HomeMy WebLinkAbout03-05-14 (2) 1505610105
REV-1500EXt0�u'(IT'
PA Department of Revenue pennsylvarda OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN —�I - -- I; — '-I
_ Harrisburg,PA 17128-0601 RESIDENT DECEDENT p( I a � �. ii J
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
12/14/2012 — JAI ;09/19 191/09/19 191/9
Decedent's Last Name�_ — Suffix Decedent's First Name MI
C —� _—j ---
Cox
J I Katherine
(if Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name 'Suffix Spouse's First Name MI
L I I I I
Spouse's Social Security Number
-- �--� THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
O 1.Original Return (310 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)
In 6.Decedent Died Testate O 7. Decedent Maintained a Living Trust 0 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
David C. Cox (717) 580-5339
REGISTER OLLS USE ONEN
Q �
pp77 � r�7
First Line of Address /T C7 X. O
Z75:x:3
509 Joyce Road [p—r�� 1 n r-
Uri
Second Line of Address V C7 CZ CD
L _ Na M
City or Post Office State ZIP Code D FI D
Camp Hill -- - P 17011 tV
Correspondent's e-mail address:dCOX51 @comCast.net
Under penalties of perjury,1 declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
R is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGN E OF PfR M RE$pONSIBLE FOR FILING RETURN DATE y
ADDPWtS
509 Joyce Road, Camp Hill, PA 17011
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 1505610105 J
1505610205
REV-1500 EX(Fl)
Decedent's Social Security Number
Decedent's Name: Katherine C. Cox
RECAPITULATION
1. Real Estate(Schedule A). ............................................ 1. 0.00
2. Stocks and Bonds(Schedule B) .......... ...... ....... .. . ............. 2. 40,628.97
3. Closety,Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0.00
4. Mortgages and Notes Receivable(Schedule D)......................... .. 4. 1 0.00
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).... ... 5. 1 14,006.88
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 0.00
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7. 28,699.55
8. Total Gross Assets(total Lines 1 through 7)............. ................ 8. ' 83,335.40
9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. i 5-940.63
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)....... .. ...... 10. 644.35
11. Total Deductions(total Lines 9 and 10)................................. 11. 6,584.98 1
12. Net Value of Estate(Line 8 minus Line 11) .............. ................ 12. 76,750.42 Ij
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ................ .. . ..... 13. I 0.00
14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14. I 76,750.42
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 (-"--- -"- ----------------i
(a)( X.0- 15.
16. Amount of Line 14 taxable --�
at lineal rate X.0 45 76,750.42 16.1 3,453.77
17. Amount of Line 14 taxable
at sibling rate X.12 17,
18. Amount of Line 14 taxable
at collateral rate X.15
19. TAX DUE ............................. 3,453.77
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
L 1505610205 1505610205
REVA500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Katherine C. Cox
STREETADDRESS
Country Meadows of West Shore
4905 E.Trindle Road,Apt. 35, Bldg 1
CRY STATE ZIP
Mechanicsburg PA 17050
Tax Payments and Credits:
f. Tax Due(Page 2,Line 19) (1) 3,453.77
2. Credits/Payments
A.Prior Payments 3,112.38
B.Discount 163.16
Total Credits(A+B) (2) 3,275.54
3. Interest
(3) 0.00
4. ff Line 2 is greater than Line f+Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00
S. it Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 178.23
Make check payable #o: 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.......................................................................................... ❑ ■
b. retain the right to designate who shall use the property transferred or its income ........................_.................. ❑ N
c. retain a reversionary interest .............................................................................................................................. 13
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ N
1 If death occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate consideration?..............___......................................._..........................................._.... ❑ N
3. Did decedent own an"in trust for'or payable-upon-death bank account or security at his or her death?............. N ❑
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation? .............___....,....._............................................................
