HomeMy WebLinkAbout02-12-14 (2) 1505610105
REV-1500 EX(02-11)(FI) OFFICIAL USE ONLY
PA Department of Revenue pennsytvania
--l—I County Code Year File Number
Bureau of Individual Taxes
PO BOX 28o6o1 INHERITANCE TAX RETURN I ---1 1 i
Harrisburg,PA 17128-0601 RESIDENT DECEDENT 1 11 �31 1 1 -71
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
...................................................I............................................................. .............. .................
05/19/2013 04/14/1923
Decedent's Last Name Suffix Decedent's First Name MI
! HUMPHREYS ICAROLYN IG
Of Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
I
..................................... ..................................... ............................... ........................................................................................................................................................
N/A
......................... .....................I—-.................................................. ..............
Spouse's Social Security Number
.......................-__._...-_..........-j THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1.Original Return C=:) 2.Supplemental Return C=D 3. Remainder Return(Date of Death
Prior to 12-13-82)
C=:) 4.Limited Estate t-1 4a.Future Interest Compromise(date of C=) 5. Federal Estate Tax Return Required
death after 12-12-82)
CW 6.Decedent Died Testate C=D 7.Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
C=:) 9.Litigation Proceeds Received C-D 10.Spousal Poverty Credit(Date of Death C=:) 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule 0)
CORRESPONDENT- THIS SECTION VUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
.................................................................................................. ............. .................................... .......................................... .................. ............
!,Ann E. Rhoads, Esquire I 1(717)482-8392
..........J
..................................................._1........................... .................... .......................................... ......................
R EIM OF WILLSYJSE OtFtjY
Co r
C:0
M <*:) -Cl)-i
First Line of Address :�3 D r— F-'" M M
............ .................... ........... ................ 11— c M fV CJ
244 W. Main Street A C)
C:7
Second Line of Address TS
:U C0 17- M
...............................................I.....................................................................................................__1....__.......__._......... --bATE FILED r—
City or Post Office State ZIP Code
.............
.................................................................................................................................................... ............. _n
Hurnmelstown 17036—— ]
Correspondent's e-mail address:rhoadsann@hotmail.com
Under penalties of pedury,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.
SI(5NA?RE OF PERSON RESPONSIBLE F R FILING RETURN DATE_—
ADDRESS
3609 Kohler Place,Apt. 17, Camp Hill, PA 17011
kCRNATURE OF PREPARER ER T ENTATIVE D E
ADDRESS
244 W. Main Street, Hurnmelstown, PA 17036
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610105 1505610105
1505610205
REV-1500 EX(Fl)
Decedent's Social Security Number
Decedent's Name: HUMPHREYS, CAROLYN G.
RECAPITULATION
!...----......................................
._-..-- -...._........._.__.......--...__.._.._.......__.�
1. Real Estate(Schedule A). ............................................ 1.i 0.00
t i
2. Stocks and Bonds(Schedule B) ....................................... 2. 0.00
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0.00
I
4. Mortgages and Notes Receivable(Schedule D)........................... 4. 0.00
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. I 27,187.48
3
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. ! 2,186.99
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) C=) Separate Billing Requested........ 7. 840.15
8. Total Gross Assets(total Lines 1 through 7)............................. 8. 30,214.62
9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. I 13,095.56
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............... 10. j 74.84
11. Total Deductions(total Lines 9 and 10)................................. 11. ; 13,170.40
i
12. Net Value of Estate(Line 8 minus Line 11) .............................. 12. I 17,044.22
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ........................ 13. i 0.00 j
14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14.1 17,044.22
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfersunder Sec.9116 ____...._.__._........................_..._.._..........___.__...__................_..........._.........._........ ___.._.__........._.___..____.___..._........_._.........___..........-.---.---.�_..__.
