HomeMy WebLinkAbout03-17-05
REV.1500 EX (6-00)
'* COMMONWEALTH OF
PENNSYL VAN IA
. Dil. DEPARTMENT OF REVENUE
. DEPT. 280601
.. HARRISBURG, PA 17128-0601
REV-1500
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
.tl.. f - ()
5- __;Z2~
COUNTY CODE YEAR
NUMBER
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Bender, Mary, E.
1D;;~ ~;2~~:H (MM-DD-YEAR) I ~~~~ ~~f:;; (MM-DD:YEAR)
______ u___ 1 ____
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
N/A
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
196-14-1823
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
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~ 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Allach copy of Will)
o 9. Litigation Proceeds Received
o 3. Remainder Return (dale of death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
JL 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Allach Sch 0)
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Allach copy of Trusl)
o 10. Spousal Poverty Credit (dale of death belween 12-31-91 and 1-1-95)
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NAME
Jacqu~line M. Verney,_ Es~__
FIRM NAME (If Applicable)
COMPLETE MAILING ADDRESS
Jacqueline M. Verney, Esquire
44 South Hanover Street
Carlisle, PA 17013
TELEPHONE NUMBER
(717) 243-9190
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D)
(4)
(5)
0.00
0.00 '.'
0.00 " ";
0.00
0.00
10,765.49
0.00
(8) 10,765.49
12,082.50
1 ,735.45
(11) 13,817.95
(12)
(13) 0.00
(14) -3,052.46
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5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
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)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
(6)
(7)
(9)
(10)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
0.00 x .0
0.00 x .0
0.00 x .12
0.00 x .15
(15)
(16)
(17)
(18)
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
19. Tax Due
(19)
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS
650 Baltimore_pik~
CITY
Gardners,
STATEpA
ZIP
17324
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
0.00
0.00
-------
0.00
0.00
Total Credits ( A + B + C ) (2)
0.00
3. InterestJPenalty if applicable
D. Interest
E. Penalty
TotallnterestJPenalty ( D + E ) (3)
4. 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 (4)
0.00
A. Enter the interest on the tax due.
(SA)
0.00
0.00
0.00
0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
0.00
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 properly transferred;.......................................................................................... 0 [iJ
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 [iJ
c. retain a reversionary interest; or.......................................................................................................................... 0 IKI
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 IKI
2. If death occurred after December 12, 1982, did decedent transfer properly within one year of death
without receiving adequate consideration? .............................................................................................................. 0 [iJ
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 [iJ
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0 [iJ
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penatties of pe~ury, 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 knowiedge.
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~ATURE OF PREPARER OTHER THAttREPRESENTATIVE
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FILING RETURN
DATE
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DATE
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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 to or for the use of the surviving spouse is 3%
[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% [72 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 if
the survivin9 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 twenty-one 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% [72 P.S. 99116(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%, except as noted in 72 P.S. 99116(1.2) [72 P.S. S9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116(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-1509 EX+ (6-98) ~
*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
Bender, Mary E.
FILE NUMBER
~/ -6 S- - ~ 3.3
If an asset was made joint within one year of the decedent's date of death, It must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. Linda Forsythe
650 Baltimore Pike
Gardners, PA 17324
Daughter
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 DECO'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY.HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 07/12/2000 PNC Checking Acet 7,000.01 50 3,500.00
2 A 07/12/2000 GE GOV SECS CL A 14,530.97 50 7,265.49
TOTAL (Also enter on line 6, Recapitulation) $ 10,765.49
(If more space is needed, insert additional sheets of the same size)
Total Banking Statement
PN,C Bank'
~ PNCBAN<
For the period 12/09/2004 to 01/08/2005
Primary account number: 50-8057-3329
Page 1 of 3
Number of enclosures: 41
MARY E BENDER
LINDA l FORSYTHE
650 BALTIMORE PIKE
GARDNERS PA 17324-8805
Q For 24-hour banking, customer service and
transaction or interest rate informiltion,
'D' sign-on to Account Link @ by Web on
pncbank.com or call1-888-PNC-BANK
Para servicio en espanol, 1-866-HOLA-PNC
Moving? Please contact us at 1-888-PNC-BANK
l2!;] Write to: Customer Service
PO Box 609
Pittsburgh PA 15230-9738
IQ Visit us at pncbank.com
~
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TOO terrninill: 1-800-531-1648
For he:nin'5 impitircc[ clients only
Relationship Overview
Bank Deposit Accounts
Description
Interesl Checking
Total Deposits
Account Number
Deposit Balance
50-8057-3329
9..11771
9.417.71
Important Changes to Your Account Statement
E[fectil'e Fehruary 5, 2005
Certain Automate,1 Clearing House (ACH) cleposit and withclrawal transactions that appear on your acnHlllt statement 1Il~IY
display your Social Security Number or other identifying number. Effective February 5, 2005 all but the last four digits of the
identifying number will he replaced with "x.'C'C"", except for identifying numbers that arc eight or fewer digits, \vhich will appear III
full.
