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Home My WebLink About01-13-14 1505611101 REV-1500 Ex(02-11) OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes County Code Year File Number PO BOX 28o6o1 INHERITANCE TAX RETURN Q Harrisburg,PA 17128-06oi RESIDENT DECEDENT ;I, $5� ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 09 03 Qo 0 q 0 '1 ta '1 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 Spouse's Social Security Number - THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 11111111 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 O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number hay o PoTT� k,17 r,612 9,13F -ISE_STER OF INOLLS tW @LY a, : < (nX First Line of Address r_ W � o o0 Second Line of Address c _ C'> I I I 7J rV 1r" m City or Post Office State ZIP Code DAW-FILEYJ) o Correspondent's e-mail address: Under penalties of perjury I declare that I have exfnined this retufmjncluding accompanying schedule statements,and to the best of my knowledge and belief, it is true,correct and complete.Declaratit of pre rer other than the personal representative Is bas e n all information of which preparer has any knowledge. SIG NAT E F PERSON RESPON B E OR .RETURN "794 " r S MATIVE 1-7012-1 T E OF DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505611101 1505611101 J _1 1505611201 REV-1500 EX Decedent's Social Security Number , r Decedent's Name: RECAPITULATION 1. Real Estate(Schedule A). . ........ .... ... .... .. ... ...... ..... ... ... .. 1. yt i Q ," .• ..I-U r 2. Stocks and Bonds(Schedule B) ........ ..... .. ..... .. ........... ..... 2. ,b�. 3. Closely Held Corporation, Partnership or Sole-Proprietorship Schedule C 3. 4 da tQ�.'Q•O 4. Mortgages and Notes Receivable(Schedule D).. .. ... ..... ........ .. ..... 4. U 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E)... .... 5. •3, g l , 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. y %- 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested,..... .. 7. _AA' 8. Total Gross Assets(total Lines 1 through 7).... .. .. .... . ........ .. .... .. 8 y_ . -_� 9. Funeral Expenses and Administrative Costs(Schedule H)... .............. .. 9. _ 1 { C t 5 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1).:..... ... .... 10. r 5 -..�. 1- -1. CAT aT la:o I 11. Total Deductions(total Lines 9 and 10)... ...................... ... .... . 11. ) II 12. Net Value of Estate(Line 6 minus Line 11) .. ..... ..... .. ...... 12. �'�"U � w� 13. Charitable and Governmental Bequests/Sec;9113 Trusts for which an election to tax has not been made(Schedule J) . .. .. ... ..... ......... .. 13. r_ jam` f ti 14. Net Value Subject to Tax(Line 12 minus Line 13) .... ............ ... ... . . 14. \ (� �_ -•�� \�• -Xt TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 °y ',"' °` "• 'j"y+"' (a)(1.2)X.0- i1i 15. _� 16. Amount of Line 14 taxable at lineal rate X VA`-:, �� 16. 17. Amount of Line 14 taxable ""ry• ! ^} at sibling rate.X.12 �. _- • 17. � �:'1 V 18. Amount of Line 14 taxable at collateral rate X.15 18. _ k i •W I 19. TAX DUE .. .. ... .. ..... .... ...... .... .. .. .. .. .... ......... ........ 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O r \ Side 2 1505611201 1505611201. -1 1505611201 REV-1500 EX Deceadent'ss Social �Security Number Decedent's Name: �� ,•1. �/;1.,1. �-./.��..R�,.l V,� RECAPITULATION 1. Real Estate(Schedule A). ............................................ 1. �. 2. Stocks and Bonds(Schedule B) ......... 2. t r f IN (^S 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. 1 i .� 4. Mortgages and Notes Receivable(Schedule D)........................... 4. 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... S. 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. ' t e • _ ' "Q :.0�� 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property r `"h " " - (Schedule G) O Separate Billing Requested,....... 7. i. + .-� ,l ,`, It _t r O. ,(� B. Total Gross Assets(total tines 1 through 7).............:............... 8. 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. ;' IF f'f 1 rDr x 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I).:............. 10. -- s hT 11. Total Deductions(total Lines 9 and 10)........ .:... .................... 11. it 12. Net Value of Estate(Line 8 minus Line 11) ............ .:................ 12. 13. Charitable and Governmental Bequests/Sac 9113 Trusts for which ,- • - `vL i kr�;�, an election to tax has not been made(Schedule J) ........................ 13. 14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14. TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Une 14 taxable at the spousal tax rate,or transfers under Sec.9116 + n , �� (aXI.2)X.0_ i h f . ! 4 15. 1 4 16. Amount of Line 14 taxable at lineal rate X.0,-RS 17. Amount of Line 14 taxable e; {!L;;' at sibling rate X.12 ` .p'.�• ` .yv '�, .e. a 17. Ay.... 3 .,i,.•.-F hd.�... i.-,. ,s 18. Amount of Line 14 taxable' at collateral rate X.15 J. 19. TAX DUE................................... .... ................... 19. i.r !aA�w.K,.r�a,a�a{i.�.l►.fd�± i 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT t= Side 2 1505611201 1505611201 F ge 15M EX Pa 3 File Numbercedent's Complete Address:EDENT'S NAME + —.