HomeMy WebLinkAbout01-28-05
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
SEITZ NANCY
13 W COOVER STREET
MECHANICSBURG, PA 17055
nnnn fold
ESTATE INFORMATION: SSN: 207-07-6378
FILE NUMBER: 2105-0090
DECEDENT NAME: HUEY HAZEL E
DATE OF PAYMENT: 01/28/2005
POSTMARK DATE: 01/28/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 06/26/2004
NO. CD 004893
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $3,231.00
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS:
CHECK# 414
SEAL
INITIALS: MW
RECEIVED BY:
REGISTER OF WILLS
$3,231.00
GLENDA FARNER STRASBAUGH
REGISTER OF WillS
'.
b'-'500 EX 16.00:
'* COMMONWEALTH OF
PENNSYLVANIA
. DEPARTMENT OF REVENUE
DEPT 280601
"' HARRISBURG, PA 17128-0601
'"
>-
~g(l)
u """
'"~U
",00
u~-'
~'"
~
"
~Ci PI^,c6~
REV-1500
OFFlCIAL lJSE Or-;l_'{
FILE NUMBER
~~--0'S
COUNTY CODE YEAR
INHERITANCE TAX RETURN
RESIDENT DECEDENT
()oGO
_ __ ---1 __ _
NUMBER
SOCIAL SECURITY NUMBER
f-
Z
UJ
C
UJ
U
UJ
C
DECEDENT'S NAME (LAST fiRST, AND MIDDLE INITIALl
I.J ~ A z.€ L.
DATE Of DEATH (MM,D ,YEAR) DATE Of BIRTH (MM-DD,YEAR)
,)-/~-
6~-~{;,'()
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST, AND MIDDLE INITlALI
AlA-
~ 1. Original Return
o 4. limited Estate
D 6. Decedent Died Testate (Mach copy of Will)
o 9. litigation Proceeds Received
377
E
,Ci '7
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 2. Supplemental Relurn
o 4a, FuturelnterestComprom'lse Idateoldeath iJfter 12-12.82)
o 7. DecedenlMaintained a Living Trust (AtlachcopyoITruSt'i
o 10. Spousal Poverty Credit (dale ofdealh between 12.31.91 aDd 1-1-95)
o 3. Remainder Return (oate 0' Death p,ior 10 12 <'3-82;'
o 5. Federal Estate Tax Return Required
8. To\al Number of Safe Deposit Bo)(es
o 11. Election to tax under Sec. 9113(A) (AltacrScrOI
>,
~
z
'"
"
z
o
~
<n
w
~
~
o
"
,Tllllii~
NAME
N
(-~1~.1:1"~" ''''i'i:i.?;''~~~1~I\Ojt;I~'"';'\' ' :,"', ,{, /," <~';>~ ".,,', 1'11' r;'ii'.$~r:j~;~J":~~~;!?'
"J r~"'.t .~. ".....~ !}l;, ,~J~,,, ..,J _,_ ... ~ ~ ..,~~ ~ ~"~'" ", . >(., ~ i>,._ !,; w.t.~.,:;, ...."'i,~;k;;tC~
itl.'TOf-
FIRM NAME (If ApplicaDle)
TELEPHONE NUMBER
IPb-33";9
Real Estate (Schedule A)
2 Stocks and Bonds (Schedule B)
3 Closely Held Corporation, Partnership or Sole.Proprietorship
4 Mortgages & Notes Receivable (Schedule D)
5 Cash, Bank Deposits & Miscellaneous Personal Property
Z (Schedule E)
0 6 Jointly Owned Property (Schedule F)
~ o Separate Billing Requested
~ Inter-Vivos Transfers & Miscellaneous Noo-Probate Property
f- (Schedule G or l)
a:
<( 8 Total Gross Assets (total Lines 1-7)
U 9 Funeral Expenses & AdminlstratilJe Costs (Schedule H)
UJ
c::
10 Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11 Total Deductions (total Lines 9 & 10)
12 Net Value of Estate (Line 8 minus Line 11)
COMPLETE MAILING ADDRESS <' I
J 3 w . CD'O ve r ~,.