Choice Plan
Interest Checking Account Summary
A!O!Oolln! number: c:;rLROC:;7_":l32Q
Mary E Bender
Linda L Forsythe
Balance Summary
Beginning
balance
Deposits and
other additions
15,275.81
Checks and other
deductions
16.306.90
Ending
balance
9,'117.71
Please see the Activity Detail section for
additional inforrniltion.
10,1-18.77
Average monthly
balance
10,5%.03
Charges
and fees
.00
Transaction Summary
Checks paid/
withdrawals
Check Card pas
signed transactions
Check Card/Bankcard
pas PIN transactions
41
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Total ATM
transactions
PNC Bank
A TM transactions
Other Bank
ATM transactions
o
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FORM9S:IR-Ol0c
Total.Banking Statement
C For 24-hour customer service information, sign-on to Account Link @
~
by Web on pncbank.com or call 1-888-PNC-BANK
Account numher: 50-8057-3329 - continued
For the period 12/09/2004 to 01/06/2005
MARY E BENDER
Primary account number: 50-8057-3329
Page 2 of 3
Interest Summary
I.'
Annual Percentage
Yield Earned (APYE)
Number of days
in interest period
As of 01/06, a total of $1.18 in interest was
earned this year.
Activity Detail
Deposits and Other Additions
Date Amount Description
12/14 168.82 Direct Deposit - Insurance
Glenbrook Life Ga0591637
Deposit Reference No. 027107990
Deposit Refet-ence No. 026878538
Deposit Reference No. 025218397
Interest Payment
12/15
12/17
12/21
01/06
Average collected
balance for APYE
Interest Earned
this period
0.]5%
29
10,042.84
1.18
There were 5 Deposits and Other Additions
totaling $15,275.84.
71.80
34.04
15,000.00
1.18
Checks and Substitute Checks
Check
number
1829
1833 *
1838 *
1839 T
1810
1811 T
1812
1813
18H T
1815
18.16
1817
1848
1819
1850
1851
1852 T
1853 T
185.1
1855
1856
Date Reference Check
Amount paid number number
57.57 12109 028370359 1857
2,374.00 12/15 028340794 1858
433.]8 12/10 027216998 1859
200.00 12/09 026835757 1860
91.13 12/14 027876548 186]
50.00 12/10 027341602 1862
359.50 12/14 018305523 ]863
64.00 12/14 027796947 IBM
60.00 12/14 027796823 1865
35.96 12/20 025639011 1866
37.'13 12/20 E094026735 1867
42 Al 12/20 028619091 1868
215.66 12/20 026348031 1869
63.54 12/17 028590263 1870
298.81 12/24 028623088 1871
98.37 12120 028640988 1872
150.00 12/16 027245283 1873
50.00 12/16 027232199 1874
1,185.00 12/21 027106762 1875
52.'16 12/21 026528462 1877 *
24.91 12/21 028184528
* Gap in check sequence
"T" Teller Cashed Check
T
T
T
T
T
T
T
T
T
Amount
1,000.00
28.50
35.00
500.00
600.00
850.00
50.00
1,735.'15
378.19
500.00
60.00
14.55
2,868.81
150.00
80.00
300.00
750.00
300.00
97.li
65.00
Date
paid
12,/ 17
12131
12/24
12/20
12/21
12/21
12,'27
12/23
12/30
12/28
12./28
12/29
12/29
12>29
12/28
12/30
12/30
12/31
OliO!
01/0!
Reference
number
0268i7557
021461271
028611285
026486837
025218:\66
02521831;4
02f:i26ti 108
027.351365
026353210
025!f,~070
0286913:\1
028.~30621
026013584
027797615
026726661
027132.~91
E00425G1132
027381')81
025519]17
027072')63
There were 41 checks listed totaling
$16,306.90
Daily Balance Detail
Date Ba I a nce
12/09 10,191.20
12/10 9,708.02
12/14 9,302.21
12/15 7,000.01
12/16 6,800.01
~
Date
12/ 1 7
12/20
12/21
12/23
12/24
Balance
5,770.51
4,840.68
17,128.31
15,392.86
15,059.05
Date
12/27
12/28
12/29
12/30
12/31
Balance
15,009JJ5
14,369.05
11,335.69
9,907.50
9,579.00
Date
01/04
01/06
Balance
9,4lG.53
9,417.71
0. PNC1NVESTMENTS
Member NASD and SlPC
February 16, 2005
Jackie Verney
44 S Hanover Street
Carlisle, P A 17013
Subject: Estate of Mary E Bender (196-14-1823)
Date of Death: 12/15/2004
Dear Ms. Verney:
Thank you for your telephone inquiry of February 15,2005. Please find below the
requested information:
TITLE OF ACCOUNT
Mary E Bender and
Linda L Forsythe JT TEN
DATE ACCOUNT WAS ESTABLISHED
07/12/2000
DATE OF DEATH VALUE:
1,647.503 Shares GE GOV SEeS CL A ITGAX@ 8.82 per share
Mrs. Mary E. Bender also owned an Allstate Glenbrook Annuity GA0591637. The sole
owner of this annuity was Mary E. Bender. Linda L. Forsythe, her daughter, was the sole
beneficiary for this annuity.