....., ❑
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.1,11995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent]72 P.$.§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 0 percent
(72 P.S.§9116(a)(11)If)].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 theiuse of the decedent's lineal beneficiaries is 4.5 percent,except as noted in V2 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-1503 O(t(8-12)
pennsylvania SCHEDULE B
OEPARITIEW FHEVETIUE.. f'V
INHERITANCE TAX RETURN - STOCKS';Bt;BONDS
RESIDENT DECEDENT -
ESTATE OF - - FILE NUMBER
Katherine C. Cox N.,
2012-01319
All property jointly owned�with right of survivorship must be disclosed on Schedule F.
ITEM - VALUE AT DATE
NUMBER DESCRIPTION --
OF DEATH
1' 32 sh Dow Chemical Common Stock CUSIP 260543103 $31.260/sh.
( )@ 1,000.32
2 1830 sh General Electric Common Stock(CUSIP 369604103)@$21.655/sh. 5
39,628.65
8.
t
p
y
TOTAL(Also enter on Line 2, Recapitulation) $ 3 40,628.97
If more space is needed, insert additional sheets of the same size
Alf
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REV-Isla Ex+(08-09)
i pennsyLvania SCHEDULE G
oseARTNMOFTn:vEeue INTER-VIVOS TRANSFERS AND
IId1EPITAnCE TAxpznj°" MM. NON-PROBATE PROPERTY
RE Sme+r DeaeDenr
ESTATE OF FILE NUMBER
Katherine C. Cox 2012.01319
This schedule must he completed and filed H the answer to any of questions I through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY DATE OF DEATH %OF DEWS EXCLUSION TAXABLE
SMB aslTmex+rform+s mmFr 0EED�wameeram
- NUMBER neaverFiwwsrcn.anaAawof�o®maaeiesme - VALUE OF ASSET INTEREST VAWE
I. DisCow Bank-MM Cert#520.170840.2-A w/David C.Cox 4,024.14 100 3,000.00 1,024.14
2 Discover Bank-MM Cart#520-174571.6-A w/David C.Cox 4,015.12 100 0.00 4,015.12
3 Discover Bank-MM Cert#52111784383-POD David C.Cox 4,006.69 100 0.00 4,006.69
4. Discover Bank-MM Savings Acct#523167569.0-POD David C.Cox 4,52325 100 0.00 , 4.52325
5. Discover Bank-Online Savings Acct#522-167079.3-POD David C.Cox 2,066.82 100 0.00 2,068.82
6. Perttagoa FedwA CU-Reg.Acct#3561455.01-6-POD David C.Cox 5.01 100 000 5.01
7 Pentnon Federal CU-MM Savings Aact#4146441.03-7-POD David C. 33.66 100 0.00 33.66
Pe
5 Pentagon Federal CU-MM 2 YR Cert#4342707-%l-POD David C.Cox 1.144.20 100 - 0.00 1,14420
9. Perl"On!Federal CU-MM i YR Cot#4707469.56.7-POD David C.Cox 4,041.42 100 0100 4,041.42
10. Pentagon Federal CU-MM 1 YR Cert#4707479366-POD.David C.Cox 4,041.42 100 0.00 4,041.42
tt. PA Site Employees Credft Union Regular Shane Act.#8441064564-A Md 5.00 100 ODD 5.00
Data C.Cox
12 Watmd Street Sear sties Money Market Acct.#3=79083- POD David C. 3,790.82 . 100 0.00 3,790.82
TOTAL(Also enter on tine 7,Recapitulation) $ 26,699.55.
If more space Is needed,use additional sheer of paper of the same size.