/YlEChMJI'c.".:>lau"'Ji Pt4
1705:;)
(1)
(2)
(3)
(4)
(5)
r
,
!
,
,
!
OFFICIAL USE c5'NL\;'
J?' Lj tl:J. -
,
(6)
~~ 54:2. r
(7)
I
l.....__..~_.__...
(8)
13. 99 ~
,
(9)
(10)
7.. / 9t/, -
(11) ;< / 9 '/
(12) 7 I. R tJ c:l
(131
~3 Charitable and Governmental BequeslslSec 9113 Trusts lor which an election to tax has not been
made (Schedule J)
14 Net Value Subject to Tax (line 12 minus line 13)
-,p -
1/ ?'OCJ
,
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
z
o
j::
~
~
0..
:::iE
o
u
><
~
15 Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
16 Amount of Line 14 taxable at lineal rate
17 Amount of Line 14 taxable at sibling rate
18 Amount of Line 14 taxable at collateral rate
~g Tax Que
7 ~. 'i 0 D
x.0_(15)
x .0':1..;[ (161
2:<31-
x 12 (17)
x15 (181
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
(19)
:?.J3J
20.0
''"; -, ,,," ,,"'l'''''~'!!
~1.L-'~"'_' ~ . _ ~,,,h:~:
~
~~
.1~~:~t~
I STATE I ZIP
(1) ,)07.3/ /
I
Total Credits (A+ 8 + C) (2)
Decedent's Complete Address:
I_ _;m'~'
CITY
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
1
..
3. InteresUPenalty if applicabie
D. Interest
E. Penalty
(3)
(4)
(5) ..~
I.
,
(SA) ,
(58)
4.
TotallnteresUPenalty ( D + E )
If Line 2 is greater than line 1 + line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 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.
A. Enter the interest on the tax due.
3;(.,3'
8. Enter the lotal of Line 5 + SA. This is the BALANCE DUE.
3;1.3 /
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
~
Ii(]
~
@
1. Did decedent make a transfer and: Yes
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; or ...",.,.,., "', "" ,........................................ ...... ............................................. .......... D
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0
2. if dealh occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ................................................................. ..........,.,~.. ".. ............ ............ 0
3. Did decedenl own an "in trust fo~ or payable upon death bank accounl or security at his 6r her death? .............. 0
4. Did decedent own an Individual Retirement Accounl. annuity. or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
l3-
Under penalties of pe~ury, I declare thai I have examined this return, including accompanying schedules and statements, and to Ihe best of my knowledge and belief, il is true, correct
and tomplete.
Declaration of preparer other than the personal representative is based on aU information of which preparer has any knowlet!ge.
SIGNATURE OF PERSON RESPONSiBLE FOR FILING RETURN
ADDRESS
1?~ H ,jLl1J
t..
SIGNATURE OF PR
ROTH
h .
DATE
i/..1 ~0 ~-
I
DATE
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers 10 or for the use of the surviving spouse is 3%
172 P.S. 99116 (a) (1.1) (i)).
For dales of death on or after January 1. 1995, the lax rale imposed on the net value of transfers to or for the use of the surviving spouse is 0% 172 P.S. 99116 (a) (1.1) (Ii)
The statute does not exemot 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
the surviving spouse is the only beneficiary.
For dates of death on or after Juiy 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive paren
or a stepparenl of the child is 0% 172 P.S. 99116(a)(1.2)].
The lax rale imposed on the net value of transfers 10 or for Ihe use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)]
The tax rate imposed on the net vaiue of transfers to or for the use of the decedent's siblings is 12% 172 P.S. 9g116(a)(1.3)]. A sibling is defined, under Section 9102, as ai
individual who has at least one parent in common with the decedent, whether by blood or adoption.
. '
REV,1502 EX+ IS.g_
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF
FILE NUMBER
/-Ifrz.,; L..
All real property owned solely 8S . tenant In common mUlt be reported at fair market value. Fair market value is defined as the price at which property would be
exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property which I. Jointly-owned with right of ..urvlvorshlp must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
N/A
"~
.~.l
.
~.