The value of the annuity on Mrs. Bender's date of death was $35,069.22 the cost basis is
$35,058.22.
A member of The PNC Financial Services Group
2 East Main Street Mechanicsburg Pennsylvania 17055
www.pncinvestments.com
Important Investor Information: Securities and brokerage services are provided by PNC Investments LLC,
member NASD and SIPe. Annuities and other insurance products are offered by PNC Insurance Services, Inc.
a licensed insurance agency.
I :May Lose Value I
., No Bank Guarantee
0.
February 22, 2005
Jackie Verney
Date of Death Value for Estate of Mary E. Bender
Page 2
Please do not hesitate to contact me if I can provide you with further information.
Sincerely,
(tJ~
Charles E. Little, CFP
Vice President
Senior Financial Consultant
CEL/djp
REV-1511 EX+ (12-99'.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
6tAfbZrt.,
tt1 A Lll E-
I
FILE NUMBER
;).. 1-6 S- - -;)... "3'~
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
Hofffman Roth Funeral Home, Inc 219 North Hanover St Carlisle, PA 17013
Westminister Memorial Gardens 1159 Newville Rd. Carlisle, Pa 17013
6,897.50
1,185.00
2
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
. State
Zip
Year(s) Commission Paid:
2.
Attorney Fees
500.00
3.
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
3,500.00
Claimant Linda L. Forsythe
Street Address 650 Baltimore Pike
City Gardners
Relationship of Claimant to Decedent daughter
State P A _ Zip 17324
4 _ Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
12,082.50
Hoffman-Roth Funeral Home, Inc.
219 North Hanover Street
Carlisle, PA 17013
(717)243-4511
January 5, 2005
Linda Forsythe
650 Baltimore Pike
Gardners, P A 17324-
The Funeral Service for Mary E. Bender
14429-239
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
OUR SERVICE:
Traditional Funeral Service Package . . . . . .
FUNERAL HOME SERVICE CHARGES
SELECTED MERCHANDISE:
Monarch Casket . . . . . . . . . . . . . . . . . . . . . .
Monticello Interment Receptacle. . . . . . . . . . . . . . . . .
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THAT YOU HAVE SELECTED . . . . . . . . . . . . .
~
Cash Advances
Clergy Offering
Certified Copies of Death Certificates.
Flowers. .
Hairdresser. . . . . . . . .
TOT AL CASH ADVANCES AND SPECIAL CHARGES .
Total
Total Cost .
TOTAL AMOUNT DUE
This statement is net and payable in full within 30 days of receipt.
$3590.00
$3590.00
$1820.00
$1120.00
$6530.00
$100.00
$22.00
$215.50
$30.00
$367.50
$6897.50
$6897.50
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REV-1512 EX+ (12-03)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Bender, Mary E.
FILE NUMBER
c;( I - oS -c;?3 ~
Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
PNC crline/installloan pmt acct 40018109348553
1,735.45
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
1,735.45
o PNCBAN<
040
MOUNT HOLLY (171)
2 WEST PINE STREET
MT. HOLLY SPRINGS PA 17065
Cashbox 11
* erline/Install Loan Prnt
13:01 DEe 23 2004
Account Number
Tran Amount
fccl '1l1-Y;O:-Y
40018109348553
$1,735.45
W/S 10 WWSH1713 Sequence Number 00139
Batch 702
.,
This deposit Dr payment is accepted subiect to
verification and to the rules and regulations of
this bank. Deposits may not be available for
immediate withdrawal. Receipt should be held
until verified with your statement.
REV-1513 EX+ (9-00)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
b'iN b ~~
/IA. A.(L '-I C,
FILE NUMBER
~ I -0)- - .;l. "5 ~
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
NUMBER
I
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
Linda L. Forsythe 650 Baltimore Pike Gardners 17324
daughter
10,765.49
10,765.49
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
0.00
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
0.00
(If more space is needed, insert additional sheets of the same size)