REV-1511 Ex+(10.09)
pennsylvania SCHEDULE H
OEPARrMEWOFREMUE FUNERAL EXPENSES AND
INNEAITANa TAXREFM ADMINISTRATIVE COSTS
POWDEWoe®ert
ESTATE OF FILE NUMBER
Katherine C. Cox 2012-01319
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' Funeral Services-Payment for minister and pianist 550.00
Parthemore Funeral Home/Cremation 3,469.65
Burial at North Cemetery,Sturbridge,Mass(Town of Sturbridge) 250.00
Burial at North Cemetery,Sturbridge,Mass Travel Expenses 504.99
Grave Marker Lathering(Pepin Granite) 135.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(5)of Personal Representative(s)
Street Address
city State ZIP
Year(s)Commission Paid:
2. Attorney fees:
406.11
3. Family Exemption:(If decedent's address is not the same as daimanUs,attach explanation.)
Claimant
Shied Address
city state_ZIP
Relationship of Claimant to Dement
4. Probate Fees: 273.50
S. Accounted Fees: 0.00
6. Tax Return Prepares Fees: 0.00
7. Carlisle Sentinel-Estate Notice 104.58
Patriot News-Estate Notice 149.60
Masland 8 Bernick Account Transfer Fees 55.00
M&T Bank-Estate Account Checks 25.20
AAA Notary Fee 2.00
Register of Wills-Filing Fee for Inheritance Tax Return 15.00
TOTAL(Also enter on Line 9, Recapitulation) 5,940.63
If more space is needed,use additional sheer of paper of the same size.
REV-1512 EX+(12-12)
-yTt--pennsylvania SCHEDULE I
Q DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Katherine C. Cox 2012-01319
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
REM VALUE AT DATE
NUMBER DESCRIPTION
OF DEATH
1. Diamond Pharmacy 180.61
2 Public School Employees'Retirement System-Partial Reimbursement of December Pension 335.32
3 Verizon Wireless-Cell Phone Bill 37.61
4 M&T Bank-Service Charge 14.00
5 Comcast-Cable TV Bill 6.81
6 Trust Ambulance 70.00
TOTAL(Also enter on Line 10, Recapitulation) $ 644.35
If more space is needed,Insert additional sheets of the same size.
REV4513 EX+(01-10)
7pennsylvania SCHEDULE J
DEPARTMEM OF REWNUE
mNEMra,CE AX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Katherine C. Cox 2012-01319
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE D15TIUBUTIONS(include outright spousal distributions and transfers under
Sec.9116(a)(1.2).]
1. David C.Cox Son 100°f°
509 Joyce Road,Camp Hill PA 17011
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.
8. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
i.
TOTAL OF PART It-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.
LAST WILL AND TESTAMENT
OF
KATHERINE C. COX
I, KATHERINE C. COX, now domiciled in Cumberland County, Pennsylvania, declare
this to be my Last Will and Testament. I revoke all other wills and codicils that I may have
previously made.
Article I
My just debts and expenses of my last illness, funeral, and administration of my estate
shall be paid by my Executor from the principal of my residuary estate as soon as practicable
after my death.
Article II
All inheritance, estate, and succession taxes (including interest and penalties thereon, but
not including any generation skipping tax) payable by reason of my death shall be paid out of
and be charged generally against the principal of my residuary estate without reimbursement
from any person. This provision is not a waiver of any right which my Executor has to claim
reimbursement for any such taxes which become payable as the result of any property over
which I have the power of appointment.
Article III
I give, devise and bequeath my tangible personal property to my husband, J.
FREDERIC COX, H. In the event J. FREDERIC COX, II predeceases me or fails to survive
me by thirty (30) days, then I give, devise and bequeath my tangible personal property in
accordance with any memorandum I have handwritten or signed, located with my will or with
my valuable papers and found within 30 days of the probate of my will. Gifts may only be to
persons who survive me or to organizations which exist at my death, and if there is a conflict, the
memorandum having the latest date shall govern. To the extent no such memorandum is found,
or all of my tangible personal property is not disposed of pursuant thereto, my tangible personal
property shall be added to my residuary estate and pass under Article IV hereof.