(a)(1.2)X.0 0 0.00 15. 0.00
16. Amount of Line 14 taxable (---
at lineal rate X.0 45 17,044.22 18, 766.99
17. Amount of Line 14 taxable 0.00 17. 0.00
at sibling rate X.12
18. Amount of Line 14 taxable I
at collateral rate X.15 f-� _ Y - 0.00 i 18 , 0.00 i
19. TAX DUE ......................................................... 19. 766.99
L.._..-_
..._.......-..............................._............__..........._.............._............_........._._.....__._s
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L 1505610205 1505610205 J
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENTS NAME
CAROLYN G. HUMPHEYS
STREETADDRESS
3609 Kohler Place,Apt#17
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 766.99
2. Credits/Payments
A.Prior Payments 1,000.00
B.Discount 40.37
Total Credits(A+B) (2) 1,040.37
3. Interest
(3) 0.00
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) 273.38
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 ............................................ ❑ E
c. retain a reversionary interest.............................................................................................................................. ❑ N
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 0
2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate consideration?..................................................................................:........................... ❑
3. Did decedent own an"in trust for'or payable-upon-death bank account or security at his or her death?.............. ❑ 0
4. Did decedent own an individual retirement account,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.
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)(11)(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:
• 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+(o8-i2)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
HUMPHREYS, CAROLYN G. 21-13-0711
Include the proceeds of litigation 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 DESCRIPTION OF DEATH
1. Country Meadows Resident Refund 440.02
2. Citizens Bank Checking Account#6225118393 22,060.60
3. Citizens Bank 9-Month CD#623512126 4,007.86
4. 2013 Federal Income Tax Refund 679.00
TOTAL(Also enter on Line 5, Recapitulation) $ 27,187.48
If more space is needed,use additional sheets of paper of the same size.
REV-iSo9 EX+(oi-Jo)
pennsylvania SCHEDULE F
p DEPARTMENT OF REVENUE
I JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
HUMPHREYS,CAROLYN G. 21-13-0711
If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G.
SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A.Patricia A. Hoesch 3609 Kohler Place,Apt. 17 Daughter
Camp Hill,PA 17011
B.
C.
JOINTLY OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 10/01/83 Citizens Checking Acct.#6100384926 4,373.97 50% 2,186.99
TOTAL(Also enter on Line 6, Recapitulation) $ 2,186.99
If more space is needed,use additional sheets of paper of the same size.
REV-1510'EX+(08=09)
r Pennsylvania SCHEDULE G
i .
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND .
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER .
HUMPHREYS, CAROLYN G. .21-13-0711
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 TO DECEDENT AND DATE OF DEATH %OF DECD`S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER.'ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST OF APPUCABLE VALUE
Karol n G.Mozlack(daughter), Patricia A.Hoesch(daughter)and Nancy
1•
;Federal Civil Service Final Lump Sum Payment.Beneficiaries are: ,
x
Y ( 9 ) Y
Humphreys(step-daughter),each to receive an equal one-third(1/3)share
k �840.15 y 100 1
0 i r 4 i 8 }�
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840.15;'
TOTAL(Also enter on Line 7,Recapitulation) $ � _
}
If more space is needed,-use additional sheets of paper,of the same size.