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
, '
REV-1504 EX... (1-97) _
~k
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE OF
/~ 11 Z-E. L
FILE NUMBER
Sct1edule C.j or C.2 ('Includ'rng all supportl 9 information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a
sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
ITEM NUMBER
NUMBER
,.
DESCRIPTION
VALUE AT DATE
OF DEATH
~
N/A
,.
'f~
TOTAL (Also enter on line 3, Recapitulation) $
(ll more space \s needed, insert add'lt'lonal sheets of the same size)
REV.1505EX.(1.97j
'*
SCHEDULE C.1
CLOSEL Y.HELD CORPORATE
STOCK INFORMA liON REPORT
I~ lI~f L 1--1. \J e'1
"v;/A
FILE NUMBER
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE T f+Y.. RETURN
RESIDENT DECEDENT
ESTATE OF
State
Zip Code
State of Incorporation
Date of Incorporation
Total Number of Shareholders
Business Reporting Year
1. Name of Corporation
Address
City
2. Federal Employer LD. Number
3 Type of Business
ProductJService
4
I TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE
STOCK Voting I Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK
Common '~i. $
Preferred $
Provide ail rights and restrictions pertaining to each class of stock.
5 Was the decedent employed by the Corporafion? 0 Yes o No
If yes, Position Annual Salary $ Time Devoted to Business
6. Was the Corporation indebted to the decedent? 0 Yes o No
If yes, provide amount of indebtedness $
? Was there life insurance payable to the corporation upon the death of the decedent? 0 Ves 0 No
if yes, Cash Surrender Value $ Net proceeds payabie $
Owner of the policy
8. Did the decedent seil or transferstock of this company within one year prior to death or within two years if the date of death was prior to 12-31-82?
o Ves 0 No if yes, 0 Transfer 0 Sale Number of Shares
Transferee or Purchaser
Attac!l a separate sheet for additional transfers and/or sales.
Consideration $
Date
9. Was there a writlen shareholders agreement in effect at the time of the decedent's death?
If yes, provide a copy of the agreement
o Ves
o No
10. Was the decedent's stock sold?
o Ves 0 No
if yes, provide a copy of the agreement of sale, etc.
11 Was the corporation dissolved or iiquidated after the decedent's death? 0 Ves 0 No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
12 Did the corporation have an interest in other corporations or partnerships? 0 Ves 0 No
If yes, report the necessary information on a separate sheet, including a Schedule C-t or C-2 for each interest
A Detailed calculations used In the valuation of Ihe decedent's stock.
B. Complete caples of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years.
C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisais have been
secured, attach copies.
D. list of principal stockholders at the date of death, number of shares held and their reiationship to the decedent
E, List of officers, their salaries, bonuses and any other benefits received irom the corporation,
F. Statement of dividends paid each year. list those declared and unpaid.
G. Any other information relating to the valuation of the decedent's stock.
REV.'506 EX. 19.0*
COMMONWEALTH OF PENNSYLVANtA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C..2
PARTNERSHIP
INFORMATION REPORT
ESTATE OF )~ AZ.~ l
\-\ V ~\
-----~_. lv/A
Name of Partnership
Address
City
2. Federal Employer 1.0. Number
3. Type of Business
FILE NUMBER
Date Business Commenced
Business Reporting Year ____.___
Stale Zip Code
Product/Service
4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $
5.
A.
B.
C.
D.
6. Value of the decedent's interest $
7. Was the Partnership indebted to the decedent?
It yes, provide amount of indebtedness $
8. Was there life insurance payable to the partnership upon the death of the deceden1? 0 Yes 0 No
If yes. Cash Surrender Value $ Net proceeds payable $
Owner of the policy
DYes 0 No
9, Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was
prior to 12-31-82?
DYes 0 No
If yes, 0 Transfer 0 Sale
Percentage transferred/sold
Consideration $
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
10. Was there a written partnership agreement in effect at the time of the decedent's death? . . .. 0 Yes 0 No
If yes, provide a copy of the agreement.
Date
11. Was the decedent's partnership interest sold? 0 Yes 0 No
If yes, provide a copy of the agreement of sale, etc.