-1—�✓—J—< Vr�. ..r i S $0l 6F' Ir1CvY1dU�¢' -�—_ CITY '� ST LP �Q Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 6;)-1 2. Credits/Payinents A.Prior Payments I3.Discount Total Credits(A*8) (2) (�} .O C 1 3. Interest -- (3) 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 28 to request a refund. (4) 5. If Line 1 +Line 3 is greater than Une 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 amt: Yes Nq a, retain the use or Income of the properly transferred......................................................................................._. El �� b. retain the right to designate who shaft use the property transferred or its Income_................_........................ ❑ c. retain a reversionary interest...,........................................._.........._..........._....................................._............._ ❑ d. receive the promise for fire of either payments,benefits or care?...................................................................... ❑ w] 2. N death occurred after Dec.12,1982,did decedent transfer property within one year of death �{ wiUB cur receiving adequate consideration?............................................................................................................. © IZ7 3. Did decedent own an n trust for'or payable upon-0eath bank account or security at his or her death?.............. © C® 4. Did decedent own an individual re irement account,annuity or other non-probate properly,which contains a beneficiary designation? ..........................................:............................................................................ ❑ i 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 D percent (72 P.S.§9116(a)(1.1)(n)].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 9 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 RS.§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-1508 EX+(%I-lo) g ' pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. RESIDENT DEMEM PERSONAL PROPERTY ESTATE OF: S FILE NUMBER* � tndude the p of litigation and the date the proceeds were received by the estate. All property)Dint wit light of survivorship must be disclosed on Sdredule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1��'ciS � TOTAL(Also enter on Une 5, Recapitulation) 3 O \ If more space is needed,use additional sheets of paper of the same size. REV-1511 EX*(10-09) pennsylvania SCHEDULE H emu' DEPAPTMEMOFRE NUE FUNERAL EXPENSES AND RSIDENNCETAx RETURN ADMINISTRATIVE COSTS - REStDBrr DEQ�ENr ESTATE OF pp FILE NUMBER cl ` Decedent's dells must be reported on Schedule I. - rrEM NUMBER DESCRIPTION - AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address CRY State_LP Years)Commission Paid: Z. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as dalmant's,attach explanation.) Oalmant Street Address city - State_ZIP Relationship of Claimant to Decedent 4. Probate Fees: . 6•. Accountant Fees: 6• Tax Return Preparer Fees: . 7. TOTAL{Also enter on line 9, Recapitulation) 3 1 If more space Is needed;use additional sheets of paper of the same size. 219 North Hanover Street Cortide.Pennsylvania 17013 717.243.4511 toll free x.717 243.3723 e C. (/ •1??CC?Z ^� /IiI2 ~vInoomnonroth.corn FUNERAL_ HOME & CREMATORY, INC. nroatrotfinonroth.cUm September 24, 2009 Sharon Potteiger 478 Wolfes Bridge Road Carlisle, PA 17013 Statement of Funeral Expenses for: Robert S. Musgrave, Sr. Date of Death: September 3, 2009 Account Id: 15717-199 PACKAGE: Immediate Cremation OPTION 5-Cremation $ 1,690.00 Sub Total: $ 1,690.00 TOTAL FUNERAL HOME CHARGES: $ 1,690.00 CASH ADVANCES: Letort Cemetery $ 475.00 2 Certified Death Certificates at$6.00 each $ 12.00 Newspaper Notice- Sentinel $ 133.49 Newspaper Notice- Patriot $ 51.70 Coroner's Fee $ 25.00 Sub Total: $ 697.19 Total Funeral Expense: $ 2,387.19 Total Payments Made: $ 2,387.19 Please return this portion with your Remittance $ Amount Enclosed Robert S. Musgrave, Sr. Service ID#: 15717-199 SERVING OUR COMMUNITY SINCE 1907 WILLIAM E. HOFFMAN, PRESIDENT CHRISTOPHER H.HOFFMAN, VICE PRESIDENT ROBERT A. FnBURN III, SUPERVISOR DarsfhyR//l44!!gyrweeela/� ••—e ¢� Page .$l�aran L/}Yy/e.J(`jr Cx'Fx . �q 'bibleMenpiMSane4Yr, 0��7-��.Q�_ lc�niNnsmanr fi g� A7 C0313099�SC 232-92a-30 Check Image - 10/05/2009 Check Image - 10/05/2009 RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date: 9/11/2009 Cumberland County - Register Of Wills Receipt Time : b9:53 :28 One Courthouse Square Receipt No. : 1058198 Carlisle, PA 17013 MUSGRAVE ROBERT S SR Estate File No. : 2009-00852 -- Paid By Remarks : SHARON L POTTEIGER WZ ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 30. 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN RENUNCIATION 5. 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 8 . 00 CUMBERLAND COUNTY GENERAL FUN JCP FEE 10 . 00 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5. 00 CUMBERLAND COUNTY GENERAL FUN ---------73 . 00 -- Check# 1794 $ Total Received. . . . . . . . . $73 . 00 REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUNBER: NUMBER. NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE I TAXABLE DISTRIBUTIONS lndude outright _ Do Not List Trustee(s) OF ESTATE I g spousal distributions and transfer under Sec.9116(a)(1.2).] (2ArIl` 6le, for"} 100) 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 TAXIS 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 sPaF is needed,use additional sheets of paper of the same size.