD C: (D' � o o =3 N ? c D � ° N CD0 oa � � A w+ 22 n, { ►-� A r m rt w C - C� <> `Y7 CO (:> r. >CN 03 o tdCfls♦m