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Home My WebLink About01-13-14 1505611101 REV-1500 EX(o2-ii) ' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes County Code Year File Number PO BOX Z8o6oi INHERITANCE TAX RETURN f- Harrisburg,PA 1 7 128-o6ot RESIDENT DECEDENT iJ ENTER DECEDENT INFORMATION BELOW Social Security Number Dale of Death MMDDYYYY Date of Birth - MMDDYYYY Decedent's Last Name Suffix Decedent's First Name MI (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI mp b1_ 61;R1A,d ��Ol� F SIT S Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW Qft 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death • Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A) ' . Between 12-31-91 and 1-1-95) (Attach Schedule 0) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number S1y,1a, LID n L aflE (_r Q I y3-8 �3 ?j r OSEr6qTER OF WTILS INSd Y Co Co — Gf O M = N First Line of Address n m �, T O Cr, x w o CD Second Line of Address o n O "D -TI _171 O Z_3 EllEr-M111111 111 1 11111 r rrt City Or Post Office State ZIP Code DATE FILED r CGt1r f M/ P I I I I Correspondent's e-mail address: sr AAE.,G PC io Om 1, rgrn/1 1 I . C %� Under penalties of perjury,I declare that I have ex ined this retu ncluding accompanying sch and statements,and to the best of my knowledge and belief, it is true,coned and complete.Declaration of preparer other than t e personal representative is based on all infonnation of which preparer has any knowledge. SIGNAT OF PERSON RESP SI FOR I G RETURN DATE ADD S n / - � i I d1.1, SI NA , OF P RER OTHER THAN REP ESENTATIVE _l/� Y DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505611101 1505611101 J J 1505611201 REV-1500 EX Decedent's Social/Security Number Decedent's Name: l l/(f� f>D RECAPITULATION -=1 1. Real Estate(Schedule A). .. .... .... ... ... . .... .... ... .... .... .. . . . ... 1. C/7, 0. G 1 2. Stacks and Bonds(Schedule B) ... . .... ... ... . ... .... .. . . ... . ... .... .. 2. v 3. Closely Held Corporation, Partnership or Sale-Proprietorship(Schedule C) ... .. 3. O 4. Mortgages and Notes Receivable(Schedule D). ... . ... .... .... ... .... .... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E).. ..... 5. (0 SS�•�• 6. Jointly Owned Property(Schedule F) O Separate Billing Requested .. ... . . 6. �• �Q 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested,. ... . . . 7. 2 8. Total Gross Assets(total Lines 1 through 7).. .... .... ... . . .. . ... ... . .... 8. 9. Funeral Expenses and Administrative Costs(Schedule H).... . .. .... ... . .... 9. 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1)... ... . .. ..... . 10. Q. czs O 11. Total Deductions(total Lines 9 and 10). .. . ... . ... .... . ... . ...... ... . ... 11. 1 5 •i `O 12. Net Value of Estate(Line 8 minus Line 11) . ... ... . .... .... ... ... . ... . ... 12. •�Q 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. � g g. TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 G r� �7 (a)(1.2)X.0- 3� O V• \ I 15. D •V V 16. Amount of Line 14 taxable at lineal rate X .0_ 16. 17. Amount of Line 14 taxable at sibling rate X .12 A 17. 18. Amount of Line 14 taxable' at collateral rate X .15 r y 18. 19. TAX DUE .. ... . ... .. .... ... .... ... . .. . ....... ... . ... .... . ... .... .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 1505611201 1505611201 REV-1500 CX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME (OTADSTR E D R ES i! r l— �nl�.V-� 1 - --- CI-CI STATE ZIP A, ( 103 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) O. o 3. Interest 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 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.......................................................................................... ❑ `f f b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ c. retain a reversionary interest .............................................................................................................................. ❑ d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 2. If death occurred after Dec. 12,1982,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ JB 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ B 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation? ........................................................................................................................ ❑ -E�- 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)(1)). 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)(11)(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(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-15o8 EX+(a-ro) [� J pennsylvania SCHEDULE E Q' DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: _ 6 f u Include the pro ceed f itigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER n DESCRIPTION OF DEATH %Y30Z TOTAL(Also enter on Line 5, Recapitulation) $ If more space Is needed,use additional sheets of paper of the same size. Adams County National Bank - Images for Account 143030 Statement Dated 10/06/2009 Page 3 ueen—CMECMG AWOUW CWSINO d^--- 9'I�-0j 0/ Y303O rn i .