REV-1511 EX+(08-13)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
HUMPHEYS, CAROLYN G. 21-13-0711
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. American Memorial Life 6,355.00
2. Pastor Martin Romain(honorarium) 75.00
3. Reverend Dennis E.Fulk 75.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 0.00
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
2. Attorney Fees:
2,500.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) 3,500.00
claimant Patricia A. Hoesch
Street Address 3609 Kohler PI., Apt. 17
city Camp Hill, state PA Zip 17011
Relationship of Claimant to Decedent Dauqhter
4. Probate Fees: 173.50
5. Accountant Fees:
6. Tax Return Preparer Fees: 150.00
7. Register of Wills-Dauphin County(Oath Fee) 20.00
8. Cumberland Law Journal(Legal Ad) 75.00
9. The Patriot News(Legal Ad) 162.03
10. Citizens Bank Service Charge 10.03
TOTAL(Also enter on Line 9, Recapitulation) $ 13,095.56
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+,(12-12)
Pennsylvania. SCHEDULEI
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE.LIABILITIES &LIENS,
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
HUMPHREYS, CAROLYN G.21-13-0711 21-13-0711
Report debts incurred by the decedent prior to death that remained unpaid at the date of death;including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION . _ OF DEATH
iAlpha Diagnostics,LLC i 74 84
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,
74:
TOTAL'(Also enter on Line 10, Recapitulation) $ 84#
If more space is.needed,insert additional sheets of the same size,
r
REV-1513 EX+(01-10) ,
t
pennsylvania SCHEDULE J
N DEPARTMENT OF REVENUE - + '
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT • - •'
ESTATE OF: FILE NUMBER:
HUMPHREYS, CAROLYN G 21-13-0711
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY. Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under
Sec.9116(a)(1.2).] •' ;
1
[Patricia A.Hoesch,3609 Kohler Place,Apt.17,Camp Hill,PA 17011 daughter 1/3 residuary estate
2.( Carolyn G Mozlack,320 Ft.Duquesne Blvd.,Pittsburgh,PA 15222 daughter 1/3 residuary estate
173.. Nancy Humphreys,600.Humboldt St.,Richmond,CA 94805 - step-daughter 1/3 residuary estate
F7
F I
I per-
_....___._._. _._......_.........._.._............... INNN�IINIIIU�IN�NIINNIrNYNNI�INN�Y r
� � '
-1 - 6�.�.t • _ NICMIIIN�
a
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 SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:"
,. • �N,.� .
f dNN�I]
r
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
El 1. I • N.—:-yNexr
t `
d 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.
69•CS-11—Will and Testament.
Henry Hall,Inc,,Indiana,fA
County of X and State.of AL111
being of sound mind, memory and understanding, do make and publish this my last -TVill and
Testament, hereby revoking and making void all former-.Wills by meat any time heretofore made.
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I do hereby make, constitute and appoint
to be Execiitljk04 of this my last Will and.Testamen4L, i
IN WITNESS WHEREOF, I, ,
the Testat above named, have hereunto subscribed my name and affaxed my seal, the
day of in-the year of our Lord one-thetas
n9*e-Aftn*Td aoO
sworn to mW sWwr+'bW bdM M
Signed, sealed, published and declared by the above named
as and for last Will and Testament, in the presence of us, who have here
unto subscribed our names at aye ,PEA d, request as witnesses thereto in the presence of
said testat_Qv' and of each other.
!D'new 0AMMMEMS,
NOTARL4LSEAL
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COPY FAIR W
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LAST WILL AND TESTAMENT cn ZR c o
OF CAROLYN G. HUMPHREYS o C-> o �`
O ;0 N r- rat
I, Carolyn G. Humpreys
of 3705 W. 14`h. St. Erie, Pa. 16505
County of Erie and State of Pa.
being of sound mind, memory and understanding, do made and publish this my last Will and
Testament, hereby revoking and making void all former Wills by me at any time heretofore made,
I have a debt of a few thousand
dollars, but I have enough CD's to
pay them off. Then my home
should be sold at market price
and what is left is to divided
three ways my daughter Carolyn
G. Mozlack and Patricia A. Hoesch and
my step-daughter Nancy Humphreys.
The contents should divided there
are a lot of articles that are worth
money and should be sold. everything
else should be given awgy if
they don't want anything.
I do hereby make, constitute and appoint Patricia Hoesch
to be Executrix of this my last Will and Testament and Carolvn Mozlack
as co executrix
IN WITNESS WHEREOF, I, _ Carolyn K Humphreys
the Testat or above named, have hereunto subscribed my name and affixed my seal, the
14th day of December in the year of our Lord one tho-asand
nine hwich 2001
Sworn to and subscribed before me /S/ Ca.ro{.y—G Hyu—rry yy (SEAL)
this 14th day of Dec 20 01
Signed, sealed,published and declared by the above named testator as
and for Her last Will and Testament, in the presence of us, who have here
unto subscribed our names at ERIE. PA & request as witness thereto in the presence of
said testat or and of each other.
/S/ 1-40,Rory-DeLuca.
/S/ rruegi,t,(es��
NOTARIAL SEAL
LISA ROSS-DeLUCA,NOTARY PUBLIC
ERIE,ERIE COUNTY,PENNA.
MY COMMISSION EXPIRES MAY 2,2004
/S/