Article IV
All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever
situate, I give, devise and bequeath to my husband, J. FREDERIC COX, II, of Cumberland
County, Pennsylvania. In the event J. FREDERIC COX, II predeceases me or fails to survive
me by thirty (30) days, then I give, devise and bequeath all the rest, residue and remainder of my
estate, of whatsoever nature and wheresoever situate to my son, DAVID C. COX, of
Cumberland County, Pennsylvania,per stirpes.
Article V
I nominate, constitute and appoint my husband, J. FREDERIC COX, II, as Executor of
my Last Will and Testament. In the event of the renunciation, death, or inability to act, for any
reason whatsoever of my Executor, I nominate, constitute and appoint my son, DAVID C. COX,
as successor Executor of my Last Will and Testament. I direct that my Executor or successor
Executor be permitted to serve without bond. In addition to those powers granted by law, I grant
them power to distribute in cash or in kind, in like or in unlike shares, and to file any qualified
disclaimer I could have filed if living. My Executor or successor Executor shall receive
reasonable compensation for services rendered to my estate.
2
Article VI
In addition to the powers conferred by law, I authorize my Executor or successor
Executor, in his absolute discretion:
(a) to retain in the form received and to sell either at public or private sale, any real
estate or personal property except that which I specifically bequeath herein,
(b) to manage real estate,
(c) to invest and reinvest in all forms of property without being confined to legal
investments, and without regard to the principal of diversification,
(d) to exercise any option or right arising from the ownership of investments,
(e) to compromise claims without court approval and without consent of any
beneficiary,
(f) to file any federal income tax return for any year for which I have not filed such
return prior to my death,
(g) to make distributions in cash or in kind, or in both, and to determine the value of
any such property,
(h) to employ any attorney, investment advisor, or other agent deemed necessary by
my Executor or successor Executor; and to pay from my estate reasonable compensation for all
their services,
(i) to conduct alone or with others, any business in which I am engaged in, or have
an interest in at time of my death, and
3
G} to receive reasonable compensation in accordance with their standard schedule of
fees in effect while their services are performed.
IN WITNESS WHEREOF, 1, KATHERINE C. COX, hereby set my hand to this my
Last Will and Testament, on �f, 1�/ 2009, at Harrisburg, Pennsylvania.
KATHERINE C. COX
In our presence, the above-named KATHERINE C. COX signed this and declared this
to be her Last Will and Testament and now at her request, in her presence, and in the presence of
each other,we sign as witnesses.
Name 9 Address
2000 Linglestown Rd.. Suite 202 Harrisburg PA 17110
tw.GZw 2000 Linglestown Rd Suite 202 Harrisburg, PA 17110
1, KATHERINE C. COX, Testatrix, who signed the foregoing instrument; having been
duly qualified according to law, acknowledge that I signed and executed this instrument as my
Will, and that I signed it willingly as my free and voluntary act for the purposes therein
expressed.
Sworn to or affirmed and
Acknowledged before me by
KATHERINE C. COX, the Testatrix
on Af1� 12009.
Notary Public KATHERINE C. COX
COMMQNWEAtTri OF FENNSYt`lANlA
NIX3R3t E6al
Mc-Iissa M.ICafn,pJOtary Fuh1iC
Susquehanna Twp.,Dauphin County
MY Commission Expires Aug.t 1,24r4
4
We, the undersigned witnesses who signed the foregoing instrument, being duly qualified
according to law, depose and say that we were present and saw the Testatrix sign and execute
this instrument as her Will; that she signed and executed it willingly as her free and voluntary act
for the purposes therein expressed; that each of us in her sight and hearing signed the Will as
witnesses, and that to the best of our knowledge, that she was at that time eighteen (18) years or
more of age, of sound mind, and under no constraint or undue influence.
Sworn to or affirmed and
Subscribed to before me 9
nn� i
by � V�4r �1I2 I�— kil !i j
and v (- DCPAcwn n An s
witnesse , on�0: /y 2009.
Witn s
Notary Public
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Melissa M.Kain,Notary Public
Susquehanna Twp.,Dauphin County
My Commission Expires Aug.11,2010
5