� $ .:Soo 1-10?NS Pi MisC. Debit - 09/15/2009 ADAMS COUNTY NATIONAL BANK& FARMERS NATIONAL BANK OFNEWVILLE CHECKING STATEMENT A D,—i—afAd..,County NaIi,nal B,ok Statement Date: 10/06/09 Account#: 143030 ********'*AUTO**ALL FOR AADC 170 1078 1.1150 AB 0.485 8 1 11 Page 1 L��IIh��IIL��IL�Ihh�Id��L��Ihh��IL��II„LL��II 801 DOROTHY R MUSGRAVE 478 WOLFS BRIDGE RD CARLISLE PA 17013-8837 YOU DESERVE THE BEST. HERE IT IS. LOW FIXED rates are available on our Five-Year Home Equity Line and 10-Year Home Equity Loan. Take advantage of low minimums and no fees. our Home Equity Line comes with a visa card---tap the line whenever you wish. Call 1.877.883.2262 or visit acnb.com to find out more. Equal Housing Lender. Equal Opportunity Lender. Member FDIC. ESTEEM CHECKING Account# 143030 Account Summary Beginning Balance Activity Ending Balance Previous Statement Balance 09/03/09 $6,855.74 + Deposits and Other Credits .00 -Checks Paid or Other Debits 1 6,855.83- -Service Charges Do- + Interest Paid ,09 Ending Balance $.00 Days in Statement Period 33 Account Detail Date Activity Description Deposits/Credits Checks/Debits Balance BEGINNING BALANCE 6,855.74 09-15 INTEREST PAYMENT .09 6,855.83 09-15 CLOSING TRANSACTION 6,855.83 .00 10-06 ENDING BALANCE .00 Interest Summary From 09/04109 Through 10/06109 Days in Statement Period 33 Interest Earned $.09 Annual Percentage Yield Earned .04% Interest Paid This Year $2.56 Interest Withheld This Year $.00 EO. Box 3129, GETTYSBURG, PA 17325 1 PHONE 717.334.3161 TOLL FREE 1.888.334.ACNB (2262) www.acnb.com Page Z 143030 Overdraft Fees/Refunds Summary Description This Cycle YTD Fees for Returned Items .00 .00 Fees for Paid Items .00 .00 Fees from Service Charge .00 .00 Total Fees Charged .00 .00 Total Fees Refunded .00 .00 Description This Cycle YTD Refund of Returned Item Fees .00 .00 Refund of Paid Item Fees .00 .00 END OF STATEMENT REV-1511 EX+(10-09) - pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT _ ESTATE OF FILE NUMBE Decedent's deXsjnust be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. .--`�es-0.� B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: Z. Attorney Fees: 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 Fees: 6. Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9, Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date : 9/11/2009 Cumberland County - Register Of Wills Receipt Time : 09 : 52 : 05 One Courthouse Square Receipt No. : 1058197 Carlisle, PA 17613 MUSGRAVE DOROTHY R Estate File No. : 2009-00851 Paid By Remarks : SHARON POTTEIGER JN ------------------------ Receipt Distribution Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 45 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN RENUNCIATION 5 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 12 . 00 CUMBERLAND COUNTY GENERAL FUN JCP FEE 10 . 00 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 1794 $92 . 00 Total Received. . . . . . . . . $92 . 00 219 North Hanover Street CorfWe•Pennsylvania 17013 toll free 1.866.451.4511 fox 717.243.3723 ,• FUNERAL HOME 6T• CREMATORY, INC. inog+,a�1h.� September 22, 2009 Sharon L. Potteiger 478 Wolfes Bridge Road Carlisle, PA 17013 Statement of Funeral Expenses for: Dorothy R. Musgrave Date of Death: August 7, 2009 Account Id: 15698-182 PACKAGE: Immediate Cremation OPTION 5-Cremation $ 1,690.00 Sub Total: $ 1,690.00 MERCHANDISE: Urn: Double Companion Urn $ 280.00 Sub Total: $ 280.00 TOTAL FUNERAL HOME CHARGES: $ 1,970.00 CASH ADVANCES: 8 Certified Death Certificates at$6.00 each $ 48.00 Newspaper Notice- Sentinel $ 111.24 Newspaper Notice- Patriot $ 110.92 Coroner's Fee $ 25.00 Sub Total: $ 295.16 Total Funeral Expense: $ 2,265.16 Total Payments Made: $ 2,265.16 Please return this portion with your Remittance $ Amount Enclosed Dorothy R. Musgrave Service ID#: 15698-182 SERVING OUR COMMUNITY SINCE 1907 WILLIAM E. HOFFMAN, PRESIDENT CHRISTOPHER ROBERT Page 1 /Jora-IhyR/�aJroue ee'�a'l� v-y - Sharon<Fbflr�Pr Cxtx artGa Menniol5ennca.H, a'Ti/2S n9 ¢ awrvro $11370 $ .. A 7 a L�AWRS OOUNII ,p V03 i3099L5V 232-828-3- Check Image - 10/05/2009 Check Image - 10/05/2009 REV-1513 EX+(01-10) a I ' pennsylvania SCHEDULE J DEPARTMENT OF REVENUE��.•��'' BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER:_ e- oz (_' v `l -V 5 - RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADD ESS OF PERSON(S)RECE ING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS(Include outright spousal distributions and transfers under Sec.9116(a)(1.2).) 1. 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. $ If more space is needed,use additional sheets of paper of the same size.