12. Was the partnership dissolved or liquidated after the decedent's death? 0 Yes 0 No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
13. Was the decedent related to any of the partners?
If yes, explain
14. Did the partnership have an interest in other corporations or partnerships? 0 Yes 0 No
If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest.
DYes 0 No
THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
A. Detailed calculations used in the valuation of the decedent's partnership interest
B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year o~ death and 4 preceding years,
C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have
been secured, attach copies.
D. Any other information relating to the valuation of the decedent's partnership interest.
REV:1507 EX+ (1-97) '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF
H t-:z.. e-L \~ \J 6,./
All property jointly.owned with rIght of survi+orship must be disclosed on Schedule F.
FILE NUMBER
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
No /-IE
"
'~~
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
"~'~E""O".
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
Ii A-z..E L Jive!
Include the proceeds of litigation and the date the proceeds were received by the estate. All pr&perty joIntly-owned with the right of survivorship must be disclosed on Schedule F.
FILE NUMBER
ITEM
NUMBER
I.
DESCRIPTION
VALUE AT DATE
OF DEATH
fl-A.- /feN (:>/ttJ}(..
/o(.,'i- 3/ y.:5 G,
~h('c~",)
~5'''!'8Z'-//
I
)
W fl-y fO" '" t
I ~901,-II03()1
C'" e '- " \"d
y
~j':;(P'f,7/
,.
if
TOTAL (Also enter on line 5, Recapitulation) $ g <1:);( _
(If more space is needed, insert additional sheets of the same size)
'~'~~,",".
COMMONWEALTH OF PENNSYLVANIA
INHERlTANCE TAX RETURN
RE IDENT DECEDENT
SCHEDULE F
JOINTL Y.OWNED PROPERTY
ESTATE OF
fi"'7-E L I-\-v E:.,
If an asset was made joint within one year of the decedenfs dlte of death, It must be reported on Schedule G.
FILE NUMBER
SURVIVING JOINT TENANT{S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. Nr:.1J<j I.J Sedz..
13 w.
/'fleeJ.., b 0 J
Coo 11'- ... 5 t
(JA , 70.5.:)'
DAV,7 A 10"
8.
"
. .t~
c.
JOINTLY -OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY . %OF DATE OF DEATH
ITEM FOR JOINT MADE Include n;:me offinanclal institution and bank account number or slmllwldentittlng numbel'. Attach DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT deedforjointly-helcl real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. "'J(>.NNG7 rVioN-f7"m~Y"J 11!?~t?;lI: '-/3 so% 5'/07-'1. -
0(.,(. 02. ,<;1. ("333'(.{" I
J
2 j+ Sc.vddev INVLSt-r.Je.", t $ ..< ~ " 3:r, ~-'1 sv51cJ N) ':;)18. -
;'1%'4). 7/ ,
.
,
TOTAL (Also enter on line 6, Recapitulation) $ &, 5. ~-</:2.
(If more spaoe Is needed, insert additional sheets of the same size)
AEV.1511 EX+ (12-99j .
~'
.....,
... s.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF
/-IAZ~I- 14\J~ir
Debts of deced nt must be reported on Schedule I.
,
ITEM AJOUNT
NUMBER DESCRIPTION
A FUNERAL EXPENSES: ' /
1 /7 'ILl, .; :,
"
'l,
B ADMINISTRATIVE COSTS:
1 Personal Representative's Commissions
Name of Personal Representative{s)
Social Security Number(s)/EIN Number of Personal Representat(l/e{s)
Street Address
City State _ Zip
Year(s) Commission Paid:
2, Attorney Fees
3 Family Exemption: (II decedent's address is nol the same as claimant's, attach explanation)
Claimant
Slreet Address
City State _ Zip
Relationship 01 Claimant to Decedent
4 Probate Fees
5 Accountant's Fees
/6(; eJ',;J
6 Tax Return Preparer's Fees
3DO, ".<J
7, ;r}/l/k'E,€ /-J (21'1 D :;~NL
TOTAL (Also enter on line 9, Recapituiatlon) $ .? / p',/ 'IS-
(II more space is needed, insert additional sheets of the same size)