HomeMy WebLinkAbout12-23-13 (2) REV-1500 1505610143
EX(01-10)
k
PA Department of Revenue OFFICIAL USE ONLY
p pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO BOX.280601 INHERITANCE TAX RETURN 2 1 09 1041
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
10 30 2009 01 21 1920
Decedent's Last Name Suffix Decedent's First Name MI
ELRICK EMMA 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
❑ 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)
❑ 6 Decedent Died Testate ❑ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust) p
® 9. Litigation Proceeds Received ❑ 10.Spousal Poverty Credit(date of death 11,Election to tax under Sec.9113(A)
between 12-31-91 and 1-1-95) ❑ (Attach Sch.O)
T
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Nupber
DAVID C MILLER JR 717 39 9 " 15 rn
REG#EF; y111LLS`�'t1SE f01VL€Y.t
i rl
::7 r— f`Tt �
First line of address o Zn Cam ,
1100 SPRING GARDEN .DR
Second line of address 7J t m
SUITE A
City or Post Office State ZIP Code DATE FILED
MIDDLETOWN PA 17057
Correspondent's e-mail address: davidcmillerjr @verizon.net
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,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
,ty�evyy C�c�cu�iwc Ree Dean
ADDRESS
1009 Wooded Pond Drive, Har 'sburg, PA 17111
S ATURE RE ER 0TH T REPRE E ATIVE DA E
DAVID C MILLER JR t Z(1 1� 13
ADDRESS
1100 SPRING GARDEN DR., MIDDLETOWN, PA 17057
Side 1
L 1505610143 1505610143 J
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: E L R I C K, E M M A GENE
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. 1 , 605 . 21
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested............. 7.
8. Total Gross Assets(total Lines 1-7)....................................................................... 8. 1 , 605 . 21
9. Funeral Expenses&Administrative Costs(Schedule H)......................................... 9. 365 . 0 0
10. Debts of Decedent,Mortgage Liabilities,&Liens(Schedule 1)................................ 10.
11. Total Deductions(total Lines 9&10)...................................................................... 11. 365 . 00
12• Net Value of Estate(Line 8 minus Line 11)............................................................. 12. 1 , 240 . 2 1
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. 1 , 240 . 2 1
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.
16. Amount of Line 14 taxable
at lineal rate X .045 16.
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 1 , 240 . 2 1 18• 186 . 0 3
19. Tax Due..................................................................................................................... 19. 186 . 03
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 - 09 - 1041
Decedent's Complete Address:
DECEDENT'S NAME
Elrick, Emma Gene
STREET ADDRESS
5225 Wilson Lane
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 186.03
2. Credits/Payments
A. Prior Payments
B. Discount
Total Credits(A +B) (2) 0.00
3. Interest
(3) 0.00
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) 186.03
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;.................................................................................. 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?.............................................................. ❑ Q
2. If death occurred after December 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?......... ❑ Fx
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.
1
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 retturn 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 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). A
sibling is defined under Section 9102,as an individual who has at least one parent in common with the decedent,wkether by blood or adoption.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
COMMONWEALTH OF TAX RETURN PERSONAL PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Elrick, Emma Gene 21 -09 - 1041
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 OF DESCRIPTION
NUMBER DEATH
1 Motor Vehicle Accident Settlement- Escrow Funds 1,605.21
TOTAL(Also enter on Line 5, Recapitulation) 1,605.21
SCHEDULE H
FUNERAL EXPENSES&
COMMONWEALTH OF PENNSYLVANIA ADMINISTRATIVE^^cam(
INHERITANCE TAX RETURN /�iDMINIS 1 RATIVE COSTS
S
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Brick, Emma Gene 21 -09- 1041
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT
A.
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Ree Dean 100.00
Street Address 1009 Wooded Pond Drive
city Harrisburg State PA zip 17111
Year(s) Commission paid
2. Attorney's Fees Law Office of David C. Miller, Jr. 250.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 Cumberland County Register of Wills-Filing Fee for Supplemental Return 15.00
TOTAL(Also enter on line 9, Recapitulation) 365.00
REV-1513 EX+(11.08)
SCHEDULE J
COMMONWEALTH HER TANCEOF TAX RETURN BENEFICIARIES
BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF Brick, NUMBER
rick, Emma Gene 21 -09- 1041
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not List Trustee(s)
I TAXABLE DISTRIBUTIONS[include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
1 Ree Dean Friend One-Third (1/3) of
1009 Wooded Pond Drive Rest, Residue and
Harrisburg, PA 17111 Remainder
2 James L. Snyder Friend One-Half(1/2) of
637 Glenbrook Drive One-Third (1/3) of
Harrisburg, PA 17110 Rest, Residue and
Remainder
3 Thelma Snyder Friend One-Half(1/2) of
9 Andrew Court One-Third (1/3)of
Hanover, PA 17331 Rest, Residue and
Remainder
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
III NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
REV-1573 EX+(9-00)
SCHEDULE )
COMMONWEALTH INHERITANCE TAX PENNSYLVANIA BENEFICIARIES continued
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Brick, Emma Gene FILE NUMBER
21 -09- 1041
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not List Trustee(s)
I TAXABLE DISTRIBUTIONS[include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
4 Grace Ann Gornik Friend One-Third (1/3) of
2090 Sunset Drive Rest, Residue and
Camp Hill, PA 17011 Remainder
Page 2 of